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10,030,852
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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: diabetic ketoacidosis with history of Type I diabetes ___ ___ Major Surgical or Invasive Procedure: none History of Present Illness: ___ G1 at ___ with T1DM transferred for poorly controlled diabetes. She reports her finger sticks have been more poorly controlled over the past ___ days, reporting fasting FSBG around 200s and pre-prandial lunch/dinner FSBG in 160s-200s. She last changed her insulin pump site ___ days ago because it was falling off; it is currently on her L outer thigh. She denies concerns for pump malfunction. She has been checking her FSBG 3x/day (fasting, pre-lunch, and pre-dinner) but does not check at bedtime or in the middle of the night. Pt presented for a routine OB visit during which she reported recent poor control of her sugars, and was recommended to present to ___. Initial ___ there was 345, and she was bolused 16.2 units through her pump in the late afternoon. No other changes were made to her current pump settings. All ___ there were over 200. Per notes, she was to receive a 1L IVF bolus, however, pt denies receiving any IVF there. She underwent serum and urine labs that were notable for: Na 132, K 3.6, anion gap 13, serum osmolality 285, + serum and urine ketones. She was transferred to ___ for admission for glucose control. Past Medical History: PNC: *) ___ ___ by LMP c/w 7wk U/S *) Labs: A+/Ab-,RI,GC/CT-,RPRnr,HbsAg-,HIV-,GBS unk *) nl FFS, anterior placenta, nl sequential screen, per pt nl, fetal echo at 23 weeks at CHB *) s/p flu and Tdap ISSUES: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p lap appendectomy *) T1DM: (dx'd at ___ - s/p multiple admissions for DKA in past (most recent ___ - on Meditronic pump for ___ years - endocrinologist: Dr ___ - nl fetal echo (___) - nl baseline ___ labs, has not done 24hr urine yet - ___ 1911g(68%); AC 84% - HbA1C ~13% at conception per pt (according to PN records) - ___ 8% - ___ 1.78 - UTI in early pregnancy treated ObHx: G1 current GynHx: - LGSIL pap (___) -> for rpt in ___ year - vulvar condyloma, s/p TCA PMH: T1DM dx age ___, on inulin pump ___ year SurgHx: lap appendectomy (___) Social History: ___ Family History: mother and father with T2DM Physical Exam: Physical Exam on Discharge: CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, +1 edema FHR: present at a normal rate Pertinent Results: ___ 09:15AM BLOOD WBC-6.0 RBC-4.03 Hgb-11.3 Hct-34.2 MCV-85 MCH-28.0 MCHC-33.0 RDW-12.9 RDWSD-39.9 Plt ___ ___ 12:08AM BLOOD WBC-7.7 RBC-3.77* Hgb-10.5* Hct-31.7* MCV-84 MCH-27.9 MCHC-33.1 RDW-12.7 RDWSD-38.6 Plt ___ ___ 10:14AM BLOOD WBC-6.7 RBC-3.69* Hgb-10.3* Hct-31.0* MCV-84 MCH-27.9 MCHC-33.2 RDW-12.6 RDWSD-38.2 Plt ___ ___ 01:30AM BLOOD WBC-8.4 RBC-4.19 Hgb-11.6 Hct-35.6 MCV-85 MCH-27.7 MCHC-32.6 RDW-12.6 RDWSD-38.5 Plt ___ ___ 01:38AM BLOOD ___ PTT-25.7 ___ ___ 09:15AM BLOOD Glucose-73 UreaN-3* Creat-0.4 Na-138 K-3.6 Cl-109* HCO3-18* AnGap-15 ___ 12:08AM BLOOD Glucose-92 UreaN-5* Creat-0.4 Na-136 K-3.7 Cl-108 HCO3-15* AnGap-17 ___ 03:25PM BLOOD Glucose-112* UreaN-5* Creat-0.4 Na-138 K-3.7 Cl-111* HCO3-15* AnGap-16 ___ 10:14AM BLOOD Glucose-106* UreaN-6 Creat-0.4 Na-137 K-3.7 Cl-109* HCO3-16* AnGap-16 ___ 05:23AM BLOOD Glucose-119* UreaN-6 Creat-0.4 Na-136 K-3.6 Cl-110* HCO3-15* AnGap-15 ___ 01:30AM BLOOD Glucose-211* UreaN-7 Creat-0.5 Na-131* K-3.7 Cl-100 HCO3-15* AnGap-20 ___ 01:30AM BLOOD ALT-12 AST-13 Amylase-16 ___ 01:30AM BLOOD Lipase-28 ___ 09:15AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.8 ___ 12:08AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.9 ___ 03:25PM BLOOD Calcium-7.5* Phos-2.3* Mg-1.9 ___ 10:14AM BLOOD Calcium-7.4* Phos-1.9* Mg-1.5* ___ 05:23AM BLOOD Calcium-7.2* Phos-1.8* Mg-1.4* ___ 01:30AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.7 UricAcd-5.6 ___ 05:23AM BLOOD Acetone-NEGATIVE Osmolal-279 ___ 01:30AM BLOOD Acetone-NEGATIVE Osmolal-284 ___ 01:30AM BLOOD TSH-6.6* ___ 01:30AM BLOOD Free T4-1.1 ___ 05:23AM BLOOD RedHold-HOLD ___ 06:40AM BLOOD Type-ART pO2-102 pCO2-26* pH-7.39 calTCO2-16* Base XS--7 ___ 06:44AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03:01AM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:44PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:44AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM ___ 03:01AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 08:44PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 06:44AM URINE RBC-2 WBC-7* Bacteri-NONE Yeast-NONE Epi-10 ___ 03:01AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-2 ___ 08:44PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-1 ___ 06:44AM URINE CastHy-2* ___ 03:01AM URINE CastHy-1* ___ 03:01AM URINE Hours-RANDOM Creat-115 TotProt-46 Prot/Cr-0.4* ___ 03:01AM URINE Osmolal-1042 ___ 3:01 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION Brief Hospital Course: On ___, Ms. ___ G1P0 at 34wks, was admitted to the anteapartum service with concern for diabetic ketoacidosis in the setting of T1DM with insulin pump. Workup was negative for infectious process and presentation likely secondary to pump failure. She was initiated on an insulin drip and received IVF hydration with subsequent normalization of blood glucose and resolution of anion gap. Her diet was advanced and she was transitioned to her insulin pump. She continued to have fasting blood sugars at goal. On HD#2, her insulin pump fell out and she again received insulin drip until her pump was replaced and she was able to be transitioned. By hospital day 3, she was on her insulin pump regularly with controlled blood glucose levels. She was then discharged in stable condition with appropriate pump settings. Of note, she had an ultrasound on ___ with BPP ___ and AFI within normal limits. Medications on Admission: Humalog pump, PNV, ASA 81mg daily Discharge Medications: 1. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0200: 1.05 Units/Hr 0200 - 0600: 1.3 Units/Hr 0600 - 1200: 2.4 Units/Hr 1200 - 1500: 2 Units/Hr 1500 - 1800: 1.9 Units/Hr 1800 - 2100: 2.4 Units/Hr ___ - 0000: 1.65 Units/Hr Meal Bolus Rates: Breakfast = 1:2 Lunch = 1:4 Dinner = 1:2 Snacks = 1:2 High Bolus: Correction Factor = 1:12 Correct To ___ mg/dL MD acknowledges patient competent MD has ordered ___ consult 2. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: DKA T1DM 34 weeks gestational age Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for DKA and management of your T1DM. Your diabetes control was improved and you are now safe to be discharged home. Followup Instructions: ___
[ "T85614A", "E1010", "O24013", "T85624A", "T383X6A", "Z3A34", "O99213", "E669", "Z6836", "Y929" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: diabetic ketoacidosis with history of Type I diabetes [MASKED] [MASKED] Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] G1 at [MASKED] with T1DM transferred for poorly controlled diabetes. She reports her finger sticks have been more poorly controlled over the past [MASKED] days, reporting fasting FSBG around 200s and pre-prandial lunch/dinner FSBG in 160s-200s. She last changed her insulin pump site [MASKED] days ago because it was falling off; it is currently on her L outer thigh. She denies concerns for pump malfunction. She has been checking her FSBG 3x/day (fasting, pre-lunch, and pre-dinner) but does not check at bedtime or in the middle of the night. Pt presented for a routine OB visit during which she reported recent poor control of her sugars, and was recommended to present to [MASKED]. Initial [MASKED] there was 345, and she was bolused 16.2 units through her pump in the late afternoon. No other changes were made to her current pump settings. All [MASKED] there were over 200. Per notes, she was to receive a 1L IVF bolus, however, pt denies receiving any IVF there. She underwent serum and urine labs that were notable for: Na 132, K 3.6, anion gap 13, serum osmolality 285, + serum and urine ketones. She was transferred to [MASKED] for admission for glucose control. Past Medical History: PNC: *) [MASKED] [MASKED] by LMP c/w 7wk U/S *) Labs: A+/Ab-,RI,GC/CT-,RPRnr,HbsAg-,HIV-,GBS unk *) nl FFS, anterior placenta, nl sequential screen, per pt nl, fetal echo at 23 weeks at CHB *) s/p flu and Tdap ISSUES: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p lap appendectomy *) T1DM: (dx'd at [MASKED] - s/p multiple admissions for DKA in past (most recent [MASKED] - on Meditronic pump for [MASKED] years - endocrinologist: Dr [MASKED] - nl fetal echo ([MASKED]) - nl baseline [MASKED] labs, has not done 24hr urine yet - [MASKED] 1911g(68%); AC 84% - HbA1C ~13% at conception per pt (according to PN records) - [MASKED] 8% - [MASKED] 1.78 - UTI in early pregnancy treated ObHx: G1 current GynHx: - LGSIL pap ([MASKED]) -> for rpt in [MASKED] year - vulvar condyloma, s/p TCA PMH: T1DM dx age [MASKED], on inulin pump [MASKED] year SurgHx: lap appendectomy ([MASKED]) Social History: [MASKED] Family History: mother and father with T2DM Physical Exam: Physical Exam on Discharge: CONSTITUTIONAL: normal HEENT: normal, MMM NEURO: alert, appropriate, oriented x 4 RESP: no increased WOB HEART: extremities warm and well perfused ABDOMEN: gravid, non-tender EXTREMITIES: non-tender, +1 edema FHR: present at a normal rate Pertinent Results: [MASKED] 09:15AM BLOOD WBC-6.0 RBC-4.03 Hgb-11.3 Hct-34.2 MCV-85 MCH-28.0 MCHC-33.0 RDW-12.9 RDWSD-39.9 Plt [MASKED] [MASKED] 12:08AM BLOOD WBC-7.7 RBC-3.77* Hgb-10.5* Hct-31.7* MCV-84 MCH-27.9 MCHC-33.1 RDW-12.7 RDWSD-38.6 Plt [MASKED] [MASKED] 10:14AM BLOOD WBC-6.7 RBC-3.69* Hgb-10.3* Hct-31.0* MCV-84 MCH-27.9 MCHC-33.2 RDW-12.6 RDWSD-38.2 Plt [MASKED] [MASKED] 01:30AM BLOOD WBC-8.4 RBC-4.19 Hgb-11.6 Hct-35.6 MCV-85 MCH-27.7 MCHC-32.6 RDW-12.6 RDWSD-38.5 Plt [MASKED] [MASKED] 01:38AM BLOOD [MASKED] PTT-25.7 [MASKED] [MASKED] 09:15AM BLOOD Glucose-73 UreaN-3* Creat-0.4 Na-138 K-3.6 Cl-109* HCO3-18* AnGap-15 [MASKED] 12:08AM BLOOD Glucose-92 UreaN-5* Creat-0.4 Na-136 K-3.7 Cl-108 HCO3-15* AnGap-17 [MASKED] 03:25PM BLOOD Glucose-112* UreaN-5* Creat-0.4 Na-138 K-3.7 Cl-111* HCO3-15* AnGap-16 [MASKED] 10:14AM BLOOD Glucose-106* UreaN-6 Creat-0.4 Na-137 K-3.7 Cl-109* HCO3-16* AnGap-16 [MASKED] 05:23AM BLOOD Glucose-119* UreaN-6 Creat-0.4 Na-136 K-3.6 Cl-110* HCO3-15* AnGap-15 [MASKED] 01:30AM BLOOD Glucose-211* UreaN-7 Creat-0.5 Na-131* K-3.7 Cl-100 HCO3-15* AnGap-20 [MASKED] 01:30AM BLOOD ALT-12 AST-13 Amylase-16 [MASKED] 01:30AM BLOOD Lipase-28 [MASKED] 09:15AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.8 [MASKED] 12:08AM BLOOD Calcium-7.9* Phos-2.4* Mg-1.9 [MASKED] 03:25PM BLOOD Calcium-7.5* Phos-2.3* Mg-1.9 [MASKED] 10:14AM BLOOD Calcium-7.4* Phos-1.9* Mg-1.5* [MASKED] 05:23AM BLOOD Calcium-7.2* Phos-1.8* Mg-1.4* [MASKED] 01:30AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.7 UricAcd-5.6 [MASKED] 05:23AM BLOOD Acetone-NEGATIVE Osmolal-279 [MASKED] 01:30AM BLOOD Acetone-NEGATIVE Osmolal-284 [MASKED] 01:30AM BLOOD TSH-6.6* [MASKED] 01:30AM BLOOD Free T4-1.1 [MASKED] 05:23AM BLOOD RedHold-HOLD [MASKED] 06:40AM BLOOD Type-ART pO2-102 pCO2-26* pH-7.39 calTCO2-16* Base XS--7 [MASKED] 06:44AM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 03:01AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 08:44PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 06:44AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM [MASKED] 03:01AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [MASKED] 08:44PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 06:44AM URINE RBC-2 WBC-7* Bacteri-NONE Yeast-NONE Epi-10 [MASKED] 03:01AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-2 [MASKED] 08:44PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-1 [MASKED] 06:44AM URINE CastHy-2* [MASKED] 03:01AM URINE CastHy-1* [MASKED] 03:01AM URINE Hours-RANDOM Creat-115 TotProt-46 Prot/Cr-0.4* [MASKED] 03:01AM URINE Osmolal-1042 [MASKED] 3:01 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION Brief Hospital Course: On [MASKED], Ms. [MASKED] G1P0 at 34wks, was admitted to the anteapartum service with concern for diabetic ketoacidosis in the setting of T1DM with insulin pump. Workup was negative for infectious process and presentation likely secondary to pump failure. She was initiated on an insulin drip and received IVF hydration with subsequent normalization of blood glucose and resolution of anion gap. Her diet was advanced and she was transitioned to her insulin pump. She continued to have fasting blood sugars at goal. On HD#2, her insulin pump fell out and she again received insulin drip until her pump was replaced and she was able to be transitioned. By hospital day 3, she was on her insulin pump regularly with controlled blood glucose levels. She was then discharged in stable condition with appropriate pump settings. Of note, she had an ultrasound on [MASKED] with BPP [MASKED] and AFI within normal limits. Medications on Admission: Humalog pump, PNV, ASA 81mg daily Discharge Medications: 1. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0200: 1.05 Units/Hr 0200 - 0600: 1.3 Units/Hr 0600 - 1200: 2.4 Units/Hr 1200 - 1500: 2 Units/Hr 1500 - 1800: 1.9 Units/Hr 1800 - 2100: 2.4 Units/Hr [MASKED] - 0000: 1.65 Units/Hr Meal Bolus Rates: Breakfast = 1:2 Lunch = 1:4 Dinner = 1:2 Snacks = 1:2 High Bolus: Correction Factor = 1:12 Correct To [MASKED] mg/dL MD acknowledges patient competent MD has ordered [MASKED] consult 2. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: DKA T1DM 34 weeks gestational age Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for DKA and management of your T1DM. Your diabetes control was improved and you are now safe to be discharged home. Followup Instructions: [MASKED]
[]
[ "E669", "Y929" ]
[ "T85614A: Breakdown (mechanical) of insulin pump, initial encounter", "E1010: Type 1 diabetes mellitus with ketoacidosis without coma", "O24013: Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester", "T85624A: Displacement of insulin pump, initial encounter", "T383X6A: Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter", "Z3A34: 34 weeks gestation of pregnancy", "O99213: Obesity complicating pregnancy, third trimester", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "Y929: Unspecified place or not applicable" ]
10,030,852
22,871,136
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: poor diabetes control Major Surgical or Invasive Procedure: none History of Present Illness: ___ G1 with T1DM at 32w3d who presents for admission due to poorly controlled diabetes. Pt has been followed by her endocrinologist (Dr ___ but has been poorly controlled for most of the pregnancy. She is a poor historian, unable to give range of her ___ values. States "it depends on the day." She had a CGM which has been falling off her abdomen recently so she hasn't been using it. This morning her ___ was 182 when she woke up. She is not sure of her pump settings, but states she could look at her pump to see them. States her endocrinologist makes the changes for her. She was last seen by Dr ___ 1 week ago. Pt denies any fevers/chills, urinary symptoms, n/v/d. Denies contractions, LOF, or VB. Reports active FM. Past Medical History: PNC: *) ___ ___ by LMP c/w 7wk U/S *) Labs: A+/Ab-,RI,GC/CT-,RPRnr,HbsAg-,HIV-,GBS unk *) nl FFS, anterior placenta, nl sequential screen, per pt nl, fetal echo at 23 weeks at CHB *) s/p flu and Tdap ISSUES: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p lap appendectomy *) T1DM: (dx'd at ___ - s/p multiple admissions for DKA in past (most recent ___ - on Meditronic pump for ___ years - endocrinologist: Dr ___ - nl fetal echo (___) - nl baseline ___ labs, has not done 24hr urine yet - ___ 1911g(68%); AC 84% - HbA1C ~13% at conception per pt (according to PN records) - ___ 8% - ___ 1.78 - UTI in early pregnancy treated ObHx: G1 current GynHx: - LGSIL pap (___) -> for rpt in ___ year - vulvar condyloma, s/p TCA PMH: T1DM dx age ___, on inulin pump ___ year SurgHx: lap appendectomy (___) Social History: ___ Family History: mother and father with T2DM Physical Exam: Admission PE VS: BP 126/70, 88, 18, afebrile. ___ 226 (has pump on now) Gen: appears comfortable, NAD Lungs: CTAB Heart: RRR Abd: soft, gravid, NT FHT: 140s, mod var, +accels, no decels Toco: no ctxs Discharge PE VSS Gen: appears comfortable, NAD Lungs: CTAB Heart: RRR Abd: soft, gravid, NT Pertinent Results: ___ 04:30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 04:30PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-3 ___ 04:30PM URINE AMORPH-RARE ___ 04:30PM URINE MUCOUS-RARE ___ 03:30PM GLUCOSE-196* UREA N-9 CREAT-0.4 SODIUM-133 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17 ___ 03:30PM estGFR-Using this ___ 03:30PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.7 ___ 03:30PM WBC-8.9 RBC-4.24 HGB-12.2 HCT-36.2 MCV-85 MCH-28.8 MCHC-33.7 RDW-12.5 RDWSD-38.5 ___ 03:30PM PLT COUNT-329 Brief Hospital Course: Ms. ___ was admitted on ___ for poorly controlled TIDM and glycemic control. She had no signs or symptoms of DKA on arrival, and had reassuring lab results. She was connected with ___, who followed her during her stay. Her pump settings were adjusted and she received pump teaching. She also had an eye exam done in the ophthalmology clinic on ___ with no signs of diabetic retinopathy. A baseline 24hr urine was done and was 231mg. She also obtained a formal ultrasound that demonstrated mild polyhydramnios with MVP 8.6, EFW 2181g(84%), AC 84%. She was recommended for twice weekly testing based on her polyhydramnios and T1DM. Her glycemic control improved and she was discharged in stable condition on ___ with adjusted pump settings. Medications on Admission: Insulin pump, PNV, ASA Discharge Medications: 1. Mastisol Adhesive (gum mastic-storax-msal-alcohol) 1 package to skin prn RX *gum mastic-storax-msal-alcohol apply to skin as needed Disp #*3 Bottle Refills:*5 2. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0200: .85 Units/Hr 0200 - 0600: 1.1 Units/Hr 0600 - 0900: 2.4 Units/Hr 0900 - 1200: 2.4 Units/Hr 1200 - 1500: 1.8 Units/Hr 1500 - 1800: 1.7 Units/Hr 1800 - 2100: 2 Units/Hr ___ - 0000: 1.5 Units/Hr Meal Bolus Rates: Breakfast = 1:2 Lunch = 1:4 Dinner = 1:2 High Bolus: Correction Factor = 1:12 Correct To ___ mg/dL 3. Aspirin 81 mg PO DAILY 4. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: pregnancy at 32 weeks gestation poorly controlled T1DM Discharge Condition: stable Discharge Instructions: You were admitted to the antepartum floor for management of your diabetes. The endocrinologists from ___ met with you and made changes in your insulin regimen. Your fingersticks improved significantly and it was felt it was safe for you to be discharged. Fetal testing was reassuring while you were here. You had an eye exam which revealed no evidence of retinopathy. Followup Instructions: ___
[ "O24013", "E1065", "O99213", "O403XX0", "Z3A32", "Z794", "Z9641", "Z6836" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: poor diabetes control Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] G1 with T1DM at 32w3d who presents for admission due to poorly controlled diabetes. Pt has been followed by her endocrinologist (Dr [MASKED] but has been poorly controlled for most of the pregnancy. She is a poor historian, unable to give range of her [MASKED] values. States "it depends on the day." She had a CGM which has been falling off her abdomen recently so she hasn't been using it. This morning her [MASKED] was 182 when she woke up. She is not sure of her pump settings, but states she could look at her pump to see them. States her endocrinologist makes the changes for her. She was last seen by Dr [MASKED] 1 week ago. Pt denies any fevers/chills, urinary symptoms, n/v/d. Denies contractions, LOF, or VB. Reports active FM. Past Medical History: PNC: *) [MASKED] [MASKED] by LMP c/w 7wk U/S *) Labs: A+/Ab-,RI,GC/CT-,RPRnr,HbsAg-,HIV-,GBS unk *) nl FFS, anterior placenta, nl sequential screen, per pt nl, fetal echo at 23 weeks at CHB *) s/p flu and Tdap ISSUES: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p lap appendectomy *) T1DM: (dx'd at [MASKED] - s/p multiple admissions for DKA in past (most recent [MASKED] - on Meditronic pump for [MASKED] years - endocrinologist: Dr [MASKED] - nl fetal echo ([MASKED]) - nl baseline [MASKED] labs, has not done 24hr urine yet - [MASKED] 1911g(68%); AC 84% - HbA1C ~13% at conception per pt (according to PN records) - [MASKED] 8% - [MASKED] 1.78 - UTI in early pregnancy treated ObHx: G1 current GynHx: - LGSIL pap ([MASKED]) -> for rpt in [MASKED] year - vulvar condyloma, s/p TCA PMH: T1DM dx age [MASKED], on inulin pump [MASKED] year SurgHx: lap appendectomy ([MASKED]) Social History: [MASKED] Family History: mother and father with T2DM Physical Exam: Admission PE VS: BP 126/70, 88, 18, afebrile. [MASKED] 226 (has pump on now) Gen: appears comfortable, NAD Lungs: CTAB Heart: RRR Abd: soft, gravid, NT FHT: 140s, mod var, +accels, no decels Toco: no ctxs Discharge PE VSS Gen: appears comfortable, NAD Lungs: CTAB Heart: RRR Abd: soft, gravid, NT Pertinent Results: [MASKED] 04:30PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 04:30PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-3 [MASKED] 04:30PM URINE AMORPH-RARE [MASKED] 04:30PM URINE MUCOUS-RARE [MASKED] 03:30PM GLUCOSE-196* UREA N-9 CREAT-0.4 SODIUM-133 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17 [MASKED] 03:30PM estGFR-Using this [MASKED] 03:30PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.7 [MASKED] 03:30PM WBC-8.9 RBC-4.24 HGB-12.2 HCT-36.2 MCV-85 MCH-28.8 MCHC-33.7 RDW-12.5 RDWSD-38.5 [MASKED] 03:30PM PLT COUNT-329 Brief Hospital Course: Ms. [MASKED] was admitted on [MASKED] for poorly controlled TIDM and glycemic control. She had no signs or symptoms of DKA on arrival, and had reassuring lab results. She was connected with [MASKED], who followed her during her stay. Her pump settings were adjusted and she received pump teaching. She also had an eye exam done in the ophthalmology clinic on [MASKED] with no signs of diabetic retinopathy. A baseline 24hr urine was done and was 231mg. She also obtained a formal ultrasound that demonstrated mild polyhydramnios with MVP 8.6, EFW 2181g(84%), AC 84%. She was recommended for twice weekly testing based on her polyhydramnios and T1DM. Her glycemic control improved and she was discharged in stable condition on [MASKED] with adjusted pump settings. Medications on Admission: Insulin pump, PNV, ASA Discharge Medications: 1. Mastisol Adhesive (gum mastic-storax-msal-alcohol) 1 package to skin prn RX *gum mastic-storax-msal-alcohol apply to skin as needed Disp #*3 Bottle Refills:*5 2. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0200: .85 Units/Hr 0200 - 0600: 1.1 Units/Hr 0600 - 0900: 2.4 Units/Hr 0900 - 1200: 2.4 Units/Hr 1200 - 1500: 1.8 Units/Hr 1500 - 1800: 1.7 Units/Hr 1800 - 2100: 2 Units/Hr [MASKED] - 0000: 1.5 Units/Hr Meal Bolus Rates: Breakfast = 1:2 Lunch = 1:4 Dinner = 1:2 High Bolus: Correction Factor = 1:12 Correct To [MASKED] mg/dL 3. Aspirin 81 mg PO DAILY 4. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: pregnancy at 32 weeks gestation poorly controlled T1DM Discharge Condition: stable Discharge Instructions: You were admitted to the antepartum floor for management of your diabetes. The endocrinologists from [MASKED] met with you and made changes in your insulin regimen. Your fingersticks improved significantly and it was felt it was safe for you to be discharged. Fetal testing was reassuring while you were here. You had an eye exam which revealed no evidence of retinopathy. Followup Instructions: [MASKED]
[]
[ "Z794" ]
[ "O24013: Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester", "E1065: Type 1 diabetes mellitus with hyperglycemia", "O99213: Obesity complicating pregnancy, third trimester", "O403XX0: Polyhydramnios, third trimester, not applicable or unspecified", "Z3A32: 32 weeks gestation of pregnancy", "Z794: Long term (current) use of insulin", "Z9641: Presence of insulin pump (external) (internal)", "Z6836: Body mass index [BMI] 36.0-36.9, adult" ]
10,030,852
27,541,847
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: Elevated BPs Major Surgical or Invasive Procedure: Vacuum-assisted vaginal delivery History of Present Illness: ___ G1P0 at 36w3d with poorly controlled ___ transferred from ___ with elevated BPs. She had BPs 172/101 and 164/80 at ___ followed by mild range BPs and did not receive IV antihypertensive medications. She had PIH labs that were wnl except for urine P:C of 0.47. Her FSG were well controlled there. She was given magnesium 6g bolus and transferred to ___. Late preterm betamethasone was deferred given h/o poorly controlled T1DM. On admission, she reports feeling well other than cold symptoms that she has had for a few days. She reports a moderate HA and has not taken Tylenol. Denies vision changes or epig pain. Denies ctx, VB, LOF, reports AFM. Denies nausea, vomiting, abdominal pain. Of note, she was admitted to ___ twice during this pregnancy for poorly controlled diabetes and concern for DKA. She reports her pump has been working well recently. ROS: Denies fevers/chills. Denies vision changes. Denies chest pain/shortness of breath/palpitations. Denies abdominal pain. Denies recent falls or abdominal trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. PNC: - ___ ___ by LMP c/w 7wk U/S - Labs: A+/Ab-,RI,GC/CT-,RPRNR,HbsAg-,HIV-,GBS pnd (collected ___ - Screening: low risk sequential screen - FFS: wnl, anterior placenta - Vaccines: s/p flu and Tdap - Ultrasound ___ (at ___: 2181g, 59%, mildly increased AFI, MVP 8.6cm - Ultrasound ___ (at ___: 2777gm, 74%, AFI 16.9, BPP ___ - Issues: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p LSC appendectomy *) UTI in early pregnancy, treated *) ? Polyhydramnios: MVP 8.6cm on ___, but normal AFI 16.9 on ___ *) T1DM: - diagnosed at ___ - s/p multiple admissions for DKA in past (most recent ___ pre-pregnancy, ___ in pregnancy) - on Meditronic pump for ___ years - endocrinologist: Dr ___ - nl fetal echo (___) - nl baseline ___ labs, 24hr urine 231mg (___) - s/p optho c/s ___, no e/o diabetic retinopathy - HbA1C ~13% at conception per pt (according to ___ records) - ___ 8% - ___ 1.78 *) ___ ante admission ___ and ___: ___ consult, insulin pump adjusted, s/p pump teaching. s/p optho consult, no e/o diabetic retinopathy. s/p nutrition consult. Past Medical History: OBHx: G1 current GynHx: - LGSIL pap (___) -> for rpt in ___ year - vulvar condyloma, s/p TCA PMHx: - T1DM dx age ___, on inulin pump ___ year - Obesity PSHx: lsc appendectomy (___) Meds: Humalog pump, PNV, ASA 81mg daily Social History: ___ Family History: mother and father with T2DM Physical Exam: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema Pertinent Results: ___ 10:23PM BLOOD WBC-9.0 RBC-3.50* Hgb-9.5* Hct-28.7* MCV-82 MCH-27.1 MCHC-33.1 RDW-12.7 RDWSD-38.1 Plt ___ ___ 07:57PM BLOOD WBC-8.1 RBC-3.53* Hgb-9.2* Hct-29.1* MCV-82 MCH-26.1 MCHC-31.6* RDW-12.7 RDWSD-38.4 Plt ___ ___ 10:15AM BLOOD WBC-8.5 RBC-3.67* Hgb-9.9* Hct-30.1* MCV-82 MCH-27.0 MCHC-32.9 RDW-12.6 RDWSD-38.0 Plt ___ ___ 01:55AM BLOOD WBC-7.9 RBC-3.50* Hgb-9.3* Hct-28.6* MCV-82 MCH-26.6 MCHC-32.5 RDW-12.7 RDWSD-38.3 Plt ___ ___ 06:49PM BLOOD WBC-7.0 RBC-3.54* Hgb-9.6* Hct-29.2* MCV-83 MCH-27.1 MCHC-32.9 RDW-12.6 RDWSD-38.5 Plt ___ ___ 12:18PM BLOOD WBC-7.4 RBC-3.71* Hgb-10.0* Hct-30.5* MCV-82 MCH-27.0 MCHC-32.8 RDW-12.6 RDWSD-37.7 Plt ___ ___ 04:15AM BLOOD WBC-7.3 RBC-3.57* Hgb-9.7* Hct-29.5* MCV-83 MCH-27.2 MCHC-32.9 RDW-12.4 RDWSD-38.0 Plt ___ ___ 09:00PM BLOOD WBC-8.2 RBC-3.75* Hgb-10.1* Hct-31.1* MCV-83 MCH-26.9 MCHC-32.5 RDW-12.5 RDWSD-38.4 Plt ___ ___ 10:23PM BLOOD Creat-0.6 ___ 07:57PM BLOOD Creat-0.5 ___ 10:15AM BLOOD Creat-0.5 ___ 01:55AM BLOOD Creat-0.5 ___ 06:49PM BLOOD Creat-0.5 ___ 12:18PM BLOOD Creat-0.5 ___ 04:15AM BLOOD Glucose-111* UreaN-6 Creat-0.5 Na-133 K-3.7 Cl-101 HCO3-18* AnGap-18 ___ 09:00PM BLOOD Glucose-148* UreaN-7 Creat-0.5 Na-132* K-6.1* Cl-103 HCO3-16* AnGap-19 ___ 10:23PM BLOOD ALT-7 AST-13 ___ 07:57PM BLOOD ALT-7 AST-13 ___ 10:15AM BLOOD ALT-8 AST-15 ___ 01:55AM BLOOD ALT-8 AST-13 ___ 06:49PM BLOOD ALT-8 AST-13 ___ 12:18PM BLOOD ALT-8 AST-15 ___ 04:15AM BLOOD ALT-8 AST-13 ___ 09:00PM BLOOD ALT-11 AST-43* ___ 10:23PM BLOOD UricAcd-6.6* ___ 10:15AM BLOOD UricAcd-5.5 ___ 01:55AM BLOOD UricAcd-5.3 ___ 12:18PM BLOOD Mg-4.9* UricAcd-4.7 ___ 04:15AM BLOOD Mg-4.3* UricAcd-4.2 ___ 09:00PM BLOOD Calcium-8.1* Phos-4.2 Mg-3.5* UricAcd-3.9 ___ 10:04AM BLOOD Type-ART pO2-23* pCO2-53* pH-7.27* calTCO2-25 Base XS--3 Comment-CORD ___ ___ 10:02AM BLOOD ___ pO2-80* pCO2-39 pH-7.32* calTCO2-21 Base XS--5 Comment-CORD VEIN Brief Hospital Course: On ___, Ms. ___ was transferred from ___ at 36w3d with elevated BPs to the 170s/100s and P:C of 0.47. She was given a 6g Magnesium bolus at ___. Late preterm betamethasone was deferred given history of poorly controlled T1DM. Upon arrival, she was continued on magnesium infusion and reported a ___ HA treated with tylenol. For her T1DM, ___ was consulted and recommended transition from humalog pump to insulin gtt. Pt was then counseled and started on induction of labor for pre-eclampsia with severe features by blood pressure. *) Pre-eclampsia, severe by BPs Pt was continued on magnesium infusion. Her BPs ranged from normotensive to intermittently in the severe range. She was given an additional 2g bolus of Mag when Mag level returned subtherapeutic. PEC labs were trended q8 hours. She was continued on labetalol 200mg BID and uptitrated to TID. She was also kept on subcutaneous heparin for VTE prophylaxis. Her headache was treated with tylenol and compazine. During the second stage of labor, she was noted to have hematuria with adequate urine volume likely due to obstruction from fetal head. Cr was normal at 0.6. She was continued on magnesium for 24 hours postpartum and did not require continuation of labetalol in the postpartum period for BP control. *) T1DM Pt's insulin gtt and D10 were titrated per protocol during the intrapartum period. During the postpartum period, pt was transitioned from gtt to pump once taking PO. Pt was followed by ___ throughout her hospital course. *) Induction of labor She received 6 doses of PV cytotec and started on pitocin which was uptitrated per protocol. She then had a foley bulb placed and declined a second placement. Pitocin was uptitrated to 20units per protocol and maintained from ___ at 1100 to ___ at 0430. Pitocin was turned off then restarted on ___ at 0600. She was then AROM'ed at 1315. On ___ at 0030, pt was fully dilated at +1 station. She labored down for an hour, after which she pushed for 20 minutes with good effort. She then labored down again for one hour, after which she resumed pushing with variable intensity. After prolonged second stage and maternal exhaustion, pt was counseled on and underwent a vacuum assisted delivery at 0937 of a viable baby girl, complicated by shoulder dystocia x 2 minutes that resolved with McRobert's maneuver, suprapubic pressure, ___ maneuver. *) Bilateral groin pain - pt complained of bilateral groin pain in the postpartum period, likely musculoskeletal in origin due to prolonged labor course. She was seen and evaluated by physical therapy after pain was adequately controlled. She was able to ambulate without assistance upon discharge. By postpartum day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled. Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 2. Ibuprofen 600 mg PO Q6H:PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*1 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Moderate to Severe Pain RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 4. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0600: .7 Units/Hr 0600 - 0000: .8 Units/Hr Meal Bolus Rates: Breakfast = 1:8 Lunch = 1:8 Dinner = 1:8 High Bolus: Correction Factor = 1:30 Correct To ___ mg/dL Discharge Disposition: Home Discharge Diagnosis: 36 week gestation, type 1 diabetes, preeclampsia with severe features, prolonged second stage, shoulder dystocia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns. Followup Instructions: ___
[ "O1414", "O2402", "Z6841", "E1065", "O631", "O99214", "O660", "O7581", "O701", "O691XX0", "Z370", "Z9641", "Z794", "Z3A37" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Elevated BPs Major Surgical or Invasive Procedure: Vacuum-assisted vaginal delivery History of Present Illness: [MASKED] G1P0 at 36w3d with poorly controlled [MASKED] transferred from [MASKED] with elevated BPs. She had BPs 172/101 and 164/80 at [MASKED] followed by mild range BPs and did not receive IV antihypertensive medications. She had PIH labs that were wnl except for urine P:C of 0.47. Her FSG were well controlled there. She was given magnesium 6g bolus and transferred to [MASKED]. Late preterm betamethasone was deferred given h/o poorly controlled T1DM. On admission, she reports feeling well other than cold symptoms that she has had for a few days. She reports a moderate HA and has not taken Tylenol. Denies vision changes or epig pain. Denies ctx, VB, LOF, reports AFM. Denies nausea, vomiting, abdominal pain. Of note, she was admitted to [MASKED] twice during this pregnancy for poorly controlled diabetes and concern for DKA. She reports her pump has been working well recently. ROS: Denies fevers/chills. Denies vision changes. Denies chest pain/shortness of breath/palpitations. Denies abdominal pain. Denies recent falls or abdominal trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. PNC: - [MASKED] [MASKED] by LMP c/w 7wk U/S - Labs: A+/Ab-,RI,GC/CT-,RPRNR,HbsAg-,HIV-,GBS pnd (collected [MASKED] - Screening: low risk sequential screen - FFS: wnl, anterior placenta - Vaccines: s/p flu and Tdap - Ultrasound [MASKED] (at [MASKED]: 2181g, 59%, mildly increased AFI, MVP 8.6cm - Ultrasound [MASKED] (at [MASKED]: 2777gm, 74%, AFI 16.9, BPP [MASKED] - Issues: *) obesity, current weight 260# *) acute appendicitis at 16wks, s/p LSC appendectomy *) UTI in early pregnancy, treated *) ? Polyhydramnios: MVP 8.6cm on [MASKED], but normal AFI 16.9 on [MASKED] *) T1DM: - diagnosed at [MASKED] - s/p multiple admissions for DKA in past (most recent [MASKED] pre-pregnancy, [MASKED] in pregnancy) - on Meditronic pump for [MASKED] years - endocrinologist: Dr [MASKED] - nl fetal echo ([MASKED]) - nl baseline [MASKED] labs, 24hr urine 231mg ([MASKED]) - s/p optho c/s [MASKED], no e/o diabetic retinopathy - HbA1C ~13% at conception per pt (according to [MASKED] records) - [MASKED] 8% - [MASKED] 1.78 *) [MASKED] ante admission [MASKED] and [MASKED]: [MASKED] consult, insulin pump adjusted, s/p pump teaching. s/p optho consult, no e/o diabetic retinopathy. s/p nutrition consult. Past Medical History: OBHx: G1 current GynHx: - LGSIL pap ([MASKED]) -> for rpt in [MASKED] year - vulvar condyloma, s/p TCA PMHx: - T1DM dx age [MASKED], on inulin pump [MASKED] year - Obesity PSHx: lsc appendectomy ([MASKED]) Meds: Humalog pump, PNV, ASA 81mg daily Social History: [MASKED] Family History: mother and father with T2DM Physical Exam: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema Pertinent Results: [MASKED] 10:23PM BLOOD WBC-9.0 RBC-3.50* Hgb-9.5* Hct-28.7* MCV-82 MCH-27.1 MCHC-33.1 RDW-12.7 RDWSD-38.1 Plt [MASKED] [MASKED] 07:57PM BLOOD WBC-8.1 RBC-3.53* Hgb-9.2* Hct-29.1* MCV-82 MCH-26.1 MCHC-31.6* RDW-12.7 RDWSD-38.4 Plt [MASKED] [MASKED] 10:15AM BLOOD WBC-8.5 RBC-3.67* Hgb-9.9* Hct-30.1* MCV-82 MCH-27.0 MCHC-32.9 RDW-12.6 RDWSD-38.0 Plt [MASKED] [MASKED] 01:55AM BLOOD WBC-7.9 RBC-3.50* Hgb-9.3* Hct-28.6* MCV-82 MCH-26.6 MCHC-32.5 RDW-12.7 RDWSD-38.3 Plt [MASKED] [MASKED] 06:49PM BLOOD WBC-7.0 RBC-3.54* Hgb-9.6* Hct-29.2* MCV-83 MCH-27.1 MCHC-32.9 RDW-12.6 RDWSD-38.5 Plt [MASKED] [MASKED] 12:18PM BLOOD WBC-7.4 RBC-3.71* Hgb-10.0* Hct-30.5* MCV-82 MCH-27.0 MCHC-32.8 RDW-12.6 RDWSD-37.7 Plt [MASKED] [MASKED] 04:15AM BLOOD WBC-7.3 RBC-3.57* Hgb-9.7* Hct-29.5* MCV-83 MCH-27.2 MCHC-32.9 RDW-12.4 RDWSD-38.0 Plt [MASKED] [MASKED] 09:00PM BLOOD WBC-8.2 RBC-3.75* Hgb-10.1* Hct-31.1* MCV-83 MCH-26.9 MCHC-32.5 RDW-12.5 RDWSD-38.4 Plt [MASKED] [MASKED] 10:23PM BLOOD Creat-0.6 [MASKED] 07:57PM BLOOD Creat-0.5 [MASKED] 10:15AM BLOOD Creat-0.5 [MASKED] 01:55AM BLOOD Creat-0.5 [MASKED] 06:49PM BLOOD Creat-0.5 [MASKED] 12:18PM BLOOD Creat-0.5 [MASKED] 04:15AM BLOOD Glucose-111* UreaN-6 Creat-0.5 Na-133 K-3.7 Cl-101 HCO3-18* AnGap-18 [MASKED] 09:00PM BLOOD Glucose-148* UreaN-7 Creat-0.5 Na-132* K-6.1* Cl-103 HCO3-16* AnGap-19 [MASKED] 10:23PM BLOOD ALT-7 AST-13 [MASKED] 07:57PM BLOOD ALT-7 AST-13 [MASKED] 10:15AM BLOOD ALT-8 AST-15 [MASKED] 01:55AM BLOOD ALT-8 AST-13 [MASKED] 06:49PM BLOOD ALT-8 AST-13 [MASKED] 12:18PM BLOOD ALT-8 AST-15 [MASKED] 04:15AM BLOOD ALT-8 AST-13 [MASKED] 09:00PM BLOOD ALT-11 AST-43* [MASKED] 10:23PM BLOOD UricAcd-6.6* [MASKED] 10:15AM BLOOD UricAcd-5.5 [MASKED] 01:55AM BLOOD UricAcd-5.3 [MASKED] 12:18PM BLOOD Mg-4.9* UricAcd-4.7 [MASKED] 04:15AM BLOOD Mg-4.3* UricAcd-4.2 [MASKED] 09:00PM BLOOD Calcium-8.1* Phos-4.2 Mg-3.5* UricAcd-3.9 [MASKED] 10:04AM BLOOD Type-ART pO2-23* pCO2-53* pH-7.27* calTCO2-25 Base XS--3 Comment-CORD [MASKED] [MASKED] 10:02AM BLOOD [MASKED] pO2-80* pCO2-39 pH-7.32* calTCO2-21 Base XS--5 Comment-CORD VEIN Brief Hospital Course: On [MASKED], Ms. [MASKED] was transferred from [MASKED] at 36w3d with elevated BPs to the 170s/100s and P:C of 0.47. She was given a 6g Magnesium bolus at [MASKED]. Late preterm betamethasone was deferred given history of poorly controlled T1DM. Upon arrival, she was continued on magnesium infusion and reported a [MASKED] HA treated with tylenol. For her T1DM, [MASKED] was consulted and recommended transition from humalog pump to insulin gtt. Pt was then counseled and started on induction of labor for pre-eclampsia with severe features by blood pressure. *) Pre-eclampsia, severe by BPs Pt was continued on magnesium infusion. Her BPs ranged from normotensive to intermittently in the severe range. She was given an additional 2g bolus of Mag when Mag level returned subtherapeutic. PEC labs were trended q8 hours. She was continued on labetalol 200mg BID and uptitrated to TID. She was also kept on subcutaneous heparin for VTE prophylaxis. Her headache was treated with tylenol and compazine. During the second stage of labor, she was noted to have hematuria with adequate urine volume likely due to obstruction from fetal head. Cr was normal at 0.6. She was continued on magnesium for 24 hours postpartum and did not require continuation of labetalol in the postpartum period for BP control. *) T1DM Pt's insulin gtt and D10 were titrated per protocol during the intrapartum period. During the postpartum period, pt was transitioned from gtt to pump once taking PO. Pt was followed by [MASKED] throughout her hospital course. *) Induction of labor She received 6 doses of PV cytotec and started on pitocin which was uptitrated per protocol. She then had a foley bulb placed and declined a second placement. Pitocin was uptitrated to 20units per protocol and maintained from [MASKED] at 1100 to [MASKED] at 0430. Pitocin was turned off then restarted on [MASKED] at 0600. She was then AROM'ed at 1315. On [MASKED] at 0030, pt was fully dilated at +1 station. She labored down for an hour, after which she pushed for 20 minutes with good effort. She then labored down again for one hour, after which she resumed pushing with variable intensity. After prolonged second stage and maternal exhaustion, pt was counseled on and underwent a vacuum assisted delivery at 0937 of a viable baby girl, complicated by shoulder dystocia x 2 minutes that resolved with McRobert's maneuver, suprapubic pressure, [MASKED] maneuver. *) Bilateral groin pain - pt complained of bilateral groin pain in the postpartum period, likely musculoskeletal in origin due to prolonged labor course. She was seen and evaluated by physical therapy after pain was adequately controlled. She was able to ambulate without assistance upon discharge. By postpartum day 4, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with postpartum outpatient follow-up scheduled. Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 2. Ibuprofen 600 mg PO Q6H:PRN Moderate Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*1 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Moderate to Severe Pain RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 4. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Basal Rates: Midnight - 0600: .7 Units/Hr 0600 - 0000: .8 Units/Hr Meal Bolus Rates: Breakfast = 1:8 Lunch = 1:8 Dinner = 1:8 High Bolus: Correction Factor = 1:30 Correct To [MASKED] mg/dL Discharge Disposition: Home Discharge Diagnosis: 36 week gestation, type 1 diabetes, preeclampsia with severe features, prolonged second stage, shoulder dystocia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Nothing in the vagina for 6 weeks (No sex, douching, tampons) Do not drive while taking Percocet Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at [MASKED] if you develop shortness of breath, dizziness, palpitations, fever of 101 or above, abdominal pain, heavy vaginal bleeding, nausea/vomiting, depression, or any other concerns. Followup Instructions: [MASKED]
[]
[ "Z794" ]
[ "O1414: Severe pre-eclampsia complicating childbirth", "O2402: Pre-existing type 1 diabetes mellitus, in childbirth", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E1065: Type 1 diabetes mellitus with hyperglycemia", "O631: Prolonged second stage (of labor)", "O99214: Obesity complicating childbirth", "O660: Obstructed labor due to shoulder dystocia", "O7581: Maternal exhaustion complicating labor and delivery", "O701: Second degree perineal laceration during delivery", "O691XX0: Labor and delivery complicated by cord around neck, with compression, not applicable or unspecified", "Z370: Single live birth", "Z9641: Presence of insulin pump (external) (internal)", "Z794: Long term (current) use of insulin", "Z3A37: 37 weeks gestation of pregnancy" ]
10,030,863
22,221,453
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Multihance Attending: ___. Chief Complaint: referred from clinic for hypertensive urgency Major Surgical or Invasive Procedure: None History of Present Illness: ___ woman with long-standing history of hypertension currently non-compliant with home medications, hyperparathyroidism, and depression presenting from clinic for blood pressure to 230/160s. Patient reports long history of treatment for hypertension but has not been compliant with her medications as they often make her feel fatigued. Notes intermittent mild headaches for which she will occasionally take amlodipine on a PRN basis. Further notes a few episodes of chest discomfort in past several weeks. Recent episode of nocturnal dyspnea which she attributes to sleep apnea. However, no current symptoms of headache, visual disturbance, chest pain, or dyspnea. Feeling well overall and eager to attend her own wedding on ___. In the ED, vital signs were 98.2 ___ 100% RA. Labs notable for negative troponin x1. EKG with evidence of LVH. T-wave inversions in precordial leads and aVL. UA 1 RBC. Received captopril 25 mg. Past Medical History: - HTN - CKD stage II - Migraines - Variant Arterial Anatomy - ? pancreatic divisum - Hyperparathyroidism ___ Vit D Deficiency ___ PTH: 100) - Depression Social History: ___ Family History: Notable for mother with pheochromocytoma in ___ s/p adrenal resection. Physical Exam: ADMISSION EXAM ========================== Vitals: Temp: 98.1 PO HR: 88 BP: 185/125 RR: 18 O2 sat: 96% O2 delivery: Ra General: Well appearing woman in no acute distress. Comfortable. AAOx3. HEENT: Normocephalic, atraumatic. EOMI. MMM. Cardiac: Regular rate & rhythm. Normal S1/S2. ___ holosystolic murmur over the left upper sternal border. Pulmonary: Clear to auscultation bilaterally. Breathing comfortably on room air. Abdomen: Soft, non-tender, non-distended. Extremities: Warm, well perfused, non-edematous. DISCHARGE EXAM ========================== Vitals: Temp: 98.1 PO HR: 88 BP: 185/125 RR: 18 O2 sat: 96% O2 delivery: Ra General: Well appearing woman in no acute distress. Comfortable. AAOx3. HEENT: Normocephalic, atraumatic. EOMI. MMM. Cardiac: Regular rate & rhythm. Normal S1/S2. ___ holosystolic murmur over the left upper sternal border. Pulmonary: Clear to auscultation bilaterally. Breathing comfortably on room air. Abdomen: Soft, non-tender, non-distended. Extremities: Warm, well perfused, non-edematous. Pertinent Results: LABS =================================== ___ 09:19AM BLOOD WBC-10.5* RBC-4.54# Hgb-13.1 Hct-39.3 MCV-87# MCH-28.9 MCHC-33.3 RDW-14.6 RDWSD-46.2 Plt ___ ___ 09:19AM BLOOD Neuts-76.7* Lymphs-16.5* Monos-5.5 Eos-0.4* Baso-0.4 Im ___ AbsNeut-8.09* AbsLymp-1.74 AbsMono-0.58 AbsEos-0.04 AbsBaso-0.04 ___ 09:19AM BLOOD Plt ___ ___ 09:19AM BLOOD Glucose-91 UreaN-13 Creat-1.0 Na-141 K-3.9 Cl-102 HCO3-20* AnGap-19* ___ 09:19AM BLOOD ALT-16 AST-16 AlkPhos-77 TotBili-0.4 ___ 09:19AM BLOOD cTropnT-<0.01 ___ 09:19AM BLOOD Albumin-4.7 Calcium-9.2 Phos-3.2 Mg-1.9 ___ 09:44AM URINE Color-Straw Appear-Clear Sp ___ ___ 09:44AM URINE Blood-MOD* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 09:44AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-2 ___ 09:44AM URINE Mucous-RARE* ___ 09:44AM URINE UCG-NEGATIVE MICRO =================================== UCx (___): pending Brief Hospital Course: ___ woman with long-standing history of severe primary hypertension non-compliant with medications was admitted for hypertensive urgency. Responded well to PO captopril. Transitioned to resume home chlorthalidone and amlodipine. Given strong patient preference and absence of end-organ damage was discharged same day with plan for close outpatient follow up. # HYPERTENSIVE URGENCY Referred to ED from clinic for incidentally noted BP 230/160s without associated symptoms. Although patient does have recent symptoms of intermittent mild chest pain and possible dyspnea, which are concerning for previously un-recognized hypertensive emergency, they are not actively occurring at time of presentation or during admission. No evidence of acute end-organ damage. Workup included EKG with LVH but no evidence of active ischemia, troponin negative. Of note patient has had extensive workup for secondary hypertension (including MRI to evaluate for renal artery stenosis, borderline urine metanephrines with normal serum, unremarkable head imaging, reassuring renin/angiotensin levels). The degree of current hypertension is due to medication non-adherence (previously on ___ meds, not taking any consistently now) and responded well to captopril. Given strong patient preference to leave hospital, and in the absence of symptoms or end-organ damage, it was reasonable for same day discharge with plan to resume her prior medications of amlodipine and chlorthalidone with close outpatient follow up. TRANSITIONAL ISSUES: ========================================= [ ] Re-started chlorthalidone 25mg daily [ ] Re-started amlodipine 10mg daily [ ] Patient was noted to have systolic murmur at left upper sternal border, II/VI. Please continue to monitor, consider echo if needed [ ] UA with 1 RBC - consider repeat as outpatient [ ] Consider referral to maternal-fetal medicine given very high risk pregnancy with current blood pressures Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. CloNIDine 0.1 mg PO BID 4. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. HELD- CloNIDine 0.1 mg PO BID This medication was held. Do not restart CloNIDine until you discuss with your PCP 4. HELD- Losartan Potassium 100 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you discuss with your PCP ___: Home Discharge Diagnosis: Primary: ============= Essential hypertension Secondary: ============= Delayed menses 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. Why you were admitted: ================================================== -- You had a very high blood pressure at urgent care earlier today and sent to the emergency department. There was concern given you had recently had chest discomfort, and this may be due to your blood pressure. What was done during your hospitalization: ================================================== -- You were given medications to help lower your blood pressure. You were monitored for a short time with improved blood pressures. -- You were asked to stay overnight to observe your blood pressures and make sure they came down to a normal level. However, you wanted to leave the hospital against our recommendation, and you were started on two medications to take for your blood pressure every day. What you should do after you leave the hospital: ================================================== -- Please take your blood pressure medications every day. This is important to help prevent strokes, heart attacks, heart dysfunction, and serious complications of the kidneys and eyes. -- Please limit the amount of salt in your diet. Do not add salt to foods. -- Please follow up with your primary care physician in the next week to have your blood pressure checked, and your medications adjusted as necessary. We wish you the best, Your ___ care team Followup Instructions: ___
[ "I160", "N910", "Z9114", "I129", "N182", "I517", "J45909", "E559", "E211", "F17200" ]
Allergies: Multihance Chief Complaint: referred from clinic for hypertensive urgency Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] woman with long-standing history of hypertension currently non-compliant with home medications, hyperparathyroidism, and depression presenting from clinic for blood pressure to 230/160s. Patient reports long history of treatment for hypertension but has not been compliant with her medications as they often make her feel fatigued. Notes intermittent mild headaches for which she will occasionally take amlodipine on a PRN basis. Further notes a few episodes of chest discomfort in past several weeks. Recent episode of nocturnal dyspnea which she attributes to sleep apnea. However, no current symptoms of headache, visual disturbance, chest pain, or dyspnea. Feeling well overall and eager to attend her own wedding on [MASKED]. In the ED, vital signs were 98.2 [MASKED] 100% RA. Labs notable for negative troponin x1. EKG with evidence of LVH. T-wave inversions in precordial leads and aVL. UA 1 RBC. Received captopril 25 mg. Past Medical History: - HTN - CKD stage II - Migraines - Variant Arterial Anatomy - ? pancreatic divisum - Hyperparathyroidism [MASKED] Vit D Deficiency [MASKED] PTH: 100) - Depression Social History: [MASKED] Family History: Notable for mother with pheochromocytoma in [MASKED] s/p adrenal resection. Physical Exam: ADMISSION EXAM ========================== Vitals: Temp: 98.1 PO HR: 88 BP: 185/125 RR: 18 O2 sat: 96% O2 delivery: Ra General: Well appearing woman in no acute distress. Comfortable. AAOx3. HEENT: Normocephalic, atraumatic. EOMI. MMM. Cardiac: Regular rate & rhythm. Normal S1/S2. [MASKED] holosystolic murmur over the left upper sternal border. Pulmonary: Clear to auscultation bilaterally. Breathing comfortably on room air. Abdomen: Soft, non-tender, non-distended. Extremities: Warm, well perfused, non-edematous. DISCHARGE EXAM ========================== Vitals: Temp: 98.1 PO HR: 88 BP: 185/125 RR: 18 O2 sat: 96% O2 delivery: Ra General: Well appearing woman in no acute distress. Comfortable. AAOx3. HEENT: Normocephalic, atraumatic. EOMI. MMM. Cardiac: Regular rate & rhythm. Normal S1/S2. [MASKED] holosystolic murmur over the left upper sternal border. Pulmonary: Clear to auscultation bilaterally. Breathing comfortably on room air. Abdomen: Soft, non-tender, non-distended. Extremities: Warm, well perfused, non-edematous. Pertinent Results: LABS =================================== [MASKED] 09:19AM BLOOD WBC-10.5* RBC-4.54# Hgb-13.1 Hct-39.3 MCV-87# MCH-28.9 MCHC-33.3 RDW-14.6 RDWSD-46.2 Plt [MASKED] [MASKED] 09:19AM BLOOD Neuts-76.7* Lymphs-16.5* Monos-5.5 Eos-0.4* Baso-0.4 Im [MASKED] AbsNeut-8.09* AbsLymp-1.74 AbsMono-0.58 AbsEos-0.04 AbsBaso-0.04 [MASKED] 09:19AM BLOOD Plt [MASKED] [MASKED] 09:19AM BLOOD Glucose-91 UreaN-13 Creat-1.0 Na-141 K-3.9 Cl-102 HCO3-20* AnGap-19* [MASKED] 09:19AM BLOOD ALT-16 AST-16 AlkPhos-77 TotBili-0.4 [MASKED] 09:19AM BLOOD cTropnT-<0.01 [MASKED] 09:19AM BLOOD Albumin-4.7 Calcium-9.2 Phos-3.2 Mg-1.9 [MASKED] 09:44AM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 09:44AM URINE Blood-MOD* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 09:44AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-2 [MASKED] 09:44AM URINE Mucous-RARE* [MASKED] 09:44AM URINE UCG-NEGATIVE MICRO =================================== UCx ([MASKED]): pending Brief Hospital Course: [MASKED] woman with long-standing history of severe primary hypertension non-compliant with medications was admitted for hypertensive urgency. Responded well to PO captopril. Transitioned to resume home chlorthalidone and amlodipine. Given strong patient preference and absence of end-organ damage was discharged same day with plan for close outpatient follow up. # HYPERTENSIVE URGENCY Referred to ED from clinic for incidentally noted BP 230/160s without associated symptoms. Although patient does have recent symptoms of intermittent mild chest pain and possible dyspnea, which are concerning for previously un-recognized hypertensive emergency, they are not actively occurring at time of presentation or during admission. No evidence of acute end-organ damage. Workup included EKG with LVH but no evidence of active ischemia, troponin negative. Of note patient has had extensive workup for secondary hypertension (including MRI to evaluate for renal artery stenosis, borderline urine metanephrines with normal serum, unremarkable head imaging, reassuring renin/angiotensin levels). The degree of current hypertension is due to medication non-adherence (previously on [MASKED] meds, not taking any consistently now) and responded well to captopril. Given strong patient preference to leave hospital, and in the absence of symptoms or end-organ damage, it was reasonable for same day discharge with plan to resume her prior medications of amlodipine and chlorthalidone with close outpatient follow up. TRANSITIONAL ISSUES: ========================================= [ ] Re-started chlorthalidone 25mg daily [ ] Re-started amlodipine 10mg daily [ ] Patient was noted to have systolic murmur at left upper sternal border, II/VI. Please continue to monitor, consider echo if needed [ ] UA with 1 RBC - consider repeat as outpatient [ ] Consider referral to maternal-fetal medicine given very high risk pregnancy with current blood pressures Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. CloNIDine 0.1 mg PO BID 4. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. HELD- CloNIDine 0.1 mg PO BID This medication was held. Do not restart CloNIDine until you discuss with your PCP 4. HELD- Losartan Potassium 100 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you discuss with your PCP [MASKED]: Home Discharge Diagnosis: Primary: ============= Essential hypertension Secondary: ============= Delayed menses 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. Why you were admitted: ================================================== -- You had a very high blood pressure at urgent care earlier today and sent to the emergency department. There was concern given you had recently had chest discomfort, and this may be due to your blood pressure. What was done during your hospitalization: ================================================== -- You were given medications to help lower your blood pressure. You were monitored for a short time with improved blood pressures. -- You were asked to stay overnight to observe your blood pressures and make sure they came down to a normal level. However, you wanted to leave the hospital against our recommendation, and you were started on two medications to take for your blood pressure every day. What you should do after you leave the hospital: ================================================== -- Please take your blood pressure medications every day. This is important to help prevent strokes, heart attacks, heart dysfunction, and serious complications of the kidneys and eyes. -- Please limit the amount of salt in your diet. Do not add salt to foods. -- Please follow up with your primary care physician in the next week to have your blood pressure checked, and your medications adjusted as necessary. We wish you the best, Your [MASKED] care team Followup Instructions: [MASKED]
[]
[ "I129", "J45909" ]
[ "I160: Hypertensive urgency", "N910: Primary amenorrhea", "Z9114: Patient's other noncompliance with medication regimen", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N182: Chronic kidney disease, stage 2 (mild)", "I517: Cardiomegaly", "J45909: Unspecified asthma, uncomplicated", "E559: Vitamin D deficiency, unspecified", "E211: Secondary hyperparathyroidism, not elsewhere classified", "F17200: Nicotine dependence, unspecified, uncomplicated" ]
10,030,937
29,265,770
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: Dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: ___ s/p pLTCS for arrest of dilation on ___ presents with two days of worsening shortness of breath. She describes onset of symptoms two nights ago, which she noticed as she was trying to lie down to go to bed and couldn't take a deep breath. Her SOB has gotten progressively worse over the last two days, making it difficult for her to walk more than a few feet without being symptomatic. She cannot lie flat. She is short of breath when trying to speak multiple sentences. This does not feel like her SOB associated with her asthma in the past. She has been using her inhaler excessively with no relief. She intermittently feels as if her heart is racing. Denies chest pain. Has intermittent abdominal cramping, however denies significant abdominal pain or incisional pain. Only taking Tylenol and motrin for pain; never needed oxycodone. Has had a BM. Voiding without issue; previously bloody urine has resolved. She did have a mild HA on presentation to the ED, which resolved with Tylenol. She is breastfeeding and the baby has been doing really well. Past Medical History: OBHx: ___ - s/p pLTCS on ___ for arrest of dilation at 8cm after prolonged augmentation of labor with Pitocin following SROM GYNHx: - previously normal menstrual cycles - denies hx of abnormal Pap testing (last Pap ___ - denies hx of STIs - denies hx of GYN surgeries or procedures, aside from recent primarly LTCS - has small posterior fibroid (2z2x2cm) PMHx: - migraine HA - asthma PSHx: - pLTCS Medications: albuterol inhaler All: NKDA Social History: ___ Family History: Denies hypertensive disease in her family, bleeding disorders or history of blood clots. Physical Exam: Physical Exam on Admission: 98.7 HR83 BP149/95 RR20 O2sat 100% RA 97.81 HR74 BP 148/100 RR16 O2sat 100% RA 98.1 HR86 BP151/89 RR22 O2sat 100% RA Gen: NAD CV: mild tachycardia, regular rhythm Pulm: mild increased work of breathing, tachypneaic at rest; mildly decreased breath sounds at bilateral bases, no wheezes appreciated, no crackles appreciated Abd: softly distended, appropriately mildly TTP, fundus firm, incision c/d/I, no drainage or bleeding GU: pad w/mild spotting Ext: WWP, no edema or tenderness appreciated of ___ _ ________________________________________________________________ Physical Exam on Discharge: 24 HR Data (last updated ___ @ 315) Temp: 99.7 (Tm 100.8), BP: 149/90 (127-152/79-99), HR: 87 (71-90), RR: 18, O2 sat: 95% (95-97), O2 delivery: Ra Fluid Balance (last updated ___ @ 2305) Last 8 hours No data found Last 24 hours Total cumulative -345ml IN: Total 840ml, PO Amt 840ml OUT: Total 1185ml, Urine Amt 1185ml General: Sitting up in bed in no acute distress, A&Ox3 Breasts: soft, non-tender, no erythema, soft, no focal areas of induration, fluctuance, or tenderness, nipples intact Lungs: Lungs clear to auscultation bilaterally, no wheezes or crackles Abd: soft, nontender, fundus firm below umbilicus Incision: clean, dry, intact, no erythema/induration, dressed in steri-strips stained with serosanguinous fluid Extremities: no calf tenderness, no edema Pertinent Results: ___ 11:12AM BLOOD WBC-7.9 RBC-3.55* Hgb-9.4* Hct-29.5* MCV-83 MCH-26.5 MCHC-31.9* RDW-14.4 RDWSD-42.9 Plt ___ ___ 12:20PM BLOOD Neuts-72.5* ___ Monos-4.8* Eos-0.8* Baso-0.3 NRBC-0.4* Im ___ AbsNeut-5.50 AbsLymp-1.52 AbsMono-0.36 AbsEos-0.06 AbsBaso-0.02 ___ 05:10AM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-141 K-3.9 Cl-106 HCO3-20* AnGap-15 ___ 11:12AM BLOOD ALT-59* AST-26 ___ 12:20PM BLOOD cTropnT-<0.01 ___ 12:20PM BLOOD cTropnT-<0.01 ___ 12:20PM BLOOD proBNP-631* ___ 02:22PM BLOOD pO2-22* pCO2-37 pH-7.40 calTCO2-24 Base XS--1 Comment-ABG ADDED CTA Chest (___): 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral multifocal nodular ground-glass opacities likely represents moderate pulmonary edema, in the setting of cardiomegaly and bilateral pleural effusions. CXR ___, prelim read): Right greater than left bilateral perihilar opacities are worrisome for asymmetric pulmonary edema, moderate to severe on the right and moderate on the left. Pulmonary hemorrhage not excluded. Trace right greater than left pleural effusions. EKG (___): Normal sinus rhythm ___ (___): No evidence of deep venous thrombosis in the right lower extremity veins. Transthoracic Echocardiogram (___): Normal global and regional biventricular systolic function. Mild mitral and tricuspid regurgitation. Mild pulmonary hypertension. Brief Hospital Course: Ms. ___ was readmitted to the Postpartum service after she presented to the Emergency Department with dyspnea on exertion. Thorough workup in the ED found mild pulmonary edema on chest x-ray, and was otherwise negative for acute cardiac or pulmonary etiology. For this, she was given one dose of IV furosemide which helped relieve her symptoms before readmission. On the Postpartum floor, she was comfortable on exam, though still with symptoms of dyspnea on exertion. She complained of a mild headache improved with ibuprofen and acetaminophen and eating, and was well overnight. Two times over the course of her admission, Ms. ___ had a fever, to 101.1 and 100.8, respectively. Thorough evaluation for fever etiology was negative, though Ms. ___ had been breast pumping and feeding intermittently since undergoing CT in the ED, making engorgement the most probable etiology. On night 2 of her admission, Ms. ___ received a second dose of IV furosemide for further improved symptoms, and the next day received a transthoracic echocardiogram without evidence of peripartum cardiomyopathy. By hospital day 3, she was symptomatically improved and continuing to meet all postpartum and self-care milestones, and was deemed safe for discharge with plan for follow up with peripartum cardiology. Medications on Admission: Albuterol inhaler Ibuprofen Acetaminophen Discharge Medications: 1. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth q 6 hours prn pain Disp #*40 Tablet Refills:*0 2. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Ferrous Sulfate 325 mg PO BID Discharge Disposition: Home Discharge Diagnosis: ___ s/p pLTCS ___ re-admitted with dyspnea on exertion, orthopnea, dx w GHTN (started labetolol) and seen by cardiology and cleared. Fever from engorgement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: see ob sheet Followup Instructions: ___
[ "O135", "O9953", "J811", "O9279", "J45909", "O9089", "R51", "R319", "O9081", "D649" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] s/p pLTCS for arrest of dilation on [MASKED] presents with two days of worsening shortness of breath. She describes onset of symptoms two nights ago, which she noticed as she was trying to lie down to go to bed and couldn't take a deep breath. Her SOB has gotten progressively worse over the last two days, making it difficult for her to walk more than a few feet without being symptomatic. She cannot lie flat. She is short of breath when trying to speak multiple sentences. This does not feel like her SOB associated with her asthma in the past. She has been using her inhaler excessively with no relief. She intermittently feels as if her heart is racing. Denies chest pain. Has intermittent abdominal cramping, however denies significant abdominal pain or incisional pain. Only taking Tylenol and motrin for pain; never needed oxycodone. Has had a BM. Voiding without issue; previously bloody urine has resolved. She did have a mild HA on presentation to the ED, which resolved with Tylenol. She is breastfeeding and the baby has been doing really well. Past Medical History: OBHx: [MASKED] - s/p pLTCS on [MASKED] for arrest of dilation at 8cm after prolonged augmentation of labor with Pitocin following SROM GYNHx: - previously normal menstrual cycles - denies hx of abnormal Pap testing (last Pap [MASKED] - denies hx of STIs - denies hx of GYN surgeries or procedures, aside from recent primarly LTCS - has small posterior fibroid (2z2x2cm) PMHx: - migraine HA - asthma PSHx: - pLTCS Medications: albuterol inhaler All: NKDA Social History: [MASKED] Family History: Denies hypertensive disease in her family, bleeding disorders or history of blood clots. Physical Exam: Physical Exam on Admission: 98.7 HR83 BP149/95 RR20 O2sat 100% RA 97.81 HR74 BP 148/100 RR16 O2sat 100% RA 98.1 HR86 BP151/89 RR22 O2sat 100% RA Gen: NAD CV: mild tachycardia, regular rhythm Pulm: mild increased work of breathing, tachypneaic at rest; mildly decreased breath sounds at bilateral bases, no wheezes appreciated, no crackles appreciated Abd: softly distended, appropriately mildly TTP, fundus firm, incision c/d/I, no drainage or bleeding GU: pad w/mild spotting Ext: WWP, no edema or tenderness appreciated of [MASKED] [MASKED] Physical Exam on Discharge: 24 HR Data (last updated [MASKED] @ 315) Temp: 99.7 (Tm 100.8), BP: 149/90 (127-152/79-99), HR: 87 (71-90), RR: 18, O2 sat: 95% (95-97), O2 delivery: Ra Fluid Balance (last updated [MASKED] @ 2305) Last 8 hours No data found Last 24 hours Total cumulative -345ml IN: Total 840ml, PO Amt 840ml OUT: Total 1185ml, Urine Amt 1185ml General: Sitting up in bed in no acute distress, A&Ox3 Breasts: soft, non-tender, no erythema, soft, no focal areas of induration, fluctuance, or tenderness, nipples intact Lungs: Lungs clear to auscultation bilaterally, no wheezes or crackles Abd: soft, nontender, fundus firm below umbilicus Incision: clean, dry, intact, no erythema/induration, dressed in steri-strips stained with serosanguinous fluid Extremities: no calf tenderness, no edema Pertinent Results: [MASKED] 11:12AM BLOOD WBC-7.9 RBC-3.55* Hgb-9.4* Hct-29.5* MCV-83 MCH-26.5 MCHC-31.9* RDW-14.4 RDWSD-42.9 Plt [MASKED] [MASKED] 12:20PM BLOOD Neuts-72.5* [MASKED] Monos-4.8* Eos-0.8* Baso-0.3 NRBC-0.4* Im [MASKED] AbsNeut-5.50 AbsLymp-1.52 AbsMono-0.36 AbsEos-0.06 AbsBaso-0.02 [MASKED] 05:10AM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-141 K-3.9 Cl-106 HCO3-20* AnGap-15 [MASKED] 11:12AM BLOOD ALT-59* AST-26 [MASKED] 12:20PM BLOOD cTropnT-<0.01 [MASKED] 12:20PM BLOOD cTropnT-<0.01 [MASKED] 12:20PM BLOOD proBNP-631* [MASKED] 02:22PM BLOOD pO2-22* pCO2-37 pH-7.40 calTCO2-24 Base XS--1 Comment-ABG ADDED CTA Chest ([MASKED]): 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral multifocal nodular ground-glass opacities likely represents moderate pulmonary edema, in the setting of cardiomegaly and bilateral pleural effusions. CXR [MASKED], prelim read): Right greater than left bilateral perihilar opacities are worrisome for asymmetric pulmonary edema, moderate to severe on the right and moderate on the left. Pulmonary hemorrhage not excluded. Trace right greater than left pleural effusions. EKG ([MASKED]): Normal sinus rhythm [MASKED] ([MASKED]): No evidence of deep venous thrombosis in the right lower extremity veins. Transthoracic Echocardiogram ([MASKED]): Normal global and regional biventricular systolic function. Mild mitral and tricuspid regurgitation. Mild pulmonary hypertension. Brief Hospital Course: Ms. [MASKED] was readmitted to the Postpartum service after she presented to the Emergency Department with dyspnea on exertion. Thorough workup in the ED found mild pulmonary edema on chest x-ray, and was otherwise negative for acute cardiac or pulmonary etiology. For this, she was given one dose of IV furosemide which helped relieve her symptoms before readmission. On the Postpartum floor, she was comfortable on exam, though still with symptoms of dyspnea on exertion. She complained of a mild headache improved with ibuprofen and acetaminophen and eating, and was well overnight. Two times over the course of her admission, Ms. [MASKED] had a fever, to 101.1 and 100.8, respectively. Thorough evaluation for fever etiology was negative, though Ms. [MASKED] had been breast pumping and feeding intermittently since undergoing CT in the ED, making engorgement the most probable etiology. On night 2 of her admission, Ms. [MASKED] received a second dose of IV furosemide for further improved symptoms, and the next day received a transthoracic echocardiogram without evidence of peripartum cardiomyopathy. By hospital day 3, she was symptomatically improved and continuing to meet all postpartum and self-care milestones, and was deemed safe for discharge with plan for follow up with peripartum cardiology. Medications on Admission: Albuterol inhaler Ibuprofen Acetaminophen Discharge Medications: 1. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth q 6 hours prn pain Disp #*40 Tablet Refills:*0 2. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Ferrous Sulfate 325 mg PO BID Discharge Disposition: Home Discharge Diagnosis: [MASKED] s/p pLTCS [MASKED] re-admitted with dyspnea on exertion, orthopnea, dx w GHTN (started labetolol) and seen by cardiology and cleared. Fever from engorgement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: see ob sheet Followup Instructions: [MASKED]
[]
[ "J45909", "D649" ]
[ "O135: Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating the puerperium", "O9953: Diseases of the respiratory system complicating the puerperium", "J811: Chronic pulmonary edema", "O9279: Other disorders of lactation", "J45909: Unspecified asthma, uncomplicated", "O9089: Other complications of the puerperium, not elsewhere classified", "R51: Headache", "R319: Hematuria, unspecified", "O9081: Anemia of the puerperium", "D649: Anemia, unspecified" ]
10,031,308
20,329,709
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "I am scared of something" Major Surgical or Invasive Procedure: none History of Present Illness: For further details of the history and presentation, please see OMR, including Dr. ___ initial consultation note dated ___ and Dr. ___ staff consultation note dated ___. . Briefly, this is a ___ year old, single, employed ___ refugee man, with reported history of extensive trauma (tortured during imprisonment in ___ for 59 days), daily cannabis use, no formal psychiatric history or suicide attempts, who presented to ___ ED via EMS due to paranoia. . Upon initial interview, patient reported was here because he felt scared and believes the FBI and CIA were after him, although he had no idea why they would be after him. Patient reported that he was born in ___ and moved with his family to ___ when he was young. Stated that since ___ (at the age of ___) he became involved in politics and protested against the ___ government resulting in him being shunned by his community and family. In ___ he was arrested and has been arrested for a total of 4 times. Patient was given refugee status in ___ by an international organization and came to the ___ in ___. When he arrived to the ___, he was questioned by the FBI and has been questioned by the FBI numerous time, with last time being 6 months ago. Patient reportedly received his green card 2 days prior to presentation. . Mr. ___ reported he had been doing well until four months ago after listening to ___ album, 444, which resonated with him. Since then he has been suffering from insomnia, constant flashbacks. He reports that everything starts with a 4 in his life (he was in jail 4 times, this started 4 months ago and he tried to graduate high school 4 times). Patient also reported difficulty with memory, difficulty concentrating and visual hallucinations of "future war." Denied AH, SI/HI. Denied low mood, feelings of hopelessness/helplessness/worthlessness. Patient also reported that on the day prior to presentation he and his friend, who is an ___ refugee, took an impulsive trip to ___ to celebrate the patient getting his green card. This morning, the friend asked him to join him to come to an appointment. The friend was very vague about the purpose of the appointment and patient was asked to wait in the car or cafeteria. Patient saw the meeting and noted that there was FBI paperwork and determined that his friend was sharing information with the FBI about their trip to ___ yesterday as part of an investigation on the patient. He also reports that he saw lots of cash in the friend's car which was "scary". He reports that he does not trust this friend and does not want this writer to call him. . On interview with Dr. ___, patient was noted to be a limited historian and was notably ruminative about feeling suspicious and paranoid about others, describing a "felt energy" which no one else can feel. Reported he was feeling others were colluding with the FBI and CIA to come after him and then told a loose, rambling narrative about "feeling music that I have never felt before," and experiencing an expansive mood. Noted to be restless on examination with expansive affect, with accelerated thought process, tangential on examination with looseness of associations. . Per collateral obtained from the patient's case manager at ___ ___, who had known him for years but was no longer working with him: She reported the patient is high functioning at baseline and has been working for the organization ___ and attending events. He was originally taken out of prison in ___ by ___ and ___ International who gave him 48 hours to pack his things and move to ___. He later came to ___ as a political refugee in ___ and was questioned by the FBI upon entrance and they continued to question him for a while. He was eligible for a green card in ___ but he didn't get it until two days ago. He was at the survivors of torture program at ___ but stopped going and stopping taking his medications (unclear dx and medications). This year he has been intermittently "self-medicating" by binge-drinking and then going on "health sprees" by doing cleanses and going to the gym obsessively. ___ called ___ today stating that he needed the president's phone number and was extremely perseverative. He was under the belief that his friend, who is an ___ refugee is working for the FBI. He has been getting increasingly paranoid for the past several months. He has been fixated on rap music and its meaning. . On the phone today, patient mentioned being scared and having thoughts of wanting to return to ___ to get away from the FBI. ___ is concerned that patient has the ability and means to do this and that he may not be able to return to the ___ if he goes to ___ even though living in ___ is what he has wanted for all this time and he finally got his green card. Patient also somewhat impulsively took a day trip to ___ yesterday which is unlike him. . ED Course: Patient was agitated in the ED, noted to be standing in front of the door to his room with four staff members attempting to calm him down. Patient stated he needed to leave the hospital and go to court, stating, "I am not safe in this hospital, I need to go to a different hospital." Patient asked the psychiatry resident to "tell everyone" he needs to leave and wanted to speak to the "doctor responsible for keeping me here against my will." Stated that everyone in the hospital will get into trouble if he brings his lawyer in, stating, "You don't want my people to come here..." Patient was seen later in the day for escalating agitation and received a chemical restraint with Haldol 5 mg IM/Ativan 2 mg IM . Patient interviewed in team and was notably pleasant with this interviewer but had a difficult time relaying a completely coherent history. He reported he had been doing "great" but then went on to state that although "not much" had been going on that "everyone in my life had been dealing with some kind of depression." Reported he came to the ED because he was feeling a "little scared." He then went on to state that he wanted to leave "because I have been here four business days." He admitted to calling 911 and when asked why he stated, "I came to the ___ in ___ as a refugee." He stated the FBI "Had bothered me too many times... they questioned me, saying they wanted to have coffee and tea with me, asking me about politics and I wasn't feeling comfortable." Patient reported this had been going on for the past ___ years and stated that on the day of presentation he had been out with his best friend, "I found out he was in a meeting with the FBI about me," reporting it made him feel depressed and scared, "if you don't trust me, why would you let me in this country?" Reported he doesn't feel trusted in the ___, and that it is "unwelcoming in this country." . Mr. ___ reported that he currently lives in ___ with his roommates, who are also refugees. Stated he spends his time working, "taking care of himself," and going shopping. Reported he was currently working at the ___ and that had been going well. Patient denied depressed mood, stating he has been feeling "very good" for the past four months. He confirmed that four months ago he was listening to ___ 444 record, and stated, "this changed my thinking-- I learned that you shouldn't let someone old you down." He then went on to talk about "always facing god... I have my own feeling with god." He then talked about "following the number four... it's the number where I find links-- 42 was ___ number and he was the first black man to play baseball, I go back and see ___ and everything in politics is planned that way, ___.. I'm trying to understand this country." He then went on to state that he had died four times, had been in four countries, that there are four letters in his first name and that he speaks four languages (___) and that he has four brothers. Stated that he had a child pass away ___ years and 4 months ago. Denied frank grandiosity, but stated that "I'm feeling more strong than yesterday and stronger everyday... my confidence is special." . On psychiatric review of systems, patient denied depressed mood, endorsed "good" sleep, approximately ___ hours per night. Reported good energy and concentration, "beautiful" appetite. Denied suicidal ideation or homicidal ideation. Denied AVH. Denied history of decreased need for sleep, hypersexuality. Denied anxiety on my examination but did state that he had history of flashbacks in the past but denied they were bothering him at this time. Reported history of nightmares of the FBI out to get him. Denied alcohol use but admitted to cannabis use, stating he smokes it about $25 per week. Past Medical History: Past Psychiatric History - Prior diagnoses: denies - Hospitalizations: denies - Current treaters and treatment: none - Medication and ECT trials: Trazodone (groggy) - Suicide attempts: denies - Self-injurious behavior: denies - Harm to others: denies - Access to weapons: denies . Past Medical History: - Back and shoulder pain + head injuries from being tortured in prison Denies history of seizures. Social History: Substance use history: - Alcohol: denies alcohol x 4 months, used to drink ___sleep prior - Tobacco: 1.5 ppd - Caffeine: 4 shots of espresso daily - Other illicit substances and IVDU: MJ daily x 4 months (denies daily use on my exam) . Personal and Social History: Per OMR, patient. Born and raised in ___ to a ___ family as the oldest of ___ with 4 brothers and 2 sisters. He reported growing up in ___ was difficult, as he was treated like a "second class citizen." Stated his father and mother both worked for the ___ as ___. Patient reported that he began protesting the ___ regime "because I did not feel right not being a free man." Stated he did not complete high school due to incarcerations for protesting. Reported he had gone on a hunger strike for 12 days, which was a human rights violation. Stated that the ___ Times got a hold of his story, and he was able to get out of the ___. Patient also reported that in ___ he had been dating a girl when he as about ___ years old but that her father would not let her marry him. Patient reported she became pregnant and her father forced her to have an abortion. Patient reportedly came to the ___ in ___ as noted above. Denies legal issues since arriving to the ___ and received his green card 2 days prior to presentation. Stated he had been dating a girl until recently and that she had become pregnant and had an abortion as well. When asked how this affected him, he stated, "the lord giveth and the lord taketh." Currently reportedly working in ___ with roommates and working at ___, although his former case manager states he was working at the same ___ as her. Denies access to guns Family History: FAMILY PSYCHIATRIC HISTORY: - History of psychiatric disorders: denies - History of suicide attempts: denies - History of substance use: denies Physical Exam: VITAL SIGNS: T98.4 BP:113/68 HR:84 RR:18 SpO2:99 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. Distal pulses ___ throughout. -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No wheezes/rhonchi/rales. -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 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: 2 and symmetrical throughout 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: Days of the week backwards with 0 errors. -Orientation: Oriented to person, time, place, situation -Executive function (go-no go, Luria, trails, FAS): Not tested -Memory: 4 out of 4 registration, 4 out of 4 recall after 5 ___ grossly intact -Fund of knowledge: Consistent with education; intact to last 3 presidents -Calculations: 7 quarters = "$1.75" -Abstraction: Interprets "the grass is always greener on the other side" as "as the grass something going on the other side is more green", and "you cannot judge a book by its cover "as "you cannot know what is inside book you need to look inside to understand" -Visuospatial: Not assessed -Language: Native ___ speaker, speaks ___ well, however does report that he is more comfortable with aerobic and ___. No paraphasic errors, appropriate to conversation Mental Status: -Appearance: man appearing stated age, well groomed, wearing hospital gown, in no apparent distress -Behavior: Sitting up in interview chair, appropriate eye contact, psychomotor agitation of bouncing his legs. -Attitude: Cooperative, engaged, friendly for the most part, however does become more irritable when talking about staying in the hospital or usage of his electronics to speak with his family. -Mood: "I am great " -Affect: Flat affect, full range, labile, at times not congruent with mood. -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Content: ---Safety: Denies SI/HI ---Delusions: Patient shares concerns for the FBI and CIA he also shares ideas of reference that the television and the radio are sharing information related to the conditions in the ___: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: Poor Mental Status Exam: -Appearance: man appearing stated age, well groomed, wearing grey sweater and sweatpants, in no apparent distress -Behavior: Sitting up in interview chair, intense eye contact at times, speech rapid but interruptible, no psychomotor agitation -Attitude: Cooperative, engaged, friendly, -Mood: "fantastic" -Affect: expansive affect, mood congruent, -Speech: Normal rate, volume, and tone -Thought process: Linear, at times circumstantial, no loose associations -Thought Content: ---Safety: Denies SI/HI ---Delusions: No longer endorsing preoccupations with being monitored by government ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: fair Discharge Examination: VS: 98.0 117/72 85 16 100% A/B: Appears stated age, dressed casually with good hygiene and grooming, calm, cooperative with interviewer, good eye contact, no psychomotor agitation or retardation noted S: normal rate, volume, prosody M: "good" A: hyperthymic, inappropriate to situation TC: denies SI/HI, AVH TP: linear, goal and future oriented C: awake, alert and oriented x3 I/J: improved/improved Pertinent Results: ___: Na: 141 ___: K: 4.1 ___: Cl: 101 ___: CO2: 28 ___: BUN: 10 ___: Creat: 0.9 ___: Glucose: 89 ___: WBC: 6.7 ___: RBC: 5.25 ___: HGB: 17.1 ___: HCT: 49.0 ___: MCV: 93 ___: MCH: 32.6* ___: MCHC: 34.9 ___: RDW: 12.0 ___: Plt Count: 180 ___: Neuts%: 76.8* ___: Lymphs: 12.6* ___: MONOS: 9.3 ___: Eos: 0.6* ___: BASOS: 0.4 ___: AbsNeuts: 5.12 ___: Benzodiazepine: ___: Barbiturate: NEG ___: Opiate: NEG ___: Cocaine: NEG ___: Amphetamine: NEG ___: Methadone: NEG Brief Hospital Course: This is a ___ year old single, employed ___ male refugee, with reported history of extensive trauma (tortured during imprisonment in ___ for 59 days), daily cannabis use, no formal psychiatric history or suicide attempts, who presented to ___ ED via EMS due to paranoia. . History and presentation notable for a profound history of reported trauma with numerous incarcerations for political activity and immigration to ___ in ___ but without formal psychiatric history until recently with patient reporting approximately 4 months of symptoms after listening to ___ ___ album. History is concerning for underlying and paranoia that the FBI and CIA are out to get him (patient reportedly has been questioned by the FBI in the past but patient is now paranoid his friends are being questioned) with thoughts of fleeing to ___ in order to escape this perceived persecution (unable to confirm his story at this time). Collateral from his former case manager concerning for increasing paranoia with patient recently perseverting on obtaining the president's phone number, impulsivity (going to ___ with his friend without apparently planning this trip), which appears to be out of character for him. ED course notable for expansive mood with periods of irritability and agitation, requiring chemical restraint. . Mental status examination on admission was concerning for mania with psychotic features-- patient appears well groomed but is notably hyperthymic and expansive with rapid speech, thought process that is notable for derailments, tangentiality, looseness of associations and thought content that is concerning for ideas of reference and paranoid delusions (that likely have some basis in reality). . Diagnostically, given his young age and presentation, I am concerned for an affective psychosis at this time, particularly BPAD Type I, manic, with psychotic features. However, his cannabis use may very well be contributing to his current presentation, and I cannot rule out substance induced psychosis/mania at this time. Given his young age and good health, an underlying medical condition is unlikely to be contributing to his current presentation. Given lack of negative symptoms, apparent lack of prodromal phase, I think that a primary psychotic disorder such as schizophrenia is further down on the differential. Of note, although the patient has a history of trauma and PTSD symptoms, he does not appear anxious, dysphoric, or distressed on my examination-- I do not believe is presentation is due to untreated PTSD or anxiety symptoms, although certainly he is at high risk for anxiety disorders. . #. Legal/Safety: Patient admitted to ___ on a ___, upon admission, he declined to sign a conditional voluntary form, stating he did not want to be in the hospital. He maintained his safety throughout his hospitalization on 15 minute checks and did not require physical or chemical restraints. Given lack of evidence of threat to self, others, or inability to care for self (with patient able to attend to ADL's independently), we did not feel he met criteria to file a 7&8b, particularly as he was willing to follow up with outpatient treaters. . #. BPAD: currently manic, with psychotic features - Patient declined additional medical workup including, B12, folate, TSH, RPR, LFT's, metabolic panel, stating he had already had enough blood drawn. - After discussion of the risks and benefits, we offered the patient risperidone 1 mg po qhs and 1 mg po tid prn agitation in addition to Ativan 0.5 mg po prn. However, patient consistently declined this medication, stating he did not feel he needed it. Noted to somewhat paranoid during his hospitalization, stating he felt his friend was forced by the FBI to put cameras in his room and that his friend was recording his conversations. Mental status examinations were notable for ongoing paranoia, preoccupation with the number "4" with magical thinking surrounding this number, cheerful but intense affect and consistent denial of suicidal ideation or thoughts of self harm. - Of note, patient was seen by Dr. ___, medical director of the inpatient unit and Dr. ___, vice chair of the department of the psychiatry. Both clinicians agreed with likely diagnosis of psychosis and paranoia with assessment that it would be reasonable to discharge with referral to outpatient supports upon the expiration of his ___. - On day of discharge, the patient reported he was looking forward to returning home and following up with physical therapy for a shoulder injury. Denied SI/HI, AVH on examination with thought process that was linear, goal and future oriented. . #. PTSD: with patient reporting history of flashbacks and nightmares, unclear if he has truly been diagnosed with this in the past - Patient declined medications during this admission with no complaints of PTSD symptoms. . #. Cannabis use: see above, patient inconsistent in how much MJ he is using - Patient as educated on the deleterious effects of cannabis on his mental health and stated he was planning on abstaining from cannabis once discharged, as he felt this was contributing to his paranoia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Nicotine Polacrilex 1 STCK PO Q1H:PRN nicotine craving Discharge Disposition: Home Discharge Diagnosis: Bipolar Affective Disorder, with psychotic features Cannabis use disorder Discharge Condition: VS: 98.0 117/72 85 16 100% A/B: Appears stated age, dressed casually with good hygiene and grooming, calm, cooperative with interviewer, good eye contact, no psychomotor agitation or retardation noted S: normal rate, volume, prosody M: 'good' A: hyperthymic, inappropriate to situation TC: denies SI/HI, AVH TP: linear, goal and future oriented C: awake, alert and oriented x3 I/J: improved/improved Discharge Instructions: -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. 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: ___
[ "F312", "F1210", "F4310", "X58XXXS", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I am scared of something" Major Surgical or Invasive Procedure: none History of Present Illness: For further details of the history and presentation, please see OMR, including Dr. [MASKED] initial consultation note dated [MASKED] and Dr. [MASKED] staff consultation note dated [MASKED]. . Briefly, this is a [MASKED] year old, single, employed [MASKED] refugee man, with reported history of extensive trauma (tortured during imprisonment in [MASKED] for 59 days), daily cannabis use, no formal psychiatric history or suicide attempts, who presented to [MASKED] ED via EMS due to paranoia. . Upon initial interview, patient reported was here because he felt scared and believes the FBI and CIA were after him, although he had no idea why they would be after him. Patient reported that he was born in [MASKED] and moved with his family to [MASKED] when he was young. Stated that since [MASKED] (at the age of [MASKED]) he became involved in politics and protested against the [MASKED] government resulting in him being shunned by his community and family. In [MASKED] he was arrested and has been arrested for a total of 4 times. Patient was given refugee status in [MASKED] by an international organization and came to the [MASKED] in [MASKED]. When he arrived to the [MASKED], he was questioned by the FBI and has been questioned by the FBI numerous time, with last time being 6 months ago. Patient reportedly received his green card 2 days prior to presentation. . Mr. [MASKED] reported he had been doing well until four months ago after listening to [MASKED] album, 444, which resonated with him. Since then he has been suffering from insomnia, constant flashbacks. He reports that everything starts with a 4 in his life (he was in jail 4 times, this started 4 months ago and he tried to graduate high school 4 times). Patient also reported difficulty with memory, difficulty concentrating and visual hallucinations of "future war." Denied AH, SI/HI. Denied low mood, feelings of hopelessness/helplessness/worthlessness. Patient also reported that on the day prior to presentation he and his friend, who is an [MASKED] refugee, took an impulsive trip to [MASKED] to celebrate the patient getting his green card. This morning, the friend asked him to join him to come to an appointment. The friend was very vague about the purpose of the appointment and patient was asked to wait in the car or cafeteria. Patient saw the meeting and noted that there was FBI paperwork and determined that his friend was sharing information with the FBI about their trip to [MASKED] yesterday as part of an investigation on the patient. He also reports that he saw lots of cash in the friend's car which was "scary". He reports that he does not trust this friend and does not want this writer to call him. . On interview with Dr. [MASKED], patient was noted to be a limited historian and was notably ruminative about feeling suspicious and paranoid about others, describing a "felt energy" which no one else can feel. Reported he was feeling others were colluding with the FBI and CIA to come after him and then told a loose, rambling narrative about "feeling music that I have never felt before," and experiencing an expansive mood. Noted to be restless on examination with expansive affect, with accelerated thought process, tangential on examination with looseness of associations. . Per collateral obtained from the patient's case manager at [MASKED] [MASKED], who had known him for years but was no longer working with him: She reported the patient is high functioning at baseline and has been working for the organization [MASKED] and attending events. He was originally taken out of prison in [MASKED] by [MASKED] and [MASKED] International who gave him 48 hours to pack his things and move to [MASKED]. He later came to [MASKED] as a political refugee in [MASKED] and was questioned by the FBI upon entrance and they continued to question him for a while. He was eligible for a green card in [MASKED] but he didn't get it until two days ago. He was at the survivors of torture program at [MASKED] but stopped going and stopping taking his medications (unclear dx and medications). This year he has been intermittently "self-medicating" by binge-drinking and then going on "health sprees" by doing cleanses and going to the gym obsessively. [MASKED] called [MASKED] today stating that he needed the president's phone number and was extremely perseverative. He was under the belief that his friend, who is an [MASKED] refugee is working for the FBI. He has been getting increasingly paranoid for the past several months. He has been fixated on rap music and its meaning. . On the phone today, patient mentioned being scared and having thoughts of wanting to return to [MASKED] to get away from the FBI. [MASKED] is concerned that patient has the ability and means to do this and that he may not be able to return to the [MASKED] if he goes to [MASKED] even though living in [MASKED] is what he has wanted for all this time and he finally got his green card. Patient also somewhat impulsively took a day trip to [MASKED] yesterday which is unlike him. . ED Course: Patient was agitated in the ED, noted to be standing in front of the door to his room with four staff members attempting to calm him down. Patient stated he needed to leave the hospital and go to court, stating, "I am not safe in this hospital, I need to go to a different hospital." Patient asked the psychiatry resident to "tell everyone" he needs to leave and wanted to speak to the "doctor responsible for keeping me here against my will." Stated that everyone in the hospital will get into trouble if he brings his lawyer in, stating, "You don't want my people to come here..." Patient was seen later in the day for escalating agitation and received a chemical restraint with Haldol 5 mg IM/Ativan 2 mg IM . Patient interviewed in team and was notably pleasant with this interviewer but had a difficult time relaying a completely coherent history. He reported he had been doing "great" but then went on to state that although "not much" had been going on that "everyone in my life had been dealing with some kind of depression." Reported he came to the ED because he was feeling a "little scared." He then went on to state that he wanted to leave "because I have been here four business days." He admitted to calling 911 and when asked why he stated, "I came to the [MASKED] in [MASKED] as a refugee." He stated the FBI "Had bothered me too many times... they questioned me, saying they wanted to have coffee and tea with me, asking me about politics and I wasn't feeling comfortable." Patient reported this had been going on for the past [MASKED] years and stated that on the day of presentation he had been out with his best friend, "I found out he was in a meeting with the FBI about me," reporting it made him feel depressed and scared, "if you don't trust me, why would you let me in this country?" Reported he doesn't feel trusted in the [MASKED], and that it is "unwelcoming in this country." . Mr. [MASKED] reported that he currently lives in [MASKED] with his roommates, who are also refugees. Stated he spends his time working, "taking care of himself," and going shopping. Reported he was currently working at the [MASKED] and that had been going well. Patient denied depressed mood, stating he has been feeling "very good" for the past four months. He confirmed that four months ago he was listening to [MASKED] 444 record, and stated, "this changed my thinking-- I learned that you shouldn't let someone old you down." He then went on to talk about "always facing god... I have my own feeling with god." He then talked about "following the number four... it's the number where I find links-- 42 was [MASKED] number and he was the first black man to play baseball, I go back and see [MASKED] and everything in politics is planned that way, [MASKED].. I'm trying to understand this country." He then went on to state that he had died four times, had been in four countries, that there are four letters in his first name and that he speaks four languages ([MASKED]) and that he has four brothers. Stated that he had a child pass away [MASKED] years and 4 months ago. Denied frank grandiosity, but stated that "I'm feeling more strong than yesterday and stronger everyday... my confidence is special." . On psychiatric review of systems, patient denied depressed mood, endorsed "good" sleep, approximately [MASKED] hours per night. Reported good energy and concentration, "beautiful" appetite. Denied suicidal ideation or homicidal ideation. Denied AVH. Denied history of decreased need for sleep, hypersexuality. Denied anxiety on my examination but did state that he had history of flashbacks in the past but denied they were bothering him at this time. Reported history of nightmares of the FBI out to get him. Denied alcohol use but admitted to cannabis use, stating he smokes it about $25 per week. Past Medical History: Past Psychiatric History - Prior diagnoses: denies - Hospitalizations: denies - Current treaters and treatment: none - Medication and ECT trials: Trazodone (groggy) - Suicide attempts: denies - Self-injurious behavior: denies - Harm to others: denies - Access to weapons: denies . Past Medical History: - Back and shoulder pain + head injuries from being tortured in prison Denies history of seizures. Social History: Substance use history: - Alcohol: denies alcohol x 4 months, used to drink sleep prior - Tobacco: 1.5 ppd - Caffeine: 4 shots of espresso daily - Other illicit substances and IVDU: MJ daily x 4 months (denies daily use on my exam) . Personal and Social History: Per OMR, patient. Born and raised in [MASKED] to a [MASKED] family as the oldest of [MASKED] with 4 brothers and 2 sisters. He reported growing up in [MASKED] was difficult, as he was treated like a "second class citizen." Stated his father and mother both worked for the [MASKED] as [MASKED]. Patient reported that he began protesting the [MASKED] regime "because I did not feel right not being a free man." Stated he did not complete high school due to incarcerations for protesting. Reported he had gone on a hunger strike for 12 days, which was a human rights violation. Stated that the [MASKED] Times got a hold of his story, and he was able to get out of the [MASKED]. Patient also reported that in [MASKED] he had been dating a girl when he as about [MASKED] years old but that her father would not let her marry him. Patient reported she became pregnant and her father forced her to have an abortion. Patient reportedly came to the [MASKED] in [MASKED] as noted above. Denies legal issues since arriving to the [MASKED] and received his green card 2 days prior to presentation. Stated he had been dating a girl until recently and that she had become pregnant and had an abortion as well. When asked how this affected him, he stated, "the lord giveth and the lord taketh." Currently reportedly working in [MASKED] with roommates and working at [MASKED], although his former case manager states he was working at the same [MASKED] as her. Denies access to guns Family History: FAMILY PSYCHIATRIC HISTORY: - History of psychiatric disorders: denies - History of suicide attempts: denies - History of substance use: denies Physical Exam: VITAL SIGNS: T98.4 BP:113/68 HR:84 RR:18 SpO2:99 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. Distal pulses [MASKED] throughout. -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No wheezes/rhonchi/rales. -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 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: 2 and symmetrical throughout 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: Days of the week backwards with 0 errors. -Orientation: Oriented to person, time, place, situation -Executive function (go-no go, Luria, trails, FAS): Not tested -Memory: 4 out of 4 registration, 4 out of 4 recall after 5 [MASKED] grossly intact -Fund of knowledge: Consistent with education; intact to last 3 presidents -Calculations: 7 quarters = "$1.75" -Abstraction: Interprets "the grass is always greener on the other side" as "as the grass something going on the other side is more green", and "you cannot judge a book by its cover "as "you cannot know what is inside book you need to look inside to understand" -Visuospatial: Not assessed -Language: Native [MASKED] speaker, speaks [MASKED] well, however does report that he is more comfortable with aerobic and [MASKED]. No paraphasic errors, appropriate to conversation Mental Status: -Appearance: man appearing stated age, well groomed, wearing hospital gown, in no apparent distress -Behavior: Sitting up in interview chair, appropriate eye contact, psychomotor agitation of bouncing his legs. -Attitude: Cooperative, engaged, friendly for the most part, however does become more irritable when talking about staying in the hospital or usage of his electronics to speak with his family. -Mood: "I am great " -Affect: Flat affect, full range, labile, at times not congruent with mood. -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Content: ---Safety: Denies SI/HI ---Delusions: Patient shares concerns for the FBI and CIA he also shares ideas of reference that the television and the radio are sharing information related to the conditions in the [MASKED]: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: Poor Mental Status Exam: -Appearance: man appearing stated age, well groomed, wearing grey sweater and sweatpants, in no apparent distress -Behavior: Sitting up in interview chair, intense eye contact at times, speech rapid but interruptible, no psychomotor agitation -Attitude: Cooperative, engaged, friendly, -Mood: "fantastic" -Affect: expansive affect, mood congruent, -Speech: Normal rate, volume, and tone -Thought process: Linear, at times circumstantial, no loose associations -Thought Content: ---Safety: Denies SI/HI ---Delusions: No longer endorsing preoccupations with being monitored by government ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: fair Discharge Examination: VS: 98.0 117/72 85 16 100% A/B: Appears stated age, dressed casually with good hygiene and grooming, calm, cooperative with interviewer, good eye contact, no psychomotor agitation or retardation noted S: normal rate, volume, prosody M: "good" A: hyperthymic, inappropriate to situation TC: denies SI/HI, AVH TP: linear, goal and future oriented C: awake, alert and oriented x3 I/J: improved/improved Pertinent Results: [MASKED]: Na: 141 [MASKED]: K: 4.1 [MASKED]: Cl: 101 [MASKED]: CO2: 28 [MASKED]: BUN: 10 [MASKED]: Creat: 0.9 [MASKED]: Glucose: 89 [MASKED]: WBC: 6.7 [MASKED]: RBC: 5.25 [MASKED]: HGB: 17.1 [MASKED]: HCT: 49.0 [MASKED]: MCV: 93 [MASKED]: MCH: 32.6* [MASKED]: MCHC: 34.9 [MASKED]: RDW: 12.0 [MASKED]: Plt Count: 180 [MASKED]: Neuts%: 76.8* [MASKED]: Lymphs: 12.6* [MASKED]: MONOS: 9.3 [MASKED]: Eos: 0.6* [MASKED]: BASOS: 0.4 [MASKED]: AbsNeuts: 5.12 [MASKED]: Benzodiazepine: [MASKED]: Barbiturate: NEG [MASKED]: Opiate: NEG [MASKED]: Cocaine: NEG [MASKED]: Amphetamine: NEG [MASKED]: Methadone: NEG Brief Hospital Course: This is a [MASKED] year old single, employed [MASKED] male refugee, with reported history of extensive trauma (tortured during imprisonment in [MASKED] for 59 days), daily cannabis use, no formal psychiatric history or suicide attempts, who presented to [MASKED] ED via EMS due to paranoia. . History and presentation notable for a profound history of reported trauma with numerous incarcerations for political activity and immigration to [MASKED] in [MASKED] but without formal psychiatric history until recently with patient reporting approximately 4 months of symptoms after listening to [MASKED] [MASKED] album. History is concerning for underlying and paranoia that the FBI and CIA are out to get him (patient reportedly has been questioned by the FBI in the past but patient is now paranoid his friends are being questioned) with thoughts of fleeing to [MASKED] in order to escape this perceived persecution (unable to confirm his story at this time). Collateral from his former case manager concerning for increasing paranoia with patient recently perseverting on obtaining the president's phone number, impulsivity (going to [MASKED] with his friend without apparently planning this trip), which appears to be out of character for him. ED course notable for expansive mood with periods of irritability and agitation, requiring chemical restraint. . Mental status examination on admission was concerning for mania with psychotic features-- patient appears well groomed but is notably hyperthymic and expansive with rapid speech, thought process that is notable for derailments, tangentiality, looseness of associations and thought content that is concerning for ideas of reference and paranoid delusions (that likely have some basis in reality). . Diagnostically, given his young age and presentation, I am concerned for an affective psychosis at this time, particularly BPAD Type I, manic, with psychotic features. However, his cannabis use may very well be contributing to his current presentation, and I cannot rule out substance induced psychosis/mania at this time. Given his young age and good health, an underlying medical condition is unlikely to be contributing to his current presentation. Given lack of negative symptoms, apparent lack of prodromal phase, I think that a primary psychotic disorder such as schizophrenia is further down on the differential. Of note, although the patient has a history of trauma and PTSD symptoms, he does not appear anxious, dysphoric, or distressed on my examination-- I do not believe is presentation is due to untreated PTSD or anxiety symptoms, although certainly he is at high risk for anxiety disorders. . #. Legal/Safety: Patient admitted to [MASKED] on a [MASKED], upon admission, he declined to sign a conditional voluntary form, stating he did not want to be in the hospital. He maintained his safety throughout his hospitalization on 15 minute checks and did not require physical or chemical restraints. Given lack of evidence of threat to self, others, or inability to care for self (with patient able to attend to ADL's independently), we did not feel he met criteria to file a 7&8b, particularly as he was willing to follow up with outpatient treaters. . #. BPAD: currently manic, with psychotic features - Patient declined additional medical workup including, B12, folate, TSH, RPR, LFT's, metabolic panel, stating he had already had enough blood drawn. - After discussion of the risks and benefits, we offered the patient risperidone 1 mg po qhs and 1 mg po tid prn agitation in addition to Ativan 0.5 mg po prn. However, patient consistently declined this medication, stating he did not feel he needed it. Noted to somewhat paranoid during his hospitalization, stating he felt his friend was forced by the FBI to put cameras in his room and that his friend was recording his conversations. Mental status examinations were notable for ongoing paranoia, preoccupation with the number "4" with magical thinking surrounding this number, cheerful but intense affect and consistent denial of suicidal ideation or thoughts of self harm. - Of note, patient was seen by Dr. [MASKED], medical director of the inpatient unit and Dr. [MASKED], vice chair of the department of the psychiatry. Both clinicians agreed with likely diagnosis of psychosis and paranoia with assessment that it would be reasonable to discharge with referral to outpatient supports upon the expiration of his [MASKED]. - On day of discharge, the patient reported he was looking forward to returning home and following up with physical therapy for a shoulder injury. Denied SI/HI, AVH on examination with thought process that was linear, goal and future oriented. . #. PTSD: with patient reporting history of flashbacks and nightmares, unclear if he has truly been diagnosed with this in the past - Patient declined medications during this admission with no complaints of PTSD symptoms. . #. Cannabis use: see above, patient inconsistent in how much MJ he is using - Patient as educated on the deleterious effects of cannabis on his mental health and stated he was planning on abstaining from cannabis once discharged, as he felt this was contributing to his paranoia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Nicotine Polacrilex 1 STCK PO Q1H:PRN nicotine craving Discharge Disposition: Home Discharge Diagnosis: Bipolar Affective Disorder, with psychotic features Cannabis use disorder Discharge Condition: VS: 98.0 117/72 85 16 100% A/B: Appears stated age, dressed casually with good hygiene and grooming, calm, cooperative with interviewer, good eye contact, no psychomotor agitation or retardation noted S: normal rate, volume, prosody M: 'good' A: hyperthymic, inappropriate to situation TC: denies SI/HI, AVH TP: linear, goal and future oriented C: awake, alert and oriented x3 I/J: improved/improved Discharge Instructions: -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. 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]
[]
[ "F17210" ]
[ "F312: Bipolar disorder, current episode manic severe with psychotic features", "F1210: Cannabis abuse, uncomplicated", "F4310: Post-traumatic stress disorder, unspecified", "X58XXXS: Exposure to other specified factors, sequela", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,031,316
27,575,109
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: amitriptyline / hydrochlorothiazide / lisinopril Attending: ___. Chief Complaint: left arm discomfort and shortness of breath Major Surgical or Invasive Procedure: ___ Coronary artery bypass grafting x2 with the left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the third obtuse marginal artery. History of Present Illness: ___ year old ___ speaking female who has been experiencing a left arm discomfort that radiates from her forearm to her chest. She states she has had it with exertion and also while in church. Her chest pain is also associated with shortness of breath. The day prior to admission she had arm pain that lasted all day long. She came in to see Dr. ___ she was referred to the ___ for further evaluation. She had a stress test that was found to be abnormal and admitted for a cardiac catheterization. During catheterization she was found to have LAD disease and occluded LCX which had a successful POBA. She is now being referred to cardiac surgery to evaluate for surgical revascularization. Past Medical History: Coronary Artery Disease Type 2 diabetes Hyperlipidemia Hypertension GERD Sleep apnea (no CPAP) Thyroid nodule Anxiety Depression Past Surgical History: Thyroidectomy (L lobe hemithyroidectomy for nodule) Lipoma removal from back and left groin Bladder suspension Social History: ___ Family History: Mom died suddenly at age ___ they said because of hypertension working in the ___ of ___. Her dad had a murmur. Physical Exam: Pulse:78 Resp:18 O2 sat: 100/RA B/P Right:131/78 Height:5'1" Weight:68.5 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] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:palp Left:palp DP Right:palp Left:palp ___ Right: palp Left:palp Radial Right:palp Left:palp Carotid Bruit: none noted Right: Left: Pertinent Results: ___ 05:52AM BLOOD WBC-8.6 RBC-3.04* Hgb-8.7* Hct-26.9* MCV-89 MCH-28.6 MCHC-32.3 RDW-13.7 RDWSD-44.0 Plt ___ ___ 05:22AM BLOOD WBC-9.5 RBC-3.16* Hgb-9.2* Hct-27.4* MCV-87 MCH-29.1 MCHC-33.6 RDW-13.5 RDWSD-42.8 Plt ___ ___ 04:12AM BLOOD WBC-9.5 RBC-3.43* Hgb-9.9* Hct-29.7* MCV-87 MCH-28.9 MCHC-33.3 RDW-13.4 RDWSD-42.0 Plt ___ ___ 05:52AM BLOOD Glucose-125* UreaN-13 Creat-0.6 Na-135 K-4.5 Cl-99 HCO3-28 AnGap-13 ___ 05:22AM BLOOD Glucose-128* UreaN-12 Creat-0.6 Na-140 K-4.4 Cl-103 HCO3-29 AnGap-12 ___ 04:12AM BLOOD Glucose-135* UreaN-12 Creat-0.7 Na-137 K-4.7 Cl-101 HCO3-31 AnGap-10 ___ 08:49PM BLOOD K-4.5 ___ 02:14AM BLOOD WBC-10.8* RBC-3.16* Hgb-9.2* Hct-27.0* MCV-85 MCH-29.1 MCHC-34.1 RDW-13.0 RDWSD-40.4 Plt ___ ___ 06:32PM BLOOD Hct-33.9* ___ 08:49PM BLOOD K-4.5 ___ 12:37PM BLOOD Glucose-185* UreaN-8 Creat-0.7 K-4.1 ___ 02:14AM BLOOD Glucose-138* UreaN-6 Creat-0.5 Na-132* K-3.8 Cl-98 HCO3-26 AnGap-12 ___ 06:32PM BLOOD K-3.6 ___ 12:23PM BLOOD UreaN-9 Creat-0.5 Cl-107 HCO3-23 AnGap-13 ___ TEE Pre-CPB: The left atrium is mildly dilated. The left atrial appendage emptying velocity is depressed (<0.4m/s). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The calculated cardiac output by continuity equation is 2.5 L/min. Right ventricular chamber size and free wall motion are normal. No thoracic aortic dissection is seen. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Post-CPB: Biventricular systolic function is preserved. The LVEF is >55%. The calculated cardiac output is 4.1L/min. The MR remains mild. Other valvular function remains unchanged. There is no evidence of aortic dissection. Brief Hospital Course: The patient was brought to the Operating Room on ___ where the patient underwent coronary artery bypass grafting x2 with the left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the third obtuse marginal artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes were left in an extra day due to drainage and + air leak. Chest tubes were pulled POD2 and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. She did have a fever of 101.6. Urine culture was pending at the time of discharge and will be followed up as an outpatient. WBC remained normal. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Losartan Potassium 100 mg PO DAILY 4. Naproxen 375 mg PO Q12H:PRN Pain - Moderate 5. Temazepam 15 mg PO QHS:PRN insomnia 6. Aspirin EC 81 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *hydromorphone 2 mg ___ tablet(s) by mouth Q 4 hours Disp #*60 Tablet Refills:*0 5. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 6. Polyethylene Glycol 17 g PO DAILY 7. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 8. Atorvastatin 80 mg PO QPM RX *atorvastatin [Lipitor] 80 mg 1 tablet(s) by mouth Q ___ Disp #*30 Tablet Refills:*1 9. amLODIPine 5 mg PO DAILY 10. Aspirin EC 81 mg PO DAILY 11. BuPROPion (Sustained Release) 150 mg PO BID 12. Losartan Potassium 100 mg PO DAILY 13. MetFORMIN (Glucophage) 1000 mg PO BID DO NOT RESUME UNTIL ___ 14. Naproxen 375 mg PO Q12H:PRN Pain - Moderate 15. Temazepam 15 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Coronary artery disease Type 2 diabetes Hyperlipidemia Hypertension GERD Sleep apnea (no CPAP) Thyroid nodule Anxiety Depression Past Surgical History: Thyroidectomy (L lobe hemithyroidectomy for nodule) Lipoma removal from back and left groin Bladder suspension Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: ___
[ "I25110", "E1165", "I10", "J95812", "D62", "E782", "K219", "G4733", "F419", "F329", "Y832", "Y92234", "I9581", "Z87891" ]
Allergies: amitriptyline / hydrochlorothiazide / lisinopril Chief Complaint: left arm discomfort and shortness of breath Major Surgical or Invasive Procedure: [MASKED] Coronary artery bypass grafting x2 with the left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the third obtuse marginal artery. History of Present Illness: [MASKED] year old [MASKED] speaking female who has been experiencing a left arm discomfort that radiates from her forearm to her chest. She states she has had it with exertion and also while in church. Her chest pain is also associated with shortness of breath. The day prior to admission she had arm pain that lasted all day long. She came in to see Dr. [MASKED] she was referred to the [MASKED] for further evaluation. She had a stress test that was found to be abnormal and admitted for a cardiac catheterization. During catheterization she was found to have LAD disease and occluded LCX which had a successful POBA. She is now being referred to cardiac surgery to evaluate for surgical revascularization. Past Medical History: Coronary Artery Disease Type 2 diabetes Hyperlipidemia Hypertension GERD Sleep apnea (no CPAP) Thyroid nodule Anxiety Depression Past Surgical History: Thyroidectomy (L lobe hemithyroidectomy for nodule) Lipoma removal from back and left groin Bladder suspension Social History: [MASKED] Family History: Mom died suddenly at age [MASKED] they said because of hypertension working in the [MASKED] of [MASKED]. Her dad had a murmur. Physical Exam: Pulse:78 Resp:18 O2 sat: 100/RA B/P Right:131/78 Height:5'1" Weight:68.5 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] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] [MASKED] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:palp Left:palp DP Right:palp Left:palp [MASKED] Right: palp Left:palp Radial Right:palp Left:palp Carotid Bruit: none noted Right: Left: Pertinent Results: [MASKED] 05:52AM BLOOD WBC-8.6 RBC-3.04* Hgb-8.7* Hct-26.9* MCV-89 MCH-28.6 MCHC-32.3 RDW-13.7 RDWSD-44.0 Plt [MASKED] [MASKED] 05:22AM BLOOD WBC-9.5 RBC-3.16* Hgb-9.2* Hct-27.4* MCV-87 MCH-29.1 MCHC-33.6 RDW-13.5 RDWSD-42.8 Plt [MASKED] [MASKED] 04:12AM BLOOD WBC-9.5 RBC-3.43* Hgb-9.9* Hct-29.7* MCV-87 MCH-28.9 MCHC-33.3 RDW-13.4 RDWSD-42.0 Plt [MASKED] [MASKED] 05:52AM BLOOD Glucose-125* UreaN-13 Creat-0.6 Na-135 K-4.5 Cl-99 HCO3-28 AnGap-13 [MASKED] 05:22AM BLOOD Glucose-128* UreaN-12 Creat-0.6 Na-140 K-4.4 Cl-103 HCO3-29 AnGap-12 [MASKED] 04:12AM BLOOD Glucose-135* UreaN-12 Creat-0.7 Na-137 K-4.7 Cl-101 HCO3-31 AnGap-10 [MASKED] 08:49PM BLOOD K-4.5 [MASKED] 02:14AM BLOOD WBC-10.8* RBC-3.16* Hgb-9.2* Hct-27.0* MCV-85 MCH-29.1 MCHC-34.1 RDW-13.0 RDWSD-40.4 Plt [MASKED] [MASKED] 06:32PM BLOOD Hct-33.9* [MASKED] 08:49PM BLOOD K-4.5 [MASKED] 12:37PM BLOOD Glucose-185* UreaN-8 Creat-0.7 K-4.1 [MASKED] 02:14AM BLOOD Glucose-138* UreaN-6 Creat-0.5 Na-132* K-3.8 Cl-98 HCO3-26 AnGap-12 [MASKED] 06:32PM BLOOD K-3.6 [MASKED] 12:23PM BLOOD UreaN-9 Creat-0.5 Cl-107 HCO3-23 AnGap-13 [MASKED] TEE Pre-CPB: The left atrium is mildly dilated. The left atrial appendage emptying velocity is depressed (<0.4m/s). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The calculated cardiac output by continuity equation is 2.5 L/min. Right ventricular chamber size and free wall motion are normal. No thoracic aortic dissection is seen. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Post-CPB: Biventricular systolic function is preserved. The LVEF is >55%. The calculated cardiac output is 4.1L/min. The MR remains mild. Other valvular function remains unchanged. There is no evidence of aortic dissection. Brief Hospital Course: The patient was brought to the Operating Room on [MASKED] where the patient underwent coronary artery bypass grafting x2 with the left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the third obtuse marginal artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes were left in an extra day due to drainage and + air leak. Chest tubes were pulled POD2 and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. She did have a fever of 101.6. Urine culture was pending at the time of discharge and will be followed up as an outpatient. WBC remained normal. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Losartan Potassium 100 mg PO DAILY 4. Naproxen 375 mg PO Q12H:PRN Pain - Moderate 5. Temazepam 15 mg PO QHS:PRN insomnia 6. Aspirin EC 81 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO DAILY Duration: 7 Days RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 4. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity RX *hydromorphone 2 mg [MASKED] tablet(s) by mouth Q 4 hours Disp #*60 Tablet Refills:*0 5. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 6. Polyethylene Glycol 17 g PO DAILY 7. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 8. Atorvastatin 80 mg PO QPM RX *atorvastatin [Lipitor] 80 mg 1 tablet(s) by mouth Q [MASKED] Disp #*30 Tablet Refills:*1 9. amLODIPine 5 mg PO DAILY 10. Aspirin EC 81 mg PO DAILY 11. BuPROPion (Sustained Release) 150 mg PO BID 12. Losartan Potassium 100 mg PO DAILY 13. MetFORMIN (Glucophage) 1000 mg PO BID DO NOT RESUME UNTIL [MASKED] 14. Naproxen 375 mg PO Q12H:PRN Pain - Moderate 15. Temazepam 15 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Coronary artery disease Type 2 diabetes Hyperlipidemia Hypertension GERD Sleep apnea (no CPAP) Thyroid nodule Anxiety Depression Past Surgical History: Thyroidectomy (L lobe hemithyroidectomy for nodule) Lipoma removal from back and left groin Bladder suspension Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [MASKED] **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: [MASKED]
[]
[ "E1165", "I10", "D62", "K219", "G4733", "F419", "F329", "Z87891" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I10: Essential (primary) hypertension", "J95812: Postprocedural air leak", "D62: Acute posthemorrhagic anemia", "E782: Mixed hyperlipidemia", "K219: Gastro-esophageal reflux disease without esophagitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "I9581: Postprocedural hypotension", "Z87891: Personal history of nicotine dependence" ]
10,031,358
28,474,294
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ACE Inhibitors / ___ Receptor Antagonist Attending: ___. Chief Complaint: Toe ulcer, fevers, chills Major Surgical or Invasive Procedure: Left hallux debridement and biopsy on ___ History of Present Illness: ___ M with ___ IDDM DM2 c/b retinopathy, nephropathy, and neuropathy, HTN, traumatic SAH c/b seizure, CVA x2 ___ last year, hypothyroidism, CKD ___ early Lithium nephropathy with secondary FSGS, chronic lymphedema and bipolar disorder presenting with increased swelling, erythema and ulceration of left first toe. Patient has had swelling of his left toe for a long time, however ___ the past few days the swelling and erythema worsened. ___ also noticed purulent drainage, but is unsure when ___ noticed it. Patient also endorses subjective fevers/chills at home x ___ days. ___ denies associated pain or paresthesias. Also denies CP/pressure, SOB, n/v, diarrhea or dysuria. ___ the ED patient reported feeling "off the rails" and more angry for the past few months and endorsed wanting to hurt someone, including the staff. ___ says these violent impulses are worse lately and feels his medication is not working. ___ requests psych evaluation as ___ is becoming more verbally abusive to his wife. ___ changes ___ sleep, appetite, racing thoughts. ___ the ED, initial vitals: 99.3 79 187/79 18 100% RA - Labs were significant for: WBC 11.3, Hgb 11.8 (at about baseline), plt 352, Cr 1.2 (baseline 1.2). - Physical exam: Ext: bilateral 2+ pitting edema to knee with diffuse erythema. R first toe amputation. Left first toe with anterior callous and ulcer not purulent with compression. No assoc. tenderness. Psych; yelling, agitated, interrupting examiner, dismissing male providers from room, saying ___ "hates men." - Imaging showed: Foot xray without evidence of ___. - ___ the ED, ___ received: IV Vanco 1mg, Haldol IM 5mg, Levothyroxine, Quetiapine 50mg, omeprazole 20mg, Metoprolol 12.5mg. - Vitals prior to transfer: 97.7 77 176/83 18 18 100% RA Upon arrival to the floor, patient denies any toe pain and endorses above story. ___ is able to recount all of his medications. While clarifying his insulin regimen, patient became acute upset about having to clarify his insulin regimen. ___ asked MD to leave the room and also said ___ will not take an insulin sliding scale as "that does not work" for him. Denied any other symptoms. REVIEW OF SYSTEMS: 10 point review of system otherwise negative. Positive per HPI. Past Medical History: Hypothyroidism DM (diabetes mellitus), type 2 with renal complications, retinopathy Diabetic retinopathy CKD (baseline 1.1-1.3) Hypertension B12 deficiency Bipolar disorder Depression Tremor, ?parkinsonism Colonic adenoma ___ esophagus Social History: ___ Family History: Per WebOMR and reviewed with patient: Maternal grandmother with DM and CAD. Sister with breast cancer and bipolar disorder. Father with stomach cancer, peptic ulcer disease, bipolar disorder, kidney disease, died of PNA. Mother with bipolar disorder, died of bone cancer (per records report of breast cancer, but patient notes it was bone cancer). Physical Exam: ADMISSION =========== Vital Signs: 97.8 157 / 83 73 20 98% RA General: Alert, oriented, no acute distress. Answering questions appropriately, however volatile emotionally. Patient upset at having to repeat his insulin dosing regimen and kicked MD out of room. HEENT: Sclerae anicteric, MMM. CV: RRR, no murmurs, rubs Lungs: Unable to examen as pt refused Abdomen: Obese. Unable to complete exam as pt refused GU: No foley Ext: Warm, well perfused. 2+ pulses. Left extremity slightly warmer than right. 1+ pitting edema bilaterally. Left toe with 1x1cm ulcer on anterior aspect of toe. Ulcer with yellow base and surrounding erythema which is localized to toe. Does have an erythematous plaque on medial shin that is not connected to the toe which pt notes is chronic although at times not as erythematous. It is non tender non pruritic. Right large toe amputation. Neuro: Unable to perform exam. DISCHARGE ============ Vital Signs: 98.1 160 / 84 80 20 98% RA General: Alert, oriented, no acute distress. HEENT: Sclerae anicteric, MMM. CV: RRR, no murmurs, rubs Lungs: CTAB Abdomen: Obese. Nontender to palpation, no guarding. GU: No foley Ext: Warm, well perfused. 2+ pulses. Left hallux bandaged. No erythema on shin or fore foot. Neuro: AAOx3. Moving all extremities with purpose. Able to ambulate to bathroom on his own. Pertinent Results: ADMISSION =========== ___ 06:44AM PLT COUNT-352# ___ 06:44AM NEUTS-65.2 LYMPHS-17.8* MONOS-11.6 EOS-4.5 BASOS-0.5 IM ___ AbsNeut-7.38* AbsLymp-2.02 AbsMono-1.31* AbsEos-0.51 AbsBaso-0.06 ___ 06:44AM WBC-11.3* RBC-4.22* HGB-11.8* HCT-37.3* MCV-88 MCH-28.0 MCHC-31.6* RDW-12.8 RDWSD-41.7 ___ 06:44AM CRP-11.7* ___ 06:44AM %HbA1c-7.1* eAG-157* ___ 06:44AM GLUCOSE-172* UREA N-23* CREAT-1.2 SODIUM-137 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17 IMAGES/STUDIES ================ Foot Xray IMPRESSION: Degenerative changes at the first MTP joint without definite acute cortical destruction to suggest acute osteomyelitis. If high clinical concern, MRI is more sensitive. No definite soft tissue gas seen. ___: IMPRESSION: No evidence of deep venous thrombosis ___ the left lower extremity veins. The left peroneal veins are not visualized. MICROBIOLOGY ================= ___ 6:45 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:50 pm SWAB Source: Left hallux wound deep. **FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final ___: BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH. 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. Work-up of organism(s) listed discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. DISCHARGE ============ ___ 06:39AM BLOOD WBC-8.9 RBC-3.71* Hgb-10.7* Hct-32.8* MCV-88 MCH-28.8 MCHC-32.6 RDW-13.0 RDWSD-41.8 Plt ___ ___ 06:39AM BLOOD Glucose-174* UreaN-24* Creat-1.5* Na-135 K-4.2 Cl-103 HCO3-20* AnGap-16 ___ 06:39AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.___ M with PMH IDDM DM2 c/b retinopathy, nephropathy, and neuropathy, HTN, traumatic SAH c/b seizure, CVA x2 ___ last year, hypothyroidism, CKD ___ early Lithium nephropathy with secondary FSGS, chronic lymphedema and bipolar disorder presenting with increased swelling, erythema and ulceration of left first toe concerning for diabetic soft tissue foot infection vs osteomyelitis. # LLE hallux ulcer infection/?osteomyelitis: Patient with chronic toe swelling and deformation, which developed ulcer 1 week and purulent drainage ___ days prior to presentation, associated with subjective fevers and chills at home. Leukocytosis 11.8 on admission. Otherwise no evidence of systemic infection throughout admission. ESR/CRP - ___ were mildly elevated. Foot Xray with out evidence of ___, however probe to bone on examination raising concern for possible ___. If ulcer is only one week old, then osteomyelitis is less likely. Podiatry took pt to OR for left hallux arthroplasty and debridement on ___, mainly to help decompress toe to help with ulcer healing. MRI was not obtained since Podiatry had decided they would take to OR regardless of MRI findings. Podiatry attending is patient's outpatient Podiatrist and noted that ___ looked like ___ had a very small area of possible osteomyelitis. Bone cultures pending at time of discharge, as was the bone pathology. Patient adamant about leaving and was extremely upset that pathology did not return on ___. After curbside discussion with ID, direct discussion with Podiatry, and patient and wife, it was decided to send patient out on oral Levofloxacin and Flagyl for 2 week soft tissue infection treatment. Outpatient Podiatry will follow up on final pathology, patient already has an appointment scheduled, and decide if any changes need to be made. Patient was treated with IV vanco (renally-dosed), Cipro, and Flagyl, and switched to oral Levofloxacin and Flagyl. Day #1 is day after OR/possible source control on ___ -> last day ___. # Lower extremity swelling: Patient has history of chronic lymphedema, however left leg was slightly more warm on initial exam. ___ was negative for DVT. Patient was given compression stockings. # Bipolar disorder: ___ ED patient reported feeling "off the rails" and more angry for the past few months and endorsed wanting to hurt someone, including the staff. ___ denied SI/HI, however requested to see Psychiatry due to his worsening anger issues. Psychiatry recommended adding Quetiapine 50mg BID to his home Quetiapine 100mg QHS. Did not meet ___, and no need for 1:1 observation. Did not require any PRNs since admission. Patient should have Psychiatry follow up for further titration of his medications. # ___ on CKD: Increased to 1.5 from his baseline of 1.2. Patient's volume status is difficult given chronic lower extremity swelling from lymphedema, and large neck makes JVP assessment difficult. UNa 22, so given slow 1L. Urine output remained at baseline. Patient adamant to leave hospital on ___. Explained this to patient and wife. They agreed to check his labs on ___ and to make sure to follow up with his PCP. Held HCTZ, should be restarted once improved per outpatient providers. Antibiotics were renally dosed. CHRONIC ISSUES # IDDM: Continued home regimen 15U of 70/30 with meals. Of note, patient fasting, so held for some meals ___ setting of lent). Patient should follow up with ___ ___ ___ and continue titration of his insulin. Ofnote, his Hgb A1c was improved to 7.1%, down from 11.2% ___ ___. # Hypothyroidism: Continued home Levothyroxine. # Hypertension: Patient hypertensive ___ 150s-160s. Restarted HCTZ 25mg after OR ___ and his blood pressures improved. However creatinine uptrending to 1.5, so HCTZ was held on discharge. Continued home Metoprolol. HCTZ should be restarted once Cr is rechecked on ___. # GERD: Continued home omeprazole. # H/o of CVA: Continued home Atorvastatin, and ASA. TRANSITIONAL ISSUES =========================== [] Holding HCTZ ___ setting ___ on CKD (Cr 1.5 on ___, from baseline of 1.2). [] Check Chem 10 on ___ and fax to PCP ___ ___. Follow Creatinine. [] Started Quetiapine 50mg BID per Psychiatry, ___ addition to 100mg QHS [] Continue Flagyl and Levofloxacin for total of two weeks (Day ___ - ___ for soft tissue infection. [] NO ALCOHOL for at least 5 days after stopping Metronidazole. [] Follow up FINAL bone pathology (should return the afternoon of ___ to confirm there was no acute ___ at surgical margins. If acute ___ need IV antibiotics. Wife, patient, ___ aware of this. [] If any changes ___ vitals, fevers, changes ___ wound, patient should return to ED or seek medical attention immediately. [] Patient w/ several months of intermittent left arm numbness and tingling, likely pinched nerve. Tinel and Phalen's test negative. Should have OT and further work up with his PCP. [] Continue extensive counseling on NOT taking such high level of Tylenol (takes up to ___ tablets per day) for his toe pain. Now much improved. However continue counseling on this. [] Patient should follow up with ___ ___ ___ for ongoing insulin titration. [] Pathology results were found to be positive for focal acute osteomyelitis, patient has outpatient podiatry appointment scheduled for ___. # CODE STATUS: FULL, confirmed # CONTACT: Wife/HCP: ___ ___ # DISPO: medicine, pending above Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. QUEtiapine Fumarate 100 mg PO QHS 7. Sertraline 50 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Hydrochlorothiazide 25 mg PO DAILY 11. Vitamin D ___ UNIT PO DAILY 12. Fenofibrate 48 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Zinc Sulfate Dose is Unknown PO DAILY 15. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown 16. 70/30 15 Units Breakfast 70/30 15 Units Lunch 70/30 15 Units Dinner Discharge Medications: 1. Levofloxacin 500 mg PO Q24H RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*12 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*36 Tablet Refills:*0 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. 70/30 15 Units Breakfast 70/30 15 Units Lunch 70/30 15 Units Dinner 5. QUEtiapine Fumarate 50 mg PO BID RX *quetiapine 50 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Zinc Sulfate 220 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Cyanocobalamin 1000 mcg PO DAILY 10. Fenofibrate 48 mg PO DAILY 11. FoLIC Acid 1 mg PO DAILY 12. Levothyroxine Sodium 125 mcg PO DAILY 13. Metoprolol Succinate XL 25 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 20 mg PO DAILY 16. QUEtiapine Fumarate 100 mg PO QHS 17. Sertraline 50 mg PO DAILY 18. Vitamin D ___ UNIT PO DAILY 19. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until your PCP restarts this 20.Outpatient Lab Work ___: Na, Cr, BUN, HCO3, Cl, K ICD10: N17.9, ___ on CKD please fax to PCP: Dr. ___ ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== Left hallux ulcer Soft tissue infection SECONDARY DIAGNOSIS ===================== Diabetes, Type II Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you at ___. You came to our hospital for a left toe ulcer that was draining. We treated you with antibiotics and by having your podiatrist remove affected bone to control the source. We need to make sure you follow up with your PCP and ___ to confirm that the pathology returned negative for acute bone infection. If it does return ith acute bone infection that may have not been removed entirely, then you will need to discuss other antibiotics with your doctors. ___ is VERY important as you may become more sick. If you have drainage or bad smell, fevers, chills or sweats you must return to the hospital for further evaluation. We wish you the very best, Your ___ Team Followup Instructions: ___
[ "E11621", "M86172", "N179", "E1121", "E1140", "F3181", "L97529", "Z794", "E1169", "E11319", "E11628", "L03032", "E1122", "T43595S", "N189", "I129", "I890", "E538", "R251", "K2270", "Z87891", "M205X2", "Z89411" ]
Allergies: ACE Inhibitors / [MASKED] Receptor Antagonist Chief Complaint: Toe ulcer, fevers, chills Major Surgical or Invasive Procedure: Left hallux debridement and biopsy on [MASKED] History of Present Illness: [MASKED] M with [MASKED] IDDM DM2 c/b retinopathy, nephropathy, and neuropathy, HTN, traumatic SAH c/b seizure, CVA x2 [MASKED] last year, hypothyroidism, CKD [MASKED] early Lithium nephropathy with secondary FSGS, chronic lymphedema and bipolar disorder presenting with increased swelling, erythema and ulceration of left first toe. Patient has had swelling of his left toe for a long time, however [MASKED] the past few days the swelling and erythema worsened. [MASKED] also noticed purulent drainage, but is unsure when [MASKED] noticed it. Patient also endorses subjective fevers/chills at home x [MASKED] days. [MASKED] denies associated pain or paresthesias. Also denies CP/pressure, SOB, n/v, diarrhea or dysuria. [MASKED] the ED patient reported feeling "off the rails" and more angry for the past few months and endorsed wanting to hurt someone, including the staff. [MASKED] says these violent impulses are worse lately and feels his medication is not working. [MASKED] requests psych evaluation as [MASKED] is becoming more verbally abusive to his wife. [MASKED] changes [MASKED] sleep, appetite, racing thoughts. [MASKED] the ED, initial vitals: 99.3 79 187/79 18 100% RA - Labs were significant for: WBC 11.3, Hgb 11.8 (at about baseline), plt 352, Cr 1.2 (baseline 1.2). - Physical exam: Ext: bilateral 2+ pitting edema to knee with diffuse erythema. R first toe amputation. Left first toe with anterior callous and ulcer not purulent with compression. No assoc. tenderness. Psych; yelling, agitated, interrupting examiner, dismissing male providers from room, saying [MASKED] "hates men." - Imaging showed: Foot xray without evidence of [MASKED]. - [MASKED] the ED, [MASKED] received: IV Vanco 1mg, Haldol IM 5mg, Levothyroxine, Quetiapine 50mg, omeprazole 20mg, Metoprolol 12.5mg. - Vitals prior to transfer: 97.7 77 176/83 18 18 100% RA Upon arrival to the floor, patient denies any toe pain and endorses above story. [MASKED] is able to recount all of his medications. While clarifying his insulin regimen, patient became acute upset about having to clarify his insulin regimen. [MASKED] asked MD to leave the room and also said [MASKED] will not take an insulin sliding scale as "that does not work" for him. Denied any other symptoms. REVIEW OF SYSTEMS: 10 point review of system otherwise negative. Positive per HPI. Past Medical History: Hypothyroidism DM (diabetes mellitus), type 2 with renal complications, retinopathy Diabetic retinopathy CKD (baseline 1.1-1.3) Hypertension B12 deficiency Bipolar disorder Depression Tremor, ?parkinsonism Colonic adenoma [MASKED] esophagus Social History: [MASKED] Family History: Per WebOMR and reviewed with patient: Maternal grandmother with DM and CAD. Sister with breast cancer and bipolar disorder. Father with stomach cancer, peptic ulcer disease, bipolar disorder, kidney disease, died of PNA. Mother with bipolar disorder, died of bone cancer (per records report of breast cancer, but patient notes it was bone cancer). Physical Exam: ADMISSION =========== Vital Signs: 97.8 157 / 83 73 20 98% RA General: Alert, oriented, no acute distress. Answering questions appropriately, however volatile emotionally. Patient upset at having to repeat his insulin dosing regimen and kicked MD out of room. HEENT: Sclerae anicteric, MMM. CV: RRR, no murmurs, rubs Lungs: Unable to examen as pt refused Abdomen: Obese. Unable to complete exam as pt refused GU: No foley Ext: Warm, well perfused. 2+ pulses. Left extremity slightly warmer than right. 1+ pitting edema bilaterally. Left toe with 1x1cm ulcer on anterior aspect of toe. Ulcer with yellow base and surrounding erythema which is localized to toe. Does have an erythematous plaque on medial shin that is not connected to the toe which pt notes is chronic although at times not as erythematous. It is non tender non pruritic. Right large toe amputation. Neuro: Unable to perform exam. DISCHARGE ============ Vital Signs: 98.1 160 / 84 80 20 98% RA General: Alert, oriented, no acute distress. HEENT: Sclerae anicteric, MMM. CV: RRR, no murmurs, rubs Lungs: CTAB Abdomen: Obese. Nontender to palpation, no guarding. GU: No foley Ext: Warm, well perfused. 2+ pulses. Left hallux bandaged. No erythema on shin or fore foot. Neuro: AAOx3. Moving all extremities with purpose. Able to ambulate to bathroom on his own. Pertinent Results: ADMISSION =========== [MASKED] 06:44AM PLT COUNT-352# [MASKED] 06:44AM NEUTS-65.2 LYMPHS-17.8* MONOS-11.6 EOS-4.5 BASOS-0.5 IM [MASKED] AbsNeut-7.38* AbsLymp-2.02 AbsMono-1.31* AbsEos-0.51 AbsBaso-0.06 [MASKED] 06:44AM WBC-11.3* RBC-4.22* HGB-11.8* HCT-37.3* MCV-88 MCH-28.0 MCHC-31.6* RDW-12.8 RDWSD-41.7 [MASKED] 06:44AM CRP-11.7* [MASKED] 06:44AM %HbA1c-7.1* eAG-157* [MASKED] 06:44AM GLUCOSE-172* UREA N-23* CREAT-1.2 SODIUM-137 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17 IMAGES/STUDIES ================ Foot Xray IMPRESSION: Degenerative changes at the first MTP joint without definite acute cortical destruction to suggest acute osteomyelitis. If high clinical concern, MRI is more sensitive. No definite soft tissue gas seen. [MASKED]: IMPRESSION: No evidence of deep venous thrombosis [MASKED] the left lower extremity veins. The left peroneal veins are not visualized. MICROBIOLOGY ================= [MASKED] 6:45 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 5:50 pm SWAB Source: Left hallux wound deep. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 3+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [MASKED]: BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH. 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. Work-up of organism(s) listed discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. ANAEROBIC CULTURE (Final [MASKED]: NO ANAEROBES ISOLATED. DISCHARGE ============ [MASKED] 06:39AM BLOOD WBC-8.9 RBC-3.71* Hgb-10.7* Hct-32.8* MCV-88 MCH-28.8 MCHC-32.6 RDW-13.0 RDWSD-41.8 Plt [MASKED] [MASKED] 06:39AM BLOOD Glucose-174* UreaN-24* Creat-1.5* Na-135 K-4.2 Cl-103 HCO3-20* AnGap-16 [MASKED] 06:39AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.[MASKED] M with PMH IDDM DM2 c/b retinopathy, nephropathy, and neuropathy, HTN, traumatic SAH c/b seizure, CVA x2 [MASKED] last year, hypothyroidism, CKD [MASKED] early Lithium nephropathy with secondary FSGS, chronic lymphedema and bipolar disorder presenting with increased swelling, erythema and ulceration of left first toe concerning for diabetic soft tissue foot infection vs osteomyelitis. # LLE hallux ulcer infection/?osteomyelitis: Patient with chronic toe swelling and deformation, which developed ulcer 1 week and purulent drainage [MASKED] days prior to presentation, associated with subjective fevers and chills at home. Leukocytosis 11.8 on admission. Otherwise no evidence of systemic infection throughout admission. ESR/CRP - [MASKED] were mildly elevated. Foot Xray with out evidence of [MASKED], however probe to bone on examination raising concern for possible [MASKED]. If ulcer is only one week old, then osteomyelitis is less likely. Podiatry took pt to OR for left hallux arthroplasty and debridement on [MASKED], mainly to help decompress toe to help with ulcer healing. MRI was not obtained since Podiatry had decided they would take to OR regardless of MRI findings. Podiatry attending is patient's outpatient Podiatrist and noted that [MASKED] looked like [MASKED] had a very small area of possible osteomyelitis. Bone cultures pending at time of discharge, as was the bone pathology. Patient adamant about leaving and was extremely upset that pathology did not return on [MASKED]. After curbside discussion with ID, direct discussion with Podiatry, and patient and wife, it was decided to send patient out on oral Levofloxacin and Flagyl for 2 week soft tissue infection treatment. Outpatient Podiatry will follow up on final pathology, patient already has an appointment scheduled, and decide if any changes need to be made. Patient was treated with IV vanco (renally-dosed), Cipro, and Flagyl, and switched to oral Levofloxacin and Flagyl. Day #1 is day after OR/possible source control on [MASKED] -> last day [MASKED]. # Lower extremity swelling: Patient has history of chronic lymphedema, however left leg was slightly more warm on initial exam. [MASKED] was negative for DVT. Patient was given compression stockings. # Bipolar disorder: [MASKED] ED patient reported feeling "off the rails" and more angry for the past few months and endorsed wanting to hurt someone, including the staff. [MASKED] denied SI/HI, however requested to see Psychiatry due to his worsening anger issues. Psychiatry recommended adding Quetiapine 50mg BID to his home Quetiapine 100mg QHS. Did not meet [MASKED], and no need for 1:1 observation. Did not require any PRNs since admission. Patient should have Psychiatry follow up for further titration of his medications. # [MASKED] on CKD: Increased to 1.5 from his baseline of 1.2. Patient's volume status is difficult given chronic lower extremity swelling from lymphedema, and large neck makes JVP assessment difficult. UNa 22, so given slow 1L. Urine output remained at baseline. Patient adamant to leave hospital on [MASKED]. Explained this to patient and wife. They agreed to check his labs on [MASKED] and to make sure to follow up with his PCP. Held HCTZ, should be restarted once improved per outpatient providers. Antibiotics were renally dosed. CHRONIC ISSUES # IDDM: Continued home regimen 15U of 70/30 with meals. Of note, patient fasting, so held for some meals [MASKED] setting of lent). Patient should follow up with [MASKED] [MASKED] [MASKED] and continue titration of his insulin. Ofnote, his Hgb A1c was improved to 7.1%, down from 11.2% [MASKED] [MASKED]. # Hypothyroidism: Continued home Levothyroxine. # Hypertension: Patient hypertensive [MASKED] 150s-160s. Restarted HCTZ 25mg after OR [MASKED] and his blood pressures improved. However creatinine uptrending to 1.5, so HCTZ was held on discharge. Continued home Metoprolol. HCTZ should be restarted once Cr is rechecked on [MASKED]. # GERD: Continued home omeprazole. # H/o of CVA: Continued home Atorvastatin, and ASA. TRANSITIONAL ISSUES =========================== [] Holding HCTZ [MASKED] setting [MASKED] on CKD (Cr 1.5 on [MASKED], from baseline of 1.2). [] Check Chem 10 on [MASKED] and fax to PCP [MASKED] [MASKED]. Follow Creatinine. [] Started Quetiapine 50mg BID per Psychiatry, [MASKED] addition to 100mg QHS [] Continue Flagyl and Levofloxacin for total of two weeks (Day [MASKED] - [MASKED] for soft tissue infection. [] NO ALCOHOL for at least 5 days after stopping Metronidazole. [] Follow up FINAL bone pathology (should return the afternoon of [MASKED] to confirm there was no acute [MASKED] at surgical margins. If acute [MASKED] need IV antibiotics. Wife, patient, [MASKED] aware of this. [] If any changes [MASKED] vitals, fevers, changes [MASKED] wound, patient should return to ED or seek medical attention immediately. [] Patient w/ several months of intermittent left arm numbness and tingling, likely pinched nerve. Tinel and Phalen's test negative. Should have OT and further work up with his PCP. [] Continue extensive counseling on NOT taking such high level of Tylenol (takes up to [MASKED] tablets per day) for his toe pain. Now much improved. However continue counseling on this. [] Patient should follow up with [MASKED] [MASKED] [MASKED] for ongoing insulin titration. [] Pathology results were found to be positive for focal acute osteomyelitis, patient has outpatient podiatry appointment scheduled for [MASKED]. # CODE STATUS: FULL, confirmed # CONTACT: Wife/HCP: [MASKED] [MASKED] # DISPO: medicine, pending above Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. QUEtiapine Fumarate 100 mg PO QHS 7. Sertraline 50 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Hydrochlorothiazide 25 mg PO DAILY 11. Vitamin D [MASKED] UNIT PO DAILY 12. Fenofibrate 48 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Zinc Sulfate Dose is Unknown PO DAILY 15. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown 16. 70/30 15 Units Breakfast 70/30 15 Units Lunch 70/30 15 Units Dinner Discharge Medications: 1. Levofloxacin 500 mg PO Q24H RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*12 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*36 Tablet Refills:*0 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. 70/30 15 Units Breakfast 70/30 15 Units Lunch 70/30 15 Units Dinner 5. QUEtiapine Fumarate 50 mg PO BID RX *quetiapine 50 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Zinc Sulfate 220 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Cyanocobalamin 1000 mcg PO DAILY 10. Fenofibrate 48 mg PO DAILY 11. FoLIC Acid 1 mg PO DAILY 12. Levothyroxine Sodium 125 mcg PO DAILY 13. Metoprolol Succinate XL 25 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 20 mg PO DAILY 16. QUEtiapine Fumarate 100 mg PO QHS 17. Sertraline 50 mg PO DAILY 18. Vitamin D [MASKED] UNIT PO DAILY 19. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until your PCP restarts this 20.Outpatient Lab Work [MASKED]: Na, Cr, BUN, HCO3, Cl, K ICD10: N17.9, [MASKED] on CKD please fax to PCP: Dr. [MASKED] [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== Left hallux ulcer Soft tissue infection SECONDARY DIAGNOSIS ===================== Diabetes, Type II Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure to care for you at [MASKED]. You came to our hospital for a left toe ulcer that was draining. We treated you with antibiotics and by having your podiatrist remove affected bone to control the source. We need to make sure you follow up with your PCP and [MASKED] to confirm that the pathology returned negative for acute bone infection. If it does return ith acute bone infection that may have not been removed entirely, then you will need to discuss other antibiotics with your doctors. [MASKED] is VERY important as you may become more sick. If you have drainage or bad smell, fevers, chills or sweats you must return to the hospital for further evaluation. We wish you the very best, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N179", "Z794", "E1122", "N189", "I129", "Z87891" ]
[ "E11621: Type 2 diabetes mellitus with foot ulcer", "M86172: Other acute osteomyelitis, left ankle and foot", "N179: Acute kidney failure, unspecified", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "F3181: Bipolar II disorder", "L97529: Non-pressure chronic ulcer of other part of left foot with unspecified severity", "Z794: Long term (current) use of insulin", "E1169: Type 2 diabetes mellitus with other specified complication", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E11628: Type 2 diabetes mellitus with other skin complications", "L03032: Cellulitis of left toe", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "T43595S: Adverse effect of other antipsychotics and neuroleptics, sequela", "N189: Chronic kidney disease, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I890: Lymphedema, not elsewhere classified", "E538: Deficiency of other specified B group vitamins", "R251: Tremor, unspecified", "K2270: Barrett's esophagus without dysplasia", "Z87891: Personal history of nicotine dependence", "M205X2: Other deformities of toe(s) (acquired), left foot", "Z89411: Acquired absence of right great toe" ]
10,031,358
29,498,981
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ACE Inhibitors / ___ Receptor Antagonist Attending: ___. Chief Complaint: slurred speech, facial droop Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old male with history of DM, HTN, HLD, and noncompliance to meds for financial reasons, who developed right facial droop and slurred speech yesterday afternoon around 3pm. He says that he was feeling like himself yesterday, and he is not missing any part of the day. Around 3pm, he called his sister, and she could not understand any words that he was saying. He noticed that his speech was slurred, but he did not have any difficulty understanding others or getting words out. He then looked in the mirror, and he noted that the right side of his face was droopy. He thought that it was due to his diabetes because he has not taken his diabetes medications in over a year. His wife came home, and she noted that his speech was slurred and that his face was asymmetric. This morning, his wife woke up and realized that her friend had had a TIA where people could not understand what they were saying. She called his PCP who recommended an urgent visit in the clinic, but she decided to bring him to the ED. In ___, he had amputation of his toes on the right foot, and he was in rehab in ___. He tried to get up and get a cup of coffee, but he was connected to a wound vacuum on his heel. He tripped and fell, and his wife says that he hit the back of his head. She did not witness the fall, and she is not sure if he lost consciousness. He was transported to ___, where he was found to have a 4mm right parafalcine subdural hemorrhage. The next day at ___, he was reported to have a seizure. His wife was not present, and there is no description over the episode other than a "generalized tonic-clonic seizure". He was started on levetiracetam, but he has not been taking it for the past two months. He currently denies headache, loss of vision, diplopia, 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. Otherwise, his general review of systems is negative. Past Medical History: Hypothyroidism DM (diabetes mellitus), type 2 with renal complications, retinopathy Diabetic retinopathy CKD (baseline 1.1-1.3) Hypertension B12 deficiency Bipolar disorder Depression Tremor, ?parkinsonism Colonic adenoma ___ esophagus Social History: ___ Family History: mGM with DM and CAD. Sister with breast cancer and bipolar disorder. Father with stomach cancer, peptic ulcer disease, bipolar disorder, kidney disease, died of PNA. Mother with bipolar disorder, died of bone cancer (per records report of breast cancer, but patient notes it was bone cancer). Physical Exam: Admission Physical Exam: Vitals: 97.3 69 151/64 18 99% RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Neck: Supple Pulmonary: No increased WOB Cardiac: RRR Abdomen: Soft, non-distended Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name days of the week backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. He was able to name both high and low frequency objects. Able to read without difficulty. Speech was dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Right facial droop, symmetric strength in upper face 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. Pronation and mild drift on the right, orbiting of the right arm Delt Bic Tri WrE IO IP Quad Ham TA L 5 ___ ___ 5 5 R 5 ___ ___ 5 5 -Sensory: No deficits to light touch -DTRs: Bi Tri ___ Pat L 2 2 2 2 R 2 2 2 2 -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. Slightly slower finger tapping on the right. -Gait: non-ambulatory ========================================= DISCHARGE PHYSICAL EXAMINATION: Vitals: 98.4 97.7 99-123/40-60 ___ 18 98%RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Pulmonary: No increased WOB Abdomen: Soft, non-distended Neurologic: -Mental Status: Alert, oriented x 3. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 5 to 4mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Right NLFF, symmetric strength in upper face IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Pronation and mild drift on the right, orbiting of the right arm Delt Bic Tri WrE IO IP Quad Ham TA L 5 ___ ___ 5 5 R 5 ___ ___ 5 5 -Sensory: No deficits to light touch -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. Slightly slower finger tapping on the right. -Gait: not tested Pertinent Results: ___ 05:20AM BLOOD WBC-9.2 RBC-4.15* Hgb-11.9* Hct-35.9* MCV-87 MCH-28.7 MCHC-33.1 RDW-13.0 RDWSD-40.4 Plt ___ ___ 02:30AM BLOOD WBC-11.4* RBC-3.96* Hgb-11.5* Hct-34.1* MCV-86 MCH-29.0 MCHC-33.7 RDW-12.9 RDWSD-39.8 Plt ___ ___ 06:15AM BLOOD WBC-11.0* RBC-4.41* Hgb-12.6* Hct-38.5* MCV-87 MCH-28.6 MCHC-32.7 RDW-13.3 RDWSD-41.4 Plt ___ ___ 05:20AM BLOOD Neuts-53.5 ___ Monos-13.2* Eos-4.0 Baso-1.0 Im ___ AbsNeut-4.92 AbsLymp-2.53 AbsMono-1.21* AbsEos-0.37 AbsBaso-0.09* ___ 06:15AM BLOOD Neuts-58.2 ___ Monos-11.4 Eos-4.0 Baso-0.9 Im ___ AbsNeut-6.40*# AbsLymp-2.72 AbsMono-1.26* AbsEos-0.44 AbsBaso-0.10* ___ 05:20AM BLOOD Plt ___ ___ 05:20AM BLOOD ___ PTT-29.5 ___ ___ 02:30AM BLOOD Plt ___ ___ 02:30AM BLOOD ___ PTT-29.5 ___ ___ 05:20AM BLOOD Glucose-233* UreaN-27* Creat-1.3* Na-134 K-4.1 Cl-99 HCO3-24 AnGap-15 ___ 02:30AM BLOOD Glucose-156* UreaN-23* Creat-1.4* Na-135 K-4.2 Cl-100 HCO3-22 AnGap-17 ___ 06:15AM BLOOD Glucose-304* UreaN-20 Creat-1.6* Na-134 K-5.8* Cl-99 HCO3-21* AnGap-20 ___ 06:15AM BLOOD ALT-16 AST-33 AlkPhos-74 TotBili-0.4 ___ 06:15AM BLOOD Lipase-50 ___ 06:15AM BLOOD cTropnT-<0.01 ___ 05:20AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.8 ___ 02:30AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.7 Cholest-203* ___ 06:15AM BLOOD Albumin-3.7 ___ 02:30AM BLOOD %HbA1c-8.5* eAG-197* ___ 02:30AM BLOOD Triglyc-396* HDL-38 CHOL/HD-5.3 LDLcalc-86 ___ 06:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ CT HEAD W/O CONTRAST 1. 13 mm hemorrhage in the left putamen, compatible with hypertensive hemorrhage. 2. Paranasal sinus inflammatory disease. ___ CXR No acute cardiopulmonary process. ___ MR HEAD W/O CONTRAST 1. Stable left putaminal hematoma with mild surrounding edema and no significant effect or midline shift. No acute infarct. 2. No visualization of the right distal V3 or V4 segments of the vertebral artery with a diminutive distal right V4 segment seen. This may represent a diminutive vessel versus occlusion. A MRA can be acquired for further evaluation if clinically indicated. 3. Paranasal sinus disease. 4. Prominence of the posterior nasopharyngeal soft tissues, which may represent prominent adenoids. Recommend correlation with direct visualization. Brief Hospital Course: Mr. ___ is a ___ year old male with history of DM, HTN, HLD, and noncompliance to medications for financial reasons who is admitted to the Neurology stroke service with right facial droop and slurred speech the day prior to admission secondary to an acute intraparenchymal hemorrhage in the Left basal ganglia. Aspirin was held initially. His stroke was most likely secondary to medication noncompliance for the 2 months prior to admission due to financial difficulties. ASA 81 daily will be restarted upon hospital discharge. He should continue his home metoprolol and HCTZ for blood pressure control. His deficits improved prior to discharge and the only notable weakness was in the right nasolabial fold. He was seen by ___, OT, and speech and swallow therapy. He will be discharged home with outpatient speech therapy. His intraparenchmal hemorrhage risk factors include the following: 1) DM: A1c 8.5% 2) Poorly controlled hypertension 3) Obesity Since he has not taken his meds for the two months prior to hospital admission, his Seroquel was restarted at the much lower dose of 100mg qhs. The Seroquel may be uptitrated as an outpatient as per his PCP or psychiatrist. The Seroquel was not restarted at his prior dose of 600mg qhs because this may have resulted in a dangerous possibility of getting a prolonged Qtc syndrome and somnolence, among other possible side effects. AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Glargine 60 Units Bedtime aspart 8 Units Breakfast aspart 8 Units Lunch aspart 8 Units Dinner 5. Levothyroxine Sodium 125 mcg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. QUEtiapine extended-release 600 mg PO QHS 8. Sertraline 50 mg PO DAILY 9. Simvastatin 40 mg PO QPM 10. Aspirin 81 mg PO DAILY 11. Cyanocobalamin 50 mcg PO DAILY 12. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Simvastatin 40 mg PO QPM RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Sertraline 50 mg PO DAILY RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Hydrochlorothiazide 25 mg PO DAILY RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. FoLIC Acid 1 mg PO DAILY 7. Cyanocobalamin 50 mcg PO DAILY 8. Levothyroxine Sodium 125 mcg PO DAILY RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 10. RX *quetiapine 100 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Vitamin D ___ UNIT PO DAILY 12. LeVETiracetam 750 mg PO BID RX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Outpatient Speech/Swallowing Therapy 1. PO diet: thin liquids, regular solids, Pills: whole in thin liquids 2. Standard aspiration precautions, including: Small bites, chew thoroughly 3. Speech tx upon discharge 14. 70/30 16 Units Breakfast 70/30 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100 unit/mL (70-30) AS DIR 16 Units before BKFT; 10 Units before DINR; Disp #*30 Syringe Refills:*0 15. KwikPen Needles KwikPen Needles 30 Discharge Disposition: Home Discharge Diagnosis: Intraparenchymal hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized due to symptoms of facial droop and slurred speech resulting from an acute bleed in your brain (intraparenchymal hemorrhage). The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Bleeding in the brain can have many different causes, so we assessed you for medical conditions that might raise your risk. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Diabetes High blood pressure High cholesterol Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
[ "I619", "G8191", "E1329", "E1140", "K2270", "Z6841", "E538", "R1310", "E11319", "R29810", "E119", "E785", "Z9114", "E039", "N189", "E669", "R471", "I129", "F319", "F329", "Z7982", "Z794", "Z89421", "Z87891" ]
Allergies: ACE Inhibitors / [MASKED] Receptor Antagonist Chief Complaint: slurred speech, facial droop Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with history of DM, HTN, HLD, and noncompliance to meds for financial reasons, who developed right facial droop and slurred speech yesterday afternoon around 3pm. He says that he was feeling like himself yesterday, and he is not missing any part of the day. Around 3pm, he called his sister, and she could not understand any words that he was saying. He noticed that his speech was slurred, but he did not have any difficulty understanding others or getting words out. He then looked in the mirror, and he noted that the right side of his face was droopy. He thought that it was due to his diabetes because he has not taken his diabetes medications in over a year. His wife came home, and she noted that his speech was slurred and that his face was asymmetric. This morning, his wife woke up and realized that her friend had had a TIA where people could not understand what they were saying. She called his PCP who recommended an urgent visit in the clinic, but she decided to bring him to the ED. In [MASKED], he had amputation of his toes on the right foot, and he was in rehab in [MASKED]. He tried to get up and get a cup of coffee, but he was connected to a wound vacuum on his heel. He tripped and fell, and his wife says that he hit the back of his head. She did not witness the fall, and she is not sure if he lost consciousness. He was transported to [MASKED], where he was found to have a 4mm right parafalcine subdural hemorrhage. The next day at [MASKED], he was reported to have a seizure. His wife was not present, and there is no description over the episode other than a "generalized tonic-clonic seizure". He was started on levetiracetam, but he has not been taking it for the past two months. He currently denies headache, loss of vision, diplopia, 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. Otherwise, his general review of systems is negative. Past Medical History: Hypothyroidism DM (diabetes mellitus), type 2 with renal complications, retinopathy Diabetic retinopathy CKD (baseline 1.1-1.3) Hypertension B12 deficiency Bipolar disorder Depression Tremor, ?parkinsonism Colonic adenoma [MASKED] esophagus Social History: [MASKED] Family History: mGM with DM and CAD. Sister with breast cancer and bipolar disorder. Father with stomach cancer, peptic ulcer disease, bipolar disorder, kidney disease, died of PNA. Mother with bipolar disorder, died of bone cancer (per records report of breast cancer, but patient notes it was bone cancer). Physical Exam: Admission Physical Exam: Vitals: 97.3 69 151/64 18 99% RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Neck: Supple Pulmonary: No increased WOB Cardiac: RRR Abdomen: Soft, non-distended Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name days of the week backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. He was able to name both high and low frequency objects. Able to read without difficulty. Speech was dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Right facial droop, symmetric strength in upper face 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. Pronation and mild drift on the right, orbiting of the right arm Delt Bic Tri WrE IO IP Quad Ham TA L 5 [MASKED] [MASKED] 5 5 R 5 [MASKED] [MASKED] 5 5 -Sensory: No deficits to light touch -DTRs: Bi Tri [MASKED] Pat L 2 2 2 2 R 2 2 2 2 -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. Slightly slower finger tapping on the right. -Gait: non-ambulatory ========================================= DISCHARGE PHYSICAL EXAMINATION: Vitals: 98.4 97.7 99-123/40-60 [MASKED] 18 98%RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Pulmonary: No increased WOB Abdomen: Soft, non-distended Neurologic: -Mental Status: Alert, oriented x 3. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 5 to 4mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Right NLFF, symmetric strength in upper face IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Pronation and mild drift on the right, orbiting of the right arm Delt Bic Tri WrE IO IP Quad Ham TA L 5 [MASKED] [MASKED] 5 5 R 5 [MASKED] [MASKED] 5 5 -Sensory: No deficits to light touch -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. Slightly slower finger tapping on the right. -Gait: not tested Pertinent Results: [MASKED] 05:20AM BLOOD WBC-9.2 RBC-4.15* Hgb-11.9* Hct-35.9* MCV-87 MCH-28.7 MCHC-33.1 RDW-13.0 RDWSD-40.4 Plt [MASKED] [MASKED] 02:30AM BLOOD WBC-11.4* RBC-3.96* Hgb-11.5* Hct-34.1* MCV-86 MCH-29.0 MCHC-33.7 RDW-12.9 RDWSD-39.8 Plt [MASKED] [MASKED] 06:15AM BLOOD WBC-11.0* RBC-4.41* Hgb-12.6* Hct-38.5* MCV-87 MCH-28.6 MCHC-32.7 RDW-13.3 RDWSD-41.4 Plt [MASKED] [MASKED] 05:20AM BLOOD Neuts-53.5 [MASKED] Monos-13.2* Eos-4.0 Baso-1.0 Im [MASKED] AbsNeut-4.92 AbsLymp-2.53 AbsMono-1.21* AbsEos-0.37 AbsBaso-0.09* [MASKED] 06:15AM BLOOD Neuts-58.2 [MASKED] Monos-11.4 Eos-4.0 Baso-0.9 Im [MASKED] AbsNeut-6.40*# AbsLymp-2.72 AbsMono-1.26* AbsEos-0.44 AbsBaso-0.10* [MASKED] 05:20AM BLOOD Plt [MASKED] [MASKED] 05:20AM BLOOD [MASKED] PTT-29.5 [MASKED] [MASKED] 02:30AM BLOOD Plt [MASKED] [MASKED] 02:30AM BLOOD [MASKED] PTT-29.5 [MASKED] [MASKED] 05:20AM BLOOD Glucose-233* UreaN-27* Creat-1.3* Na-134 K-4.1 Cl-99 HCO3-24 AnGap-15 [MASKED] 02:30AM BLOOD Glucose-156* UreaN-23* Creat-1.4* Na-135 K-4.2 Cl-100 HCO3-22 AnGap-17 [MASKED] 06:15AM BLOOD Glucose-304* UreaN-20 Creat-1.6* Na-134 K-5.8* Cl-99 HCO3-21* AnGap-20 [MASKED] 06:15AM BLOOD ALT-16 AST-33 AlkPhos-74 TotBili-0.4 [MASKED] 06:15AM BLOOD Lipase-50 [MASKED] 06:15AM BLOOD cTropnT-<0.01 [MASKED] 05:20AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.8 [MASKED] 02:30AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.7 Cholest-203* [MASKED] 06:15AM BLOOD Albumin-3.7 [MASKED] 02:30AM BLOOD %HbA1c-8.5* eAG-197* [MASKED] 02:30AM BLOOD Triglyc-396* HDL-38 CHOL/HD-5.3 LDLcalc-86 [MASKED] 06:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] CT HEAD W/O CONTRAST 1. 13 mm hemorrhage in the left putamen, compatible with hypertensive hemorrhage. 2. Paranasal sinus inflammatory disease. [MASKED] CXR No acute cardiopulmonary process. [MASKED] MR HEAD W/O CONTRAST 1. Stable left putaminal hematoma with mild surrounding edema and no significant effect or midline shift. No acute infarct. 2. No visualization of the right distal V3 or V4 segments of the vertebral artery with a diminutive distal right V4 segment seen. This may represent a diminutive vessel versus occlusion. A MRA can be acquired for further evaluation if clinically indicated. 3. Paranasal sinus disease. 4. Prominence of the posterior nasopharyngeal soft tissues, which may represent prominent adenoids. Recommend correlation with direct visualization. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with history of DM, HTN, HLD, and noncompliance to medications for financial reasons who is admitted to the Neurology stroke service with right facial droop and slurred speech the day prior to admission secondary to an acute intraparenchymal hemorrhage in the Left basal ganglia. Aspirin was held initially. His stroke was most likely secondary to medication noncompliance for the 2 months prior to admission due to financial difficulties. ASA 81 daily will be restarted upon hospital discharge. He should continue his home metoprolol and HCTZ for blood pressure control. His deficits improved prior to discharge and the only notable weakness was in the right nasolabial fold. He was seen by [MASKED], OT, and speech and swallow therapy. He will be discharged home with outpatient speech therapy. His intraparenchmal hemorrhage risk factors include the following: 1) DM: A1c 8.5% 2) Poorly controlled hypertension 3) Obesity Since he has not taken his meds for the two months prior to hospital admission, his Seroquel was restarted at the much lower dose of 100mg qhs. The Seroquel may be uptitrated as an outpatient as per his PCP or psychiatrist. The Seroquel was not restarted at his prior dose of 600mg qhs because this may have resulted in a dangerous possibility of getting a prolonged Qtc syndrome and somnolence, among other possible side effects. AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Glargine 60 Units Bedtime aspart 8 Units Breakfast aspart 8 Units Lunch aspart 8 Units Dinner 5. Levothyroxine Sodium 125 mcg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. QUEtiapine extended-release 600 mg PO QHS 8. Sertraline 50 mg PO DAILY 9. Simvastatin 40 mg PO QPM 10. Aspirin 81 mg PO DAILY 11. Cyanocobalamin 50 mcg PO DAILY 12. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: 1. Simvastatin 40 mg PO QPM RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Sertraline 50 mg PO DAILY RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Hydrochlorothiazide 25 mg PO DAILY RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. FoLIC Acid 1 mg PO DAILY 7. Cyanocobalamin 50 mcg PO DAILY 8. Levothyroxine Sodium 125 mcg PO DAILY RX *levothyroxine 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 10. RX *quetiapine 100 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Vitamin D [MASKED] UNIT PO DAILY 12. LeVETiracetam 750 mg PO BID RX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Outpatient Speech/Swallowing Therapy 1. PO diet: thin liquids, regular solids, Pills: whole in thin liquids 2. Standard aspiration precautions, including: Small bites, chew thoroughly 3. Speech tx upon discharge 14. 70/30 16 Units Breakfast 70/30 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100 unit/mL (70-30) AS DIR 16 Units before BKFT; 10 Units before DINR; Disp #*30 Syringe Refills:*0 15. KwikPen Needles KwikPen Needles 30 Discharge Disposition: Home Discharge Diagnosis: Intraparenchymal hemorrhage 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 due to symptoms of facial droop and slurred speech resulting from an acute bleed in your brain (intraparenchymal hemorrhage). The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Bleeding in the brain can have many different causes, so we assessed you for medical conditions that might raise your risk. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Diabetes High blood pressure High cholesterol Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
[]
[ "E119", "E785", "E039", "N189", "E669", "I129", "F329", "Z794", "Z87891" ]
[ "I619: Nontraumatic intracerebral hemorrhage, unspecified", "G8191: Hemiplegia, unspecified affecting right dominant side", "E1329: Other specified diabetes mellitus with other diabetic kidney complication", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "K2270: Barrett's esophagus without dysplasia", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E538: Deficiency of other specified B group vitamins", "R1310: Dysphagia, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "R29810: Facial weakness", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "E039: Hypothyroidism, unspecified", "N189: Chronic kidney disease, unspecified", "E669: Obesity, unspecified", "R471: Dysarthria and anarthria", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "F319: Bipolar disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z7982: Long term (current) use of aspirin", "Z794: Long term (current) use of insulin", "Z89421: Acquired absence of other right toe(s)", "Z87891: Personal history of nicotine dependence" ]
10,031,358
29,887,601
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ACE Inhibitors / ___ Receptor Antagonist Attending: ___ Chief Complaint: right sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a pleasant ___ man with DM2 c/b retinopathy, nephropathy, and neuropathy, HTN, B12 deficiency, traumatic SAH c/b seizure, and L putamen IPH who presents with right lower extremity weakness. He went to bed last night in his usual state of health and woke this morning with right leg weakness. He is able to feel everything but feels like leg is "dead weight." He also feels unbalanced. Denies headache, room-spinning sensation or a sensation of movement. He did fall this morning when he was trying to pick a plastic fork off the ground. He was holding on the counter but fell on his side because of his leg weakness. He did not hit his ___. Wife drove him to the ED after this. Denies any infectious symptoms such as cough, cold, urinary frequency/urgency, fever, chills, night sweats. Endorses baseline diarrhea. Of note, he was admitted ___ for slurred speech and found to have a left putamen IPH. His strength was ___ in all extremities at that time. He also had a traumatic SAH s/p fall in ___ while at rehab after toe amputation and was hospitalized at ___. There, he reportedly had one GTC and was prescribed 750mg BID. Past Medical History: Hypothyroidism DM (diabetes mellitus), type 2 with renal complications, retinopathy Diabetic retinopathy CKD (baseline 1.1-1.3) Hypertension B12 deficiency Bipolar disorder Depression Tremor, ?parkinsonism Colonic adenoma ___ esophagus Social History: ___ Family History: mGM with DM and CAD. Sister with breast cancer and bipolar disorder. Father with stomach cancer, peptic ulcer disease, bipolar disorder, kidney disease, died of PNA. Mother with bipolar disorder, died of bone cancer (per records report of breast cancer, but patient notes it was bone cancer). Physical Exam: ADMISSION PHYSICAL EXAM: General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple Extremities: Warm, no edema, s/p R big toe amputation Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. Very mild dysarthria to guttural sounds. Normal prosody. + apraxia (uses finger to pretend to brush hair, brush teeth, and butter bread). No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 4->2 brisk. VF full to number counting. EOMI, fatigable nystagmus ___ beats on left gaze, 4 beats right gaze. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 5 ___ 5 5 5 5 R 5 5 5 5 ___- 5 4+ 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 2+ 2+ 2+ 2+ 0 R 0* 0* 0* 0* 0 *pt unable to relax Plantar response flexor on L, unable to assess on R ___ toe amputation - Sensory: No deficits to light touch, decreased sensation to pin prick bilaterally to 3in above shin, decreased proprioception on L foot - Coordination: No dysmetria with finger to nose testing bilaterally. Faster on left in comparison to right - Gait: Normal initiation. Wide base. Drag right leg. Falls backward with eyes closed. DISCHARGE PHYSICAL EXAM: Mild right pronator drift and mild right finger extensor weakness. Otherwise, non-focal. Pertinent Results: LABS: ___ 05:00AM BLOOD WBC-10.9* RBC-4.07* Hgb-11.7* Hct-35.4* MCV-87 MCH-28.7 MCHC-33.1 RDW-12.6 RDWSD-39.8 Plt ___ ___ 04:12PM BLOOD WBC-10.1* RBC-4.81 Hgb-14.1 Hct-42.7 MCV-89 MCH-29.3 MCHC-33.0 RDW-12.9 RDWSD-41.4 Plt ___ ___ 04:12PM BLOOD ___ PTT-29.0 ___ ___ 05:00AM BLOOD Glucose-222* UreaN-30* Creat-1.4* Na-137 K-3.9 Cl-97 HCO3-23 AnGap-21* ___ 04:12PM BLOOD Glucose-340* UreaN-21* Creat-1.0 Na-135 K-5.2* Cl-100 HCO3-21* AnGap-19 ___ 04:12PM BLOOD ALT-21 AST-28 AlkPhos-80 TotBili-0.5 ___ 04:12PM BLOOD cTropnT-<0.01 ___ 04:50AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.6 ___ 04:12PM BLOOD Cholest-219* ___ 04:12PM BLOOD VitB12-919* Folate->20 ___ 08:04PM BLOOD %HbA1c-11.2* eAG-275* ___ 04:12PM BLOOD Triglyc-784* HDL-40 CHOL/HD-5.5 LDLmeas-109 ___ 04:12PM BLOOD TSH-2.4 ___ 04:50AM BLOOD Free T4-1.1 ___ 04:12PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:00AM BLOOD Triglyc-694* ___ 04:50AM BLOOD Free T4-1.1 ___ 07:14AM BLOOD WBC-9.6 RBC-4.19* Hgb-12.3* Hct-36.6* MCV-87 MCH-29.4 MCHC-33.6 RDW-12.8 RDWSD-39.8 Plt ___ ___ 07:14AM BLOOD Glucose-194* UreaN-27* Creat-1.2 Na-137 K-4.3 Cl-98 HCO3-25 AnGap-18 ___ 05:00AM BLOOD Glucose-222* UreaN-30* Creat-1.4* Na-137 K-3.9 Cl-97 HCO3-23 AnGap-21* ___ 04:50AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.6 IMAGING: ___ ___ and neck 1. Subtle hypodensity is seen within the left corona radiata, which may be secondary to an acute infarction. No evidence of acute intracranial hemorrhage. 2. Moderate paranasal sinus disease. 3. Unremarkable CTA of the ___ without evidence of significant stenosis or aneurysm. 4. Unremarkable CTA of the neck without evidence of internal carotid artery stenosis by NASCET criteria. ___ ___ 1. Late acute to subacute infarct involving the left corona radiata. 2. Gradient echo susceptibility in the left putaminal in corresponds to region of prior hemorrhage. No acute hemorrhage. ___ Conclusions: The left atrium is markedly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Limited study. No intracardiac source of thromboembolism identified. Globally preserved biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Normal pulmonary artery systolic pressure Brief Hospital Course: ___ is a ___ man with multiple vascular risk factors, a prior putamen IPH, and a traumatic SAH c/b a single seizure, who was hospitalized on the stroke service with a left anterior choroidal artery territory infarct. # Acute Ischemic Stroke: The day of admission he awoke with RLE weakness and his symptoms worsened over the course of the day to include right arm weakness as well. MRI confirmed an ischemic stroke. On exam he has a mild hemiparesis. Etiology may be small vessel given his numerous vascular risk factors. Cardioembolic is also possible and he is at risk for atrial fibrillation given his significantly dilated left atrium on echo. He was monitored on telemetry and no atrial fibrillation was seen. He underwent TTE which showed dilated left atrium. During admission, his cholesterol was seen to be high with his statin adjusted and a fibrate started for high triglycerides. He was evaluated by ___ for uncontrolled diabetes and had his insulin regimen adjusted to adequately control blood sugar. He worked with physical therapy/occupational therapy and was deemed appropriate for rehab. He will need further cardiac monitoring outpatient with ___ of Hearts to evaluate for underlying atrial fibrillation. He is on aspirin 81mg daily for secondary stroke prevention. # Diabetes: He was non-compliant with his diabetes regimen because he was having trouble affording his insulin. HbA1c was 11.2%. ___ was consulted and adjusted his insulin regimen to Lantus insulin to 42 units at bedtime, Humalog 14 units with meals plus correction with a correction scale to 2 units for 50> 150mg/dL before meals and 1 unit for 50> 200mg/dL at bedtime. He was seen by social work because he has trouble paying for his prescriptions, who recommended he make an appointment with a ___ volunteer outpatient for further assistance. # Hyperlipidemia: Changed his statin to atorvastatin 40mg daily given his elevated LDL on simvastatin. His fasting TGs were also elevated to 694 so he was started on a fibrate. # History of ___ c/b seizure: continued Keppra inpatient # HTN: BP meds were initially held and metoprolol was halved on for permissive HTN. BP was under reasonable control with SBP<140 without HCTZ. Please continue to monitor his BP at rehab and consider restarting his HCTZ. TRANSITINAL ISSUES: - PCP: please obtain 30 day heart monitor to evaluate for afib given ___. - SW suggested that patient make an appointment with a SHINE program volunteer through ___. ___ volunteers have been trained to assist seniors in assessing the insurance needs of seniors and assisting them in finding an appropriate Mass Health or Medicare program and Medicare Part D program to meet their needs. - Pt's insulin regimen was adjusted by ___ while inpatient. He will need close follow up for his diabetes after discharge from rehab. If needed, he can schedule a follow up appointment in the ___; to schedule, please contact ___ Appointment ___ - Patient's home HCTZ was held upon admission for permissive HTN. His BP was controlled inpatient so it was not restarted prior to discharge. Please monitor his BPs and consider restarting his home HCTZ at rehab. - C/w Aspirin, statin, and fibrate upon discharge to decrease future stroke risk ============================================ AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed – () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 109) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Simvastatin 40 mg PO QPM 2. Sertraline 50 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. LeVETiracetam 750 mg PO BID 9. Vitamin D ___ UNIT PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Hydrochlorothiazide 25 mg PO DAILY 12. NPH 38 Units Breakfast NPH 38 Units Dinner novalog 36 Units Dinner 13. QUEtiapine Fumarate 100 mg PO QHS Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Fenofibrate 48 mg PO DAILY 3. Glargine 42 Units Bedtime Humalog 14 Units Breakfast Humalog 14 Units Lunch Humalog 14 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Aspirin 81 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. LeVETiracetam 750 mg PO BID 8. Levothyroxine Sodium 125 mcg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. QUEtiapine Fumarate 100 mg PO QHS 12. Sertraline 50 mg PO DAILY 13. Vitamin D ___ UNIT PO DAILY 14. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until it is restarted at rehab Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute Ischemic Stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized due to symptoms of right-sided weakness resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: High blood pressure Uncontrolled diabetes Atherosclerosis (hardening of the arteries) We are changing your medications as follows: - adjusting your insulin regimen - starting atorvastatin and stopping simvastatin - start fenofibrate - please take aspirin 81mg every day Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
[ "I6329", "G8191", "E1121", "E1140", "Z6841", "E1165", "E11319", "E1122", "I129", "N183", "Z794", "E538", "Z87820", "I69398", "R569", "E039", "F319", "E669", "K219", "R251", "K2270", "Z87891", "Z9114", "E785" ]
Allergies: ACE Inhibitors / [MASKED] Receptor Antagonist Chief Complaint: right sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] man with DM2 c/b retinopathy, nephropathy, and neuropathy, HTN, B12 deficiency, traumatic SAH c/b seizure, and L putamen IPH who presents with right lower extremity weakness. He went to bed last night in his usual state of health and woke this morning with right leg weakness. He is able to feel everything but feels like leg is "dead weight." He also feels unbalanced. Denies headache, room-spinning sensation or a sensation of movement. He did fall this morning when he was trying to pick a plastic fork off the ground. He was holding on the counter but fell on his side because of his leg weakness. He did not hit his [MASKED]. Wife drove him to the ED after this. Denies any infectious symptoms such as cough, cold, urinary frequency/urgency, fever, chills, night sweats. Endorses baseline diarrhea. Of note, he was admitted [MASKED] for slurred speech and found to have a left putamen IPH. His strength was [MASKED] in all extremities at that time. He also had a traumatic SAH s/p fall in [MASKED] while at rehab after toe amputation and was hospitalized at [MASKED]. There, he reportedly had one GTC and was prescribed 750mg BID. Past Medical History: Hypothyroidism DM (diabetes mellitus), type 2 with renal complications, retinopathy Diabetic retinopathy CKD (baseline 1.1-1.3) Hypertension B12 deficiency Bipolar disorder Depression Tremor, ?parkinsonism Colonic adenoma [MASKED] esophagus Social History: [MASKED] Family History: mGM with DM and CAD. Sister with breast cancer and bipolar disorder. Father with stomach cancer, peptic ulcer disease, bipolar disorder, kidney disease, died of PNA. Mother with bipolar disorder, died of bone cancer (per records report of breast cancer, but patient notes it was bone cancer). Physical Exam: ADMISSION PHYSICAL EXAM: General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple Extremities: Warm, no edema, s/p R big toe amputation Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. Very mild dysarthria to guttural sounds. Normal prosody. + apraxia (uses finger to pretend to brush hair, brush teeth, and butter bread). No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 4->2 brisk. VF full to number counting. EOMI, fatigable nystagmus [MASKED] beats on left gaze, 4 beats right gaze. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength [MASKED] bilaterally. Tongue midline. - Motor: Normal bulk and tone. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 5 [MASKED] 5 5 5 5 R 5 5 5 5 [MASKED]- 5 4+ 5 5 - Reflexes: [Bic] [Tri] [[MASKED]] [Quad] [Gastroc] L 2+ 2+ 2+ 2+ 0 R 0* 0* 0* 0* 0 *pt unable to relax Plantar response flexor on L, unable to assess on R [MASKED] toe amputation - Sensory: No deficits to light touch, decreased sensation to pin prick bilaterally to 3in above shin, decreased proprioception on L foot - Coordination: No dysmetria with finger to nose testing bilaterally. Faster on left in comparison to right - Gait: Normal initiation. Wide base. Drag right leg. Falls backward with eyes closed. DISCHARGE PHYSICAL EXAM: Mild right pronator drift and mild right finger extensor weakness. Otherwise, non-focal. Pertinent Results: LABS: [MASKED] 05:00AM BLOOD WBC-10.9* RBC-4.07* Hgb-11.7* Hct-35.4* MCV-87 MCH-28.7 MCHC-33.1 RDW-12.6 RDWSD-39.8 Plt [MASKED] [MASKED] 04:12PM BLOOD WBC-10.1* RBC-4.81 Hgb-14.1 Hct-42.7 MCV-89 MCH-29.3 MCHC-33.0 RDW-12.9 RDWSD-41.4 Plt [MASKED] [MASKED] 04:12PM BLOOD [MASKED] PTT-29.0 [MASKED] [MASKED] 05:00AM BLOOD Glucose-222* UreaN-30* Creat-1.4* Na-137 K-3.9 Cl-97 HCO3-23 AnGap-21* [MASKED] 04:12PM BLOOD Glucose-340* UreaN-21* Creat-1.0 Na-135 K-5.2* Cl-100 HCO3-21* AnGap-19 [MASKED] 04:12PM BLOOD ALT-21 AST-28 AlkPhos-80 TotBili-0.5 [MASKED] 04:12PM BLOOD cTropnT-<0.01 [MASKED] 04:50AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.6 [MASKED] 04:12PM BLOOD Cholest-219* [MASKED] 04:12PM BLOOD VitB12-919* Folate->20 [MASKED] 08:04PM BLOOD %HbA1c-11.2* eAG-275* [MASKED] 04:12PM BLOOD Triglyc-784* HDL-40 CHOL/HD-5.5 LDLmeas-109 [MASKED] 04:12PM BLOOD TSH-2.4 [MASKED] 04:50AM BLOOD Free T4-1.1 [MASKED] 04:12PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 05:00AM BLOOD Triglyc-694* [MASKED] 04:50AM BLOOD Free T4-1.1 [MASKED] 07:14AM BLOOD WBC-9.6 RBC-4.19* Hgb-12.3* Hct-36.6* MCV-87 MCH-29.4 MCHC-33.6 RDW-12.8 RDWSD-39.8 Plt [MASKED] [MASKED] 07:14AM BLOOD Glucose-194* UreaN-27* Creat-1.2 Na-137 K-4.3 Cl-98 HCO3-25 AnGap-18 [MASKED] 05:00AM BLOOD Glucose-222* UreaN-30* Creat-1.4* Na-137 K-3.9 Cl-97 HCO3-23 AnGap-21* [MASKED] 04:50AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.6 IMAGING: [MASKED] [MASKED] and neck 1. Subtle hypodensity is seen within the left corona radiata, which may be secondary to an acute infarction. No evidence of acute intracranial hemorrhage. 2. Moderate paranasal sinus disease. 3. Unremarkable CTA of the [MASKED] without evidence of significant stenosis or aneurysm. 4. Unremarkable CTA of the neck without evidence of internal carotid artery stenosis by NASCET criteria. [MASKED] [MASKED] 1. Late acute to subacute infarct involving the left corona radiata. 2. Gradient echo susceptibility in the left putaminal in corresponds to region of prior hemorrhage. No acute hemorrhage. [MASKED] Conclusions: The left atrium is markedly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Limited study. No intracardiac source of thromboembolism identified. Globally preserved biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Normal pulmonary artery systolic pressure Brief Hospital Course: [MASKED] is a [MASKED] man with multiple vascular risk factors, a prior putamen IPH, and a traumatic SAH c/b a single seizure, who was hospitalized on the stroke service with a left anterior choroidal artery territory infarct. # Acute Ischemic Stroke: The day of admission he awoke with RLE weakness and his symptoms worsened over the course of the day to include right arm weakness as well. MRI confirmed an ischemic stroke. On exam he has a mild hemiparesis. Etiology may be small vessel given his numerous vascular risk factors. Cardioembolic is also possible and he is at risk for atrial fibrillation given his significantly dilated left atrium on echo. He was monitored on telemetry and no atrial fibrillation was seen. He underwent TTE which showed dilated left atrium. During admission, his cholesterol was seen to be high with his statin adjusted and a fibrate started for high triglycerides. He was evaluated by [MASKED] for uncontrolled diabetes and had his insulin regimen adjusted to adequately control blood sugar. He worked with physical therapy/occupational therapy and was deemed appropriate for rehab. He will need further cardiac monitoring outpatient with [MASKED] of Hearts to evaluate for underlying atrial fibrillation. He is on aspirin 81mg daily for secondary stroke prevention. # Diabetes: He was non-compliant with his diabetes regimen because he was having trouble affording his insulin. HbA1c was 11.2%. [MASKED] was consulted and adjusted his insulin regimen to Lantus insulin to 42 units at bedtime, Humalog 14 units with meals plus correction with a correction scale to 2 units for 50> 150mg/dL before meals and 1 unit for 50> 200mg/dL at bedtime. He was seen by social work because he has trouble paying for his prescriptions, who recommended he make an appointment with a [MASKED] volunteer outpatient for further assistance. # Hyperlipidemia: Changed his statin to atorvastatin 40mg daily given his elevated LDL on simvastatin. His fasting TGs were also elevated to 694 so he was started on a fibrate. # History of [MASKED] c/b seizure: continued Keppra inpatient # HTN: BP meds were initially held and metoprolol was halved on for permissive HTN. BP was under reasonable control with SBP<140 without HCTZ. Please continue to monitor his BP at rehab and consider restarting his HCTZ. TRANSITINAL ISSUES: - PCP: please obtain 30 day heart monitor to evaluate for afib given [MASKED]. - SW suggested that patient make an appointment with a SHINE program volunteer through [MASKED]. [MASKED] volunteers have been trained to assist seniors in assessing the insurance needs of seniors and assisting them in finding an appropriate Mass Health or Medicare program and Medicare Part D program to meet their needs. - Pt's insulin regimen was adjusted by [MASKED] while inpatient. He will need close follow up for his diabetes after discharge from rehab. If needed, he can schedule a follow up appointment in the [MASKED]; to schedule, please contact [MASKED] Appointment [MASKED] - Patient's home HCTZ was held upon admission for permissive HTN. His BP was controlled inpatient so it was not restarted prior to discharge. Please monitor his BPs and consider restarting his home HCTZ at rehab. - C/w Aspirin, statin, and fibrate upon discharge to decrease future stroke risk ============================================ AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed – () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = 109) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Simvastatin 40 mg PO QPM 2. Sertraline 50 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. LeVETiracetam 750 mg PO BID 9. Vitamin D [MASKED] UNIT PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY 11. Hydrochlorothiazide 25 mg PO DAILY 12. NPH 38 Units Breakfast NPH 38 Units Dinner novalog 36 Units Dinner 13. QUEtiapine Fumarate 100 mg PO QHS Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Fenofibrate 48 mg PO DAILY 3. Glargine 42 Units Bedtime Humalog 14 Units Breakfast Humalog 14 Units Lunch Humalog 14 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Aspirin 81 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. LeVETiracetam 750 mg PO BID 8. Levothyroxine Sodium 125 mcg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. QUEtiapine Fumarate 100 mg PO QHS 12. Sertraline 50 mg PO DAILY 13. Vitamin D [MASKED] UNIT PO DAILY 14. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until it is restarted at rehab Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Acute Ischemic Stroke 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 due to symptoms of right-sided weakness resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: High blood pressure Uncontrolled diabetes Atherosclerosis (hardening of the arteries) We are changing your medications as follows: - adjusting your insulin regimen - starting atorvastatin and stopping simvastatin - start fenofibrate - please take aspirin 81mg every day Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
[]
[ "E1165", "E1122", "I129", "Z794", "E039", "E669", "K219", "Z87891", "E785" ]
[ "I6329: Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries", "G8191: Hemiplegia, unspecified affecting right dominant side", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "Z794: Long term (current) use of insulin", "E538: Deficiency of other specified B group vitamins", "Z87820: Personal history of traumatic brain injury", "I69398: Other sequelae of cerebral infarction", "R569: Unspecified convulsions", "E039: Hypothyroidism, unspecified", "F319: Bipolar disorder, unspecified", "E669: Obesity, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R251: Tremor, unspecified", "K2270: Barrett's esophagus without dysplasia", "Z87891: Personal history of nicotine dependence", "Z9114: Patient's other noncompliance with medication regimen", "E785: Hyperlipidemia, unspecified" ]
10,031,396
22,921,074
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Acute ___ in Pain Headache Major Surgical or Invasive Procedure: Conventional Angiography History of Present Illness: ___ with PMH HTN, left breast ca s/p mastectomy who presents with headache with hypertensive emergency and found to have ICH on imaging. Patient woke up this morning at 5AM with an ___ headache that she described as throbbing, bi-frontal, without radiation. She denies any dizziness, light-headedness, visual changes, photo-/phonophobia. Reports nausea but no vomiting. She checked her blood pressure which was in the 200s so she went to the emergency room. She took a regular strength tylenol, which she states helped alleviate the pain. She has never had a HA like this before, and rarely gets headaches. She states her SBPs are normally in 140, but that her PCP recently added HCTZ to her anti-hypertensive regimen. At OSH, SBP noted to be in 200s and patient was started on a nicardipine gtt. CT showed ICH and patient was transferred to ___ for further management. By the time I saw patient she was off nicardipine gtt and SBP's were 140s. Past Medical History: HTN Breast ca s/p mastectomy ___ (no chemo or radiation therapy) Social History: ___ Family History: mother with questionable brain disease, not fully clarified Physical Exam: PHYSICAL EXAM: Vitals: General: Awake, cooperative, NAD. HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted in oropharynx. Cardiac: RRR. Well perfused. Pulmonary: Breathing comfortably on room air. Abdomen: Soft, NT/ND. Extremities: No cyanosis, clubbing, or edema bilaterally. 2+ radial, DP pulses. Skin: No rashes or other lesions noted. NEUROLOGIC EXAM: Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There are no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. Speech is not dysarthric. Able to follow both midline and appendicular commands. Able to register 3 objects and recall ___ at 5 minutes. Had good knowledge of current events. There is no evidence of apraxia or neglect. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation and no extinction. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing grossly intact to speech. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and equal strength bilaterally. -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 R ___ 5 5 -Sensory: No deficits to gross touch throughout. No extinction to DSS. Pertinent Results: ___ 08:30AM GLUCOSE-115* UREA N-26* CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14 ___ 08:30AM CALCIUM-9.7 PHOSPHATE-2.3* MAGNESIUM-1.6 ___ 08:30AM WBC-8.7 RBC-4.51 HGB-13.5 HCT-41.8 MCV-93 MCH-29.9 MCHC-32.3 RDW-13.2 RDWSD-45.2 ___ 08:30AM NEUTS-65.4 ___ MONOS-8.0 EOS-1.1 BASOS-0.8 IM ___ AbsNeut-5.68 AbsLymp-2.12 AbsMono-0.70 AbsEos-0.10 AbsBaso-0.07 ___ 08:30AM PLT COUNT-236 ___ 08:30AM ___ PTT-29.2 ___ year old lady with history of PMH HTN, left breast ca s/p mastectomy ___, in remission) who presents with headache with hypertensive emergency found to have left parafalcine ICH. #ICH Her systolics were to 200 initially. Her neurologic exam was normal. CTH showed left cingulate gyrus small ICH. DSA was negative for aneurysm. MRI showed likely cavernoma with stable hemorrhage. Her headache improved with blood pressure control. Aspirin was held and losartan was increased to 150 mg daily (from 100 mg daily). She remained stable and was discharged on HD 2 with stable neurologic exam. She will need repeat MRI in ___ months to assess for vascular abnormality. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspir-81 (aspirin) 81 mg oral DAILY 2. Rosuvastatin Calcium 10 mg PO QPM 3. Hydrochlorothiazide 25 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Losartan Potassium 150 mg PO DAILY RX *losartan 100 mg 1.5 tablet(s) by mouth once a day Disp #*45 Tablet Refills:*0 2. Hydrochlorothiazide 25 mg PO DAILY 3. Rosuvastatin Calcium 10 mg PO QPM 4. HELD- Aspir-81 (aspirin) 81 mg oral DAILY This medication was held. Do not restart Aspir-81 until told to resume from a neurologist Discharge Disposition: Home Discharge Diagnosis: Intra-parenchymal Hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ came to the hospital because of headache and high blood pressure. While ___ were here we found a small bleed on the left side of your brain which is likely due to a "cavernoma" or small cluster of blood vessels which ___ were probably born with. ___ had a special procedure which showed ___ did not have an aneurysm. We are changing your medications as follows: - We are increasing your losartan from 100 mg daily to 150 mg daily to better control your blood pressure. This is important to prevent further bleeding. - We also stopped your aspirin as it can increase your risk of bleeding. Now that ___ are leaving the hospital we recommend the following: - Please follow-up with your doctors as listed below - ___ will need to get a repeat MRI of your brain in ___ months We wish ___ the best, ___ Neurology Followup Instructions: ___
[ "I618", "I161", "I10", "R402142", "R402252", "R402362", "Z87891", "Z853" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Acute [MASKED] in Pain Headache Major Surgical or Invasive Procedure: Conventional Angiography History of Present Illness: [MASKED] with PMH HTN, left breast ca s/p mastectomy who presents with headache with hypertensive emergency and found to have ICH on imaging. Patient woke up this morning at 5AM with an [MASKED] headache that she described as throbbing, bi-frontal, without radiation. She denies any dizziness, light-headedness, visual changes, photo-/phonophobia. Reports nausea but no vomiting. She checked her blood pressure which was in the 200s so she went to the emergency room. She took a regular strength tylenol, which she states helped alleviate the pain. She has never had a HA like this before, and rarely gets headaches. She states her SBPs are normally in 140, but that her PCP recently added HCTZ to her anti-hypertensive regimen. At OSH, SBP noted to be in 200s and patient was started on a nicardipine gtt. CT showed ICH and patient was transferred to [MASKED] for further management. By the time I saw patient she was off nicardipine gtt and SBP's were 140s. Past Medical History: HTN Breast ca s/p mastectomy [MASKED] (no chemo or radiation therapy) Social History: [MASKED] Family History: mother with questionable brain disease, not fully clarified Physical Exam: PHYSICAL EXAM: Vitals: General: Awake, cooperative, NAD. HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted in oropharynx. Cardiac: RRR. Well perfused. Pulmonary: Breathing comfortably on room air. Abdomen: Soft, NT/ND. Extremities: No cyanosis, clubbing, or edema bilaterally. 2+ radial, DP pulses. Skin: No rashes or other lesions noted. NEUROLOGIC EXAM: Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There are no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. Speech is not dysarthric. Able to follow both midline and appendicular commands. Able to register 3 objects and recall [MASKED] at 5 minutes. Had good knowledge of current events. There is no evidence of apraxia or neglect. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation and no extinction. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing grossly intact to speech. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and equal strength bilaterally. -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 [MASKED] 5 5 R [MASKED] 5 5 -Sensory: No deficits to gross touch throughout. No extinction to DSS. Pertinent Results: [MASKED] 08:30AM GLUCOSE-115* UREA N-26* CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14 [MASKED] 08:30AM CALCIUM-9.7 PHOSPHATE-2.3* MAGNESIUM-1.6 [MASKED] 08:30AM WBC-8.7 RBC-4.51 HGB-13.5 HCT-41.8 MCV-93 MCH-29.9 MCHC-32.3 RDW-13.2 RDWSD-45.2 [MASKED] 08:30AM NEUTS-65.4 [MASKED] MONOS-8.0 EOS-1.1 BASOS-0.8 IM [MASKED] AbsNeut-5.68 AbsLymp-2.12 AbsMono-0.70 AbsEos-0.10 AbsBaso-0.07 [MASKED] 08:30AM PLT COUNT-236 [MASKED] 08:30AM [MASKED] PTT-29.2 [MASKED] year old lady with history of PMH HTN, left breast ca s/p mastectomy [MASKED], in remission) who presents with headache with hypertensive emergency found to have left parafalcine ICH. #ICH Her systolics were to 200 initially. Her neurologic exam was normal. CTH showed left cingulate gyrus small ICH. DSA was negative for aneurysm. MRI showed likely cavernoma with stable hemorrhage. Her headache improved with blood pressure control. Aspirin was held and losartan was increased to 150 mg daily (from 100 mg daily). She remained stable and was discharged on HD 2 with stable neurologic exam. She will need repeat MRI in [MASKED] months to assess for vascular abnormality. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspir-81 (aspirin) 81 mg oral DAILY 2. Rosuvastatin Calcium 10 mg PO QPM 3. Hydrochlorothiazide 25 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Losartan Potassium 150 mg PO DAILY RX *losartan 100 mg 1.5 tablet(s) by mouth once a day Disp #*45 Tablet Refills:*0 2. Hydrochlorothiazide 25 mg PO DAILY 3. Rosuvastatin Calcium 10 mg PO QPM 4. HELD- Aspir-81 (aspirin) 81 mg oral DAILY This medication was held. Do not restart Aspir-81 until told to resume from a neurologist Discharge Disposition: Home Discharge Diagnosis: Intra-parenchymal Hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] came to the hospital because of headache and high blood pressure. While [MASKED] were here we found a small bleed on the left side of your brain which is likely due to a "cavernoma" or small cluster of blood vessels which [MASKED] were probably born with. [MASKED] had a special procedure which showed [MASKED] did not have an aneurysm. We are changing your medications as follows: - We are increasing your losartan from 100 mg daily to 150 mg daily to better control your blood pressure. This is important to prevent further bleeding. - We also stopped your aspirin as it can increase your risk of bleeding. Now that [MASKED] are leaving the hospital we recommend the following: - Please follow-up with your doctors as listed below - [MASKED] will need to get a repeat MRI of your brain in [MASKED] months We wish [MASKED] the best, [MASKED] Neurology Followup Instructions: [MASKED]
[]
[ "I10", "Z87891" ]
[ "I618: Other nontraumatic intracerebral hemorrhage", "I161: Hypertensive emergency", "I10: Essential (primary) hypertension", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402252: Coma scale, best verbal response, oriented, at arrival to emergency department", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "Z87891: Personal history of nicotine dependence", "Z853: Personal history of malignant neoplasm of breast" ]
10,031,404
21,606,243
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Pericardiocentesis ___ History of Present Illness: Ms. ___ is an ___ year old woman with a hx of HTN, HLD, Grave's disease, discoid lupus (in remission x ___ years) who presents with pericardial effusion causing tamponade physiology now s/p pericardiocentesis. She was in her usual state of health until 3 weeks ago when she experienced 2 days of fever/chills, feeling generally unwell after getting a flu shot. She felt better on the third day and was doing well until this weekend when she experienced similar symptoms, which she took Tylenol for. She was also experiencing intermittent palpitations and worsening shortness of breath but no chest pain. She expected her symptoms to resolve but they did not so she presented to her PCP office on ___ and they told her to seek evaluation at ___ on ___. In the ___ she was found to be tachycardic with an irregular rhythm, although there was some uncertainty whether this was sinus with ectopy vs afib. SBPs were initially 130s-140s. CXR showed large cardiac sillhouette and small ___ effusions. CT obtained to r/o PE showed 2.2-2.7 cm pericardial effusion. Pulsus pardoxus was measured by ___ at 15. Dr ___ thoracic surgery was consulted in the ___ and did not feel that the patient required emergent pericardiocentesis. The patient stayed in the ___ overnight as no tertiary care beds were available. O/n the patient received 5 mg IV lopressor her HRs trended down slightly and her dyspnea improved somewhat. Stable this am on RA. Bedside ECHO done with 2.1 cm effusion with some fibrin noted, EF 70%, PASP 36, some collapse of RA/RV and resp variation across the TV. She was transferred to ___ and underwent successful pericardiocentesis with 230cc of fluid drained, pericardial drain placed and then transferred to the CCU for further management. On arrival to the CCU, patient states that she is feeling much better than before but is having some soreness at the site of the drain placement. Otherwise she denies chest pain, current shortness of breath, fever, chills, nausea, vomiting, diarrhea, leg swelling, dysuria. REVIEW OF SYSTEMS: Positive per HPI. 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: HTN HLD Grave's disease - s/p treatment ___ years ago Discoid lupus - 20+ years ago, no problems since Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Both of her parents died of strokes in their ___. History of Grave's disease in her sisters and one daughter. History of lupus in her sister. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: BP 111/63 HR 112 RR 29 O2 SAT 97% on 2L NC GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. CARDIAC/CHEST: Tachycardic. Normal S1, S2. No murmurs, rubs, or gallops. There is a pericardial drain inserting just below the sternum in place with a few mls of serosanguinous fluid collecting. 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 PHYSICAL EXAM ======================== VS: Tm 98.4 BP 139-141/74-77 HR 104-112 RR ___ O2 SAT 91-94% on RA-1.5L NC, Ambulatory O2Sat 92% on RA GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. CARDIAC/CHEST: Tachycardic. Normal S1, S2. No murmurs, rubs, or gallops. 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. Pertinent Results: ADMISSION LABS ================== Chemistry Magnesium (1.6 - 2.6 mg/dL) 2.1 TSH ___ Generation (0.27 - 4.20 uIU/mL) 1.10 Hematology ESR Pending Immunology Rheumatoid Factor Pending ___ Pending Serology ___ Type B(1) Ab Pending ___ Type B(2) Ab Pending ___ Type B(3) Ab Pending ___ Type B(4) Ab Pending ___ Type B(5) Ab Pending ___ Type B(6) Ab Pending EBV Capsid Ag IgG Ab Pending EBV Capsid Ag IgM Ab Pending HIV 1&2 Antigen & Ab Pending VZV IgG Antibody (Index) Pending VZV IgM Antibody Pending Chemistry Sodium (136 - 145 mmol/L) 133 Potassium (3.5 - 5.1 mmol/L) 4.7 Chloride (98 - 107 mmol/L) 93 Carbon Dioxide (22 - 29 mmol/L) 25 Anion Gap (6 - 18 mmol/L) 15 BUN (8 - 23 mg/dL) 25 Creatinine (0.5 - 0.9 mg/dL) 1.2 Glucose (74 - 109 mg/dL) 145 Calcium (8.8 - 10.2 mg/dL) 9.5 Magnesium (1.6 - 2.6 mg/dL) 2.4 Troponin T (0.0 - 0.01 ng/mL) < 0.01 < 0.01 Coagulation ___ (10.6 - 13.4 SECONDS) 12.4 INR 1.03 PTT (23.5 - 35.5 SECONDS) 29.8 D-Dimer (0 - 230 NG/ML) 462.8 Hematology WBC (4.5 - 10.5 X10*3/ul) 10.7 RBC (4.00 - 5.00 X10*6/ul) 4.17 Hgb (11.8 - 15.8 g/dL) 12.8 Hct (35.0 - 45.0 %) 37.6 MCV (80.0 - 100.0 fL) 90.0 MCH (27.0 - 34.0 pg) 30.6 MCHC (32.0 - 36.0 g/dL) 34.0 RDW (12.5 - 15.5 %) 14.0 Plt Count (150 - 400 X10*3/ul) 238 MPV (7.0 - 10.5 fl) 9.6 Neutrophils % (Manual) (44 - 74 %) 85 Lymphocytes % (16 - 46 %) 7 Monocytes % (5 - 12 %) 8 Eosinophils % (0 - 8 %) 0 Basophils % (0 - 2 %) 0 STUDIES: =================== CTPA ___ IMPRESSION: 1. New pericardial effusion. 2. New left pleural effusion and tiny right pleural effusion. 3. New bilateral lower lobe atelectasis. 4. No change in subtle left upper lobe parenchymal infiltrate. 5. Old right rib fractures. + TTE ___: Per report ECHO done with 2.1 cm effusion with some fibrin noted, EF 70%, PASP 36, some collapse of RA/RV and resp variation across the TV. TTE ___: Conclusions Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a very small circumferential pericardial effusion. The effusion is echo dense anteriorly, consistent with blood, inflammation or other cellular elements. Neither tamponade physiology or constriction are suggested, though transmitral/transtricuspid flows could not be assessed due to the tachycardia. Small right pleural effusion. IMPRESSION: Very small circumferential pericardial effusion without definite evidence for tamponade or constrictive physiology. CXR ___: Comparison to ___. Removal of the pulmonary artery catheter. Stable mild left pleural effusion with subsequent retrocardiac atelectasis. Stable appearance of the lung parenchyma. No pulmonary edema. No pneumonia. DISCHARGE LABS ================ ___ 07:50AM BLOOD WBC-5.2 RBC-3.56* Hgb-10.7* Hct-33.8* MCV-95 MCH-30.1 MCHC-31.7* RDW-13.2 RDWSD-46.2 Plt ___ ___ 07:50AM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-141 K-4.1 Cl-104 HCO3-26 AnGap-15 ___ 05:00AM BLOOD ALT-18 AST-24 LD(LDH)-192 AlkPhos-98 TotBili-0.6 ___ 07:50AM BLOOD Mg-2.0 Brief Hospital Course: Ms. ___ is an ___ year old woman with a hx of HTN, HLD, Grave's disease, discoid lupus (in remission x ___ years) who presented with pericardial effusion causing tamponade physiology now s/p successful pericardiocentesis with persistent mild sinus tachycardia thought secondary to pericardial inflammation. Her home losartan was held in the setting of low blood pressure but was normotensive at the time of discharge, this should be held until recheck at PCP follow up. #Pericardial effusion now s/p pericardiocentesis - Etiology of effusion unclear at this point, multiple studies pending from ___ ___ as well as ___ at time of discharge. DDx included post-viral, which seemed most likely given recent viral symptoms but could also be related to other infectious etiologies vs. rheumatologic process vs. thyroid dysfunction (although TSH nl) given history vs. malignancy. Patient was placed on NC O2 for comfort but ambulated with SPO2 92% at discharge. #Sinus tachycardia - persistent after pericardiocentesis, likely due to residual pericardial fluid vs. potentially hypovolemia, no other clear signs of infection prior to discharge, improved with 500cc of normal saline, but was still persistent at discharge. #Hyponatremia, resolved - mild hyponatremia to 133 at ___ ___, resolved prior to discharge #Acute kidney injury, resolved - Cr up to 1.2 at ___ from baseline of 1.0, was thought to be pre-renal in the setting of near-tamponade and resolved prior to discharge with discharge Cr 0.6. #HTN - Held losartan 20mg QD given soft pressures #HLD -Continued atorvastatin 20mg QHS TRANSITIONAL ISSUES ==================== -Please order transthoracic echo to follow up pericardial effusion within 1 week of discharge. -Follow up RF, ___, EBV, VZV, HIV, ___, ESR from ___. -Follow up pending pericardial fluid studies. -Losartan was held at discharge given normotension. Please restart at followup if indicated. # CODE: Full code # CONTACT/HCP: ___ (______ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 20 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. Vitamin D Dose is Unknown PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. amLODIPine 5 mg PO DAILY Discharge Medications: 1. Vitamin D 800 UNIT PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Multivitamins 1 TAB PO DAILY 6. HELD- Losartan Potassium 20 mg PO DAILY This medication was held. Do not restart Losartan Potassium until discussing with your doctor. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS =================== Pericardial effusion Sinus tachycardia Hyponatremia Acute kidney injury SECONDARY DIAGNOSIS ==================== Hypertension Hyperlipidemia 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 were experiencing palpitations and shortness of breath. You were found to have fluid built up around your heart (pericardial effusion), which was drained. You were monitored afterwards and did not have fluid build up again. You felt much better after the fluid was drained and we felt it was safe for you to leave the hospital. Please continue to take your medications as directed. Your losartan was held because your blood pressures were on the low side. You should discuss restarting this medication with your doctor. You will also have a follow up appointment with Cardiology as below. Please see your doctors as directed. It was a pleasure taking care of you, Your ___ Care Team Followup Instructions: ___
[ "I308", "J90", "N179", "E871", "E860", "I9589", "J9811", "R000", "I10", "E785", "Z8781", "L930", "R002", "Z8639", "Z87891" ]
Allergies: lisinopril Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Pericardiocentesis [MASKED] History of Present Illness: Ms. [MASKED] is an [MASKED] year old woman with a hx of HTN, HLD, Grave's disease, discoid lupus (in remission x [MASKED] years) who presents with pericardial effusion causing tamponade physiology now s/p pericardiocentesis. She was in her usual state of health until 3 weeks ago when she experienced 2 days of fever/chills, feeling generally unwell after getting a flu shot. She felt better on the third day and was doing well until this weekend when she experienced similar symptoms, which she took Tylenol for. She was also experiencing intermittent palpitations and worsening shortness of breath but no chest pain. She expected her symptoms to resolve but they did not so she presented to her PCP office on [MASKED] and they told her to seek evaluation at [MASKED] on [MASKED]. In the [MASKED] she was found to be tachycardic with an irregular rhythm, although there was some uncertainty whether this was sinus with ectopy vs afib. SBPs were initially 130s-140s. CXR showed large cardiac sillhouette and small [MASKED] effusions. CT obtained to r/o PE showed 2.2-2.7 cm pericardial effusion. Pulsus pardoxus was measured by [MASKED] at 15. Dr [MASKED] thoracic surgery was consulted in the [MASKED] and did not feel that the patient required emergent pericardiocentesis. The patient stayed in the [MASKED] overnight as no tertiary care beds were available. O/n the patient received 5 mg IV lopressor her HRs trended down slightly and her dyspnea improved somewhat. Stable this am on RA. Bedside ECHO done with 2.1 cm effusion with some fibrin noted, EF 70%, PASP 36, some collapse of RA/RV and resp variation across the TV. She was transferred to [MASKED] and underwent successful pericardiocentesis with 230cc of fluid drained, pericardial drain placed and then transferred to the CCU for further management. On arrival to the CCU, patient states that she is feeling much better than before but is having some soreness at the site of the drain placement. Otherwise she denies chest pain, current shortness of breath, fever, chills, nausea, vomiting, diarrhea, leg swelling, dysuria. REVIEW OF SYSTEMS: Positive per HPI. 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: HTN HLD Grave's disease - s/p treatment [MASKED] years ago Discoid lupus - 20+ years ago, no problems since Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Both of her parents died of strokes in their [MASKED]. History of Grave's disease in her sisters and one daughter. History of lupus in her sister. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: BP 111/63 HR 112 RR 29 O2 SAT 97% on 2L NC GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. CARDIAC/CHEST: Tachycardic. Normal S1, S2. No murmurs, rubs, or gallops. There is a pericardial drain inserting just below the sternum in place with a few mls of serosanguinous fluid collecting. 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 PHYSICAL EXAM ======================== VS: Tm 98.4 BP 139-141/74-77 HR 104-112 RR [MASKED] O2 SAT 91-94% on RA-1.5L NC, Ambulatory O2Sat 92% on RA GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. CARDIAC/CHEST: Tachycardic. Normal S1, S2. No murmurs, rubs, or gallops. 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. Pertinent Results: ADMISSION LABS ================== Chemistry Magnesium (1.6 - 2.6 mg/dL) 2.1 TSH [MASKED] Generation (0.27 - 4.20 uIU/mL) 1.10 Hematology ESR Pending Immunology Rheumatoid Factor Pending [MASKED] Pending Serology [MASKED] Type B(1) Ab Pending [MASKED] Type B(2) Ab Pending [MASKED] Type B(3) Ab Pending [MASKED] Type B(4) Ab Pending [MASKED] Type B(5) Ab Pending [MASKED] Type B(6) Ab Pending EBV Capsid Ag IgG Ab Pending EBV Capsid Ag IgM Ab Pending HIV 1&2 Antigen & Ab Pending VZV IgG Antibody (Index) Pending VZV IgM Antibody Pending Chemistry Sodium (136 - 145 mmol/L) 133 Potassium (3.5 - 5.1 mmol/L) 4.7 Chloride (98 - 107 mmol/L) 93 Carbon Dioxide (22 - 29 mmol/L) 25 Anion Gap (6 - 18 mmol/L) 15 BUN (8 - 23 mg/dL) 25 Creatinine (0.5 - 0.9 mg/dL) 1.2 Glucose (74 - 109 mg/dL) 145 Calcium (8.8 - 10.2 mg/dL) 9.5 Magnesium (1.6 - 2.6 mg/dL) 2.4 Troponin T (0.0 - 0.01 ng/mL) < 0.01 < 0.01 Coagulation [MASKED] (10.6 - 13.4 SECONDS) 12.4 INR 1.03 PTT (23.5 - 35.5 SECONDS) 29.8 D-Dimer (0 - 230 NG/ML) 462.8 Hematology WBC (4.5 - 10.5 X10*3/ul) 10.7 RBC (4.00 - 5.00 X10*6/ul) 4.17 Hgb (11.8 - 15.8 g/dL) 12.8 Hct (35.0 - 45.0 %) 37.6 MCV (80.0 - 100.0 fL) 90.0 MCH (27.0 - 34.0 pg) 30.6 MCHC (32.0 - 36.0 g/dL) 34.0 RDW (12.5 - 15.5 %) 14.0 Plt Count (150 - 400 X10*3/ul) 238 MPV (7.0 - 10.5 fl) 9.6 Neutrophils % (Manual) (44 - 74 %) 85 Lymphocytes % (16 - 46 %) 7 Monocytes % (5 - 12 %) 8 Eosinophils % (0 - 8 %) 0 Basophils % (0 - 2 %) 0 STUDIES: =================== CTPA [MASKED] IMPRESSION: 1. New pericardial effusion. 2. New left pleural effusion and tiny right pleural effusion. 3. New bilateral lower lobe atelectasis. 4. No change in subtle left upper lobe parenchymal infiltrate. 5. Old right rib fractures. + TTE [MASKED]: Per report ECHO done with 2.1 cm effusion with some fibrin noted, EF 70%, PASP 36, some collapse of RA/RV and resp variation across the TV. TTE [MASKED]: Conclusions Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a very small circumferential pericardial effusion. The effusion is echo dense anteriorly, consistent with blood, inflammation or other cellular elements. Neither tamponade physiology or constriction are suggested, though transmitral/transtricuspid flows could not be assessed due to the tachycardia. Small right pleural effusion. IMPRESSION: Very small circumferential pericardial effusion without definite evidence for tamponade or constrictive physiology. CXR [MASKED]: Comparison to [MASKED]. Removal of the pulmonary artery catheter. Stable mild left pleural effusion with subsequent retrocardiac atelectasis. Stable appearance of the lung parenchyma. No pulmonary edema. No pneumonia. DISCHARGE LABS ================ [MASKED] 07:50AM BLOOD WBC-5.2 RBC-3.56* Hgb-10.7* Hct-33.8* MCV-95 MCH-30.1 MCHC-31.7* RDW-13.2 RDWSD-46.2 Plt [MASKED] [MASKED] 07:50AM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-141 K-4.1 Cl-104 HCO3-26 AnGap-15 [MASKED] 05:00AM BLOOD ALT-18 AST-24 LD(LDH)-192 AlkPhos-98 TotBili-0.6 [MASKED] 07:50AM BLOOD Mg-2.0 Brief Hospital Course: Ms. [MASKED] is an [MASKED] year old woman with a hx of HTN, HLD, Grave's disease, discoid lupus (in remission x [MASKED] years) who presented with pericardial effusion causing tamponade physiology now s/p successful pericardiocentesis with persistent mild sinus tachycardia thought secondary to pericardial inflammation. Her home losartan was held in the setting of low blood pressure but was normotensive at the time of discharge, this should be held until recheck at PCP follow up. #Pericardial effusion now s/p pericardiocentesis - Etiology of effusion unclear at this point, multiple studies pending from [MASKED] [MASKED] as well as [MASKED] at time of discharge. DDx included post-viral, which seemed most likely given recent viral symptoms but could also be related to other infectious etiologies vs. rheumatologic process vs. thyroid dysfunction (although TSH nl) given history vs. malignancy. Patient was placed on NC O2 for comfort but ambulated with SPO2 92% at discharge. #Sinus tachycardia - persistent after pericardiocentesis, likely due to residual pericardial fluid vs. potentially hypovolemia, no other clear signs of infection prior to discharge, improved with 500cc of normal saline, but was still persistent at discharge. #Hyponatremia, resolved - mild hyponatremia to 133 at [MASKED] [MASKED], resolved prior to discharge #Acute kidney injury, resolved - Cr up to 1.2 at [MASKED] from baseline of 1.0, was thought to be pre-renal in the setting of near-tamponade and resolved prior to discharge with discharge Cr 0.6. #HTN - Held losartan 20mg QD given soft pressures #HLD -Continued atorvastatin 20mg QHS TRANSITIONAL ISSUES ==================== -Please order transthoracic echo to follow up pericardial effusion within 1 week of discharge. -Follow up RF, [MASKED], EBV, VZV, HIV, [MASKED], ESR from [MASKED]. -Follow up pending pericardial fluid studies. -Losartan was held at discharge given normotension. Please restart at followup if indicated. # CODE: Full code # CONTACT/HCP: [MASKED] ([MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 20 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. Vitamin D Dose is Unknown PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. amLODIPine 5 mg PO DAILY Discharge Medications: 1. Vitamin D 800 UNIT PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Multivitamins 1 TAB PO DAILY 6. HELD- Losartan Potassium 20 mg PO DAILY This medication was held. Do not restart Losartan Potassium until discussing with your doctor. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS =================== Pericardial effusion Sinus tachycardia Hyponatremia Acute kidney injury SECONDARY DIAGNOSIS ==================== Hypertension Hyperlipidemia 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 were experiencing palpitations and shortness of breath. You were found to have fluid built up around your heart (pericardial effusion), which was drained. You were monitored afterwards and did not have fluid build up again. You felt much better after the fluid was drained and we felt it was safe for you to leave the hospital. Please continue to take your medications as directed. Your losartan was held because your blood pressures were on the low side. You should discuss restarting this medication with your doctor. You will also have a follow up appointment with Cardiology as below. Please see your doctors as directed. It was a pleasure taking care of you, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "E871", "I10", "E785", "Z87891" ]
[ "I308: Other forms of acute pericarditis", "J90: Pleural effusion, not elsewhere classified", "N179: Acute kidney failure, unspecified", "E871: Hypo-osmolality and hyponatremia", "E860: Dehydration", "I9589: Other hypotension", "J9811: Atelectasis", "R000: Tachycardia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z8781: Personal history of (healed) traumatic fracture", "L930: Discoid lupus erythematosus", "R002: Palpitations", "Z8639: Personal history of other endocrine, nutritional and metabolic disease", "Z87891: Personal history of nicotine dependence" ]
10,031,575
21,330,901
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: None History of Present Illness: ___ pmhx of HFpEF (EF 55% ___, HTN, DMII c/b peripheral neuropathy, retinopathy, R toe osteo s/p amp, CKD (b/l 1.9-2.3), HLD presenting with chest pain. Pt awoke from sleep at 3:30am on ___ with chest pain described as sharp substernal, non-pleuritic, radiating to R arm. + nausea and diaphoresis initially, not recurrent. Has been constant since then with some mild improvement by the time of arrival to the floor. Patient has never had this chest pain before. No increased leg swelling. Weight stable on torsemide 80/40, no report of dietary indiscretion. Patient does have three pillow orthopnea at baseline. No abdominal pain, no diarrhea or dysuria, no blood in stool or urine, no severe headache, no double vision, no sore throat. No cough, no congestion. Past Medical History: - Diastolic CHF, LVEF 55% ___, possibly related to HTN. Diagnosed ___ at ___. - History of CVA - treated at ___, left sided hemiparesis, ___, no residual deficits - Diabetes mellitus, A1C 7.2% (___), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation ___ years ago - CKDIII (baseline Cr 1.7-2.0) - R toe osteomyelitis s/p amputation - iron deficiency anemia Social History: ___ Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age ___. Maternal uncle also with T2DM and ESRD on HD. Children healthy, 1 son with autism. Physical Exam: ADMISSION EXAM: VITALS: 98.7, 154/85, 73, 18, 100% RA GEN: tired, NAD HEENT: MM tacky to mildly dry CV: RRR nl s1/s2 no mrg, no reproduction of CP on palpation PULM: CTA b/l no wrc GI: S/ND/NT EXT: Non-edematous, warm DISCHARGE EXAM: Temp: 99 PO BP: 140-150s/90s HR: 90s RR: 18 O2 sat: 96% O2 delivery: RA GEN: cooperative, NAD HEENT: dry mucous membranes, mild gum inflammation on left side of mouth, no pharyngeal erythema NECK: JVP ~8cm at 30 degrees. CV: RRR nl s1/s2 no mrg PULM: CTA b/l, no crackles or wheezing ABD: S/ND/NT EXT: No ___ edema bilaterally, warm Pertinent Results: ADMISSION LABS: ___ 09:38PM BLOOD WBC-11.1* RBC-4.22 Hgb-11.9 Hct-38.3 MCV-91 MCH-28.2 MCHC-31.1* RDW-13.2 RDWSD-43.6 Plt ___ ___ 09:38PM BLOOD Neuts-74.6* ___ Monos-4.6* Eos-0.3* Baso-0.3 Im ___ AbsNeut-8.30* AbsLymp-2.19 AbsMono-0.51 AbsEos-0.03* AbsBaso-0.03 ___ 09:38PM BLOOD Glucose-95 UreaN-62* Creat-2.8* Na-142 K-5.0 Cl-108 HCO3-21* AnGap-13 ___ 09:38PM BLOOD CK(CPK)-81 ___:38PM BLOOD CK-MB-2 proBNP-237* ___ 09:38PM BLOOD cTropnT-0.02* ___ 03:00AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 03:00AM BLOOD TotProt-6.7 Calcium-9.5 Phos-3.4 Mg-2.0 ___ 03:00AM BLOOD PEP-NO SPECIFI FreeKap-110.0* FreeLam-34.7* Fr K/L-3.17* DISCHARGE LABS: ___ 09:30AM BLOOD WBC-10.5* RBC-3.63* Hgb-10.2* Hct-32.9* MCV-91 MCH-28.1 MCHC-31.0* RDW-13.3 RDWSD-44.5 Plt ___ ___ 07:51AM BLOOD Glucose-91 UreaN-39* Creat-2.4* Na-140 K-5.0 Cl-109* HCO3-17* AnGap-14 ___ 07:51AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.6 PERTINENT IMAGING: CT NECK W/O CONTRAST ___: 1. Lucency around the roots of previously treated ___ 14, with associated left facial cellulitis. No drainable fluid collection. Reactive lymphadenopathy. 2. Mildly enlarged and heterogeneous thyroid gland. No focal nodule identified. 3. Likely dental disease related left maxillary and ethmoid sinus opacification. CHEST XRAY ___: In comparison with the study of ___, there are lower lung volumes. Cardiomediastinal silhouette is stable and there is no vascular congestion, pleural effusion, or acute focal pneumonia. CARDIAC PERFUSION STUDY ___: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and systolic function. Compared to the prior study of ___, cavity size and systolic function have normalized. CHEST XRAY ___: No acute cardiopulmonary process. Brief Hospital Course: TRANSITIONAL ISSUES ====================== [ ] Discharge weight: 251 lbs [ ] Discharge Creatinine: 2.4 [ ] Restart home lisinopril as Cr returns to baseline and K within normal limits [ ] Consider pyrophosphate scan [ ] Discharged on oral Augmentin [ ] Patient discharged to follow up with OMFS at ___ on ___ for tooth extraction. PATIENT SUMMARY AND HOSPITAL COURSE: ====================================== ___ pmhx of HFpEF (EF 55% ___, HTN, DMII c/b peripheral neuropathy, retinopathy, R toe osteo s/p amp, CKD (b/l 1.9-2.3), HLD presenting with chest pain and ___ on CKD. # Sepsis secondary to dental abscess/tooth infection: Patient was noted to have worsening L sided maxillary tooth pain with associated facial swelling. Panorex imaging was obtained and evaluated by dental team. Findings showed extensive caries in left upper single molar with concern for acute exacerbation of chronic apical abscess for which she was started on oral penicillin on ___. Later that day, patient spiked a fever to 102.9F with associated rigors, sinus tachycardia to the 130s. She was started on IV vancomycin/ceftazidime/metronidazole that was narrowed to vanc/ceftriaxone/metronidazole later. ID and OMFS were consulted. OMFS recommended extraction for source control at close outpatient follow up in dental clinic. At discharge, patient was narrowed to PO Augmentin DS 875-125mg per ID recs for 10 days. # Chest pain Patient initially admitted to the ___ service for chest pain with several cardiac risk factors (HTN, DM, HLD). Chest pain was substernal, sharp, nonradiating, nonexertional, ___ on admission; chest pain stopped ___ evening. Trop 0.02 on admission, <0.01 subsequently. No ecg changes. Given cardiac risk factors, patient underwent perfusion stress study which showed normal myocardial perfusion. Given aspirin 325mg, then continued on aspirin 81mg daily. Home atorvastatin increased to 80mg QHS. Chest pain resolved spontaneously without intervention. # Chronic HFpEF (EF 55% ___: Patient was admitted with chest pain, felt to be euvolemic to slightly overloaded on exam. On hospital day 1, she received Torsemide 80mg x1 with bump in creatinine. Given her ___ and positive orthostatic hypotension, her diuretics were subsequently held during admission with improvement in creatinine. Of note, home Torsemide was most recently 80mg QAM and 40mg QPM. Given ___ on admission, this was concerning for over-diuresis. Will be discharged on home diuretic dose given improvement in Cr at time of discharge. - Patient continued on home hydralazine, spironolactone, amlodipine, imdur at discharge. Lisinopril held at time of discharge. Discharge weight 251 lbs. Discharge Creatinine 2.4. # Concern for amyloidosis TTE in ___ showed LVH with increased PCWP. Concern for infiltrative process (eg, amyloid). Serum free light chains, SPEP, UPEP negative. Consider pyrophosphate spect as outpatient if suspicion high enough for cardiac amyloidosis. # ___ on CKD (b/l 1.9-2.3): Cr 2.8 on admission. ___ felt likely to be pre-renal secondary to over-diuresis and infection ___ dental abscess. Held home torsemide and gave gentle IVF with improvement. Cr on discharge 2.4. Plan to restart home torsemide on discharge. # HTN Initially held home lisinopril, spironolactone in the setting of ___. Continued home amlodipine, imdur, and hydralazine. Restarted all home meds except lisinopril on discharge. Lisinopril should be restarted as outpatient as Cr improves and K is confirmed within normal limits (K 5.0 on discharge). Patient refused further lab draws prior to discharge. # DMII ## peripheral neuropathy ## retinopathy Continued home long acting 60 HS, home humalog 15 with dinner, and SSI. Also continued home gabapentin. # CODE: Full # CONTACT/HCP: ___ Relationship: Husband Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Ferrous Sulfate 325 mg PO DAILY 6. Gabapentin 100 mg PO BID 7. HydrALAZINE 25 mg PO TID 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 9. Lisinopril 10 mg PO DAILY 10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID 11. Spironolactone 25 mg PO DAILY 12. Torsemide 40 mg PO QPM 13. TraZODone 25 mg PO QHS:PRN insomnia 14. Humalog 15 Units Dinner tresiba 60 Units Bedtime 15. Torsemide 80 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth once a day Disp #*10 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth Every 6 hours as needed Disp #*6 Tablet Refills:*0 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Ferrous Sulfate 325 mg PO DAILY 8. Gabapentin 100 mg PO BID 9. HydrALAZINE 25 mg PO TID 10. Humalog 15 Units Dinner Tresiba 60 Units Bedtime 11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID 13. Spironolactone 25 mg PO DAILY 14. Torsemide 80 mg PO DAILY 15. Torsemide 40 mg PO QPM 16. TraZODone 25 mg PO QHS:PRN insomnia 17. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until your creatinine improves Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Sepsis due to dental abscess SECONDARY DIAGNOSIS: ====================== Acute on chronic kidney Disease Orthostatic hypotension Chronic Diastolic Heart Failure Chest Pain 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 chest pain and some kidney damage. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You underwent a stress test which showed normal blood flow to your heart. - You had tooth pain due to an infection around your tooth and needed IV antibiotics. - The dentist saw you and you will need an extraction of your tooth. 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 in one 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: 251 lbs. You should use this as your baseline after you leave the hospital. We wish you the best! Your ___ Care Team Followup Instructions: ___
[ "A419", "I130", "I5032", "N179", "R079", "E1142", "E1122", "N183", "K046", "I951", "K029", "E785", "D509", "Z89421", "Z8673" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] pmhx of HFpEF (EF 55% [MASKED], HTN, DMII c/b peripheral neuropathy, retinopathy, R toe osteo s/p amp, CKD (b/l 1.9-2.3), HLD presenting with chest pain. Pt awoke from sleep at 3:30am on [MASKED] with chest pain described as sharp substernal, non-pleuritic, radiating to R arm. + nausea and diaphoresis initially, not recurrent. Has been constant since then with some mild improvement by the time of arrival to the floor. Patient has never had this chest pain before. No increased leg swelling. Weight stable on torsemide 80/40, no report of dietary indiscretion. Patient does have three pillow orthopnea at baseline. No abdominal pain, no diarrhea or dysuria, no blood in stool or urine, no severe headache, no double vision, no sore throat. No cough, no congestion. Past Medical History: - Diastolic CHF, LVEF 55% [MASKED], possibly related to HTN. Diagnosed [MASKED] at [MASKED]. - History of CVA - treated at [MASKED], left sided hemiparesis, [MASKED], no residual deficits - Diabetes mellitus, A1C 7.2% ([MASKED]), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation [MASKED] years ago - CKDIII (baseline Cr 1.7-2.0) - R toe osteomyelitis s/p amputation - iron deficiency anemia Social History: [MASKED] Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age [MASKED]. Maternal uncle also with T2DM and ESRD on HD. Children healthy, 1 son with autism. Physical Exam: ADMISSION EXAM: VITALS: 98.7, 154/85, 73, 18, 100% RA GEN: tired, NAD HEENT: MM tacky to mildly dry CV: RRR nl s1/s2 no mrg, no reproduction of CP on palpation PULM: CTA b/l no wrc GI: S/ND/NT EXT: Non-edematous, warm DISCHARGE EXAM: Temp: 99 PO BP: 140-150s/90s HR: 90s RR: 18 O2 sat: 96% O2 delivery: RA GEN: cooperative, NAD HEENT: dry mucous membranes, mild gum inflammation on left side of mouth, no pharyngeal erythema NECK: JVP ~8cm at 30 degrees. CV: RRR nl s1/s2 no mrg PULM: CTA b/l, no crackles or wheezing ABD: S/ND/NT EXT: No [MASKED] edema bilaterally, warm Pertinent Results: ADMISSION LABS: [MASKED] 09:38PM BLOOD WBC-11.1* RBC-4.22 Hgb-11.9 Hct-38.3 MCV-91 MCH-28.2 MCHC-31.1* RDW-13.2 RDWSD-43.6 Plt [MASKED] [MASKED] 09:38PM BLOOD Neuts-74.6* [MASKED] Monos-4.6* Eos-0.3* Baso-0.3 Im [MASKED] AbsNeut-8.30* AbsLymp-2.19 AbsMono-0.51 AbsEos-0.03* AbsBaso-0.03 [MASKED] 09:38PM BLOOD Glucose-95 UreaN-62* Creat-2.8* Na-142 K-5.0 Cl-108 HCO3-21* AnGap-13 [MASKED] 09:38PM BLOOD CK(CPK)-81 [MASKED]:38PM BLOOD CK-MB-2 proBNP-237* [MASKED] 09:38PM BLOOD cTropnT-0.02* [MASKED] 03:00AM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 03:00AM BLOOD TotProt-6.7 Calcium-9.5 Phos-3.4 Mg-2.0 [MASKED] 03:00AM BLOOD PEP-NO SPECIFI FreeKap-110.0* FreeLam-34.7* Fr K/L-3.17* DISCHARGE LABS: [MASKED] 09:30AM BLOOD WBC-10.5* RBC-3.63* Hgb-10.2* Hct-32.9* MCV-91 MCH-28.1 MCHC-31.0* RDW-13.3 RDWSD-44.5 Plt [MASKED] [MASKED] 07:51AM BLOOD Glucose-91 UreaN-39* Creat-2.4* Na-140 K-5.0 Cl-109* HCO3-17* AnGap-14 [MASKED] 07:51AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.6 PERTINENT IMAGING: CT NECK W/O CONTRAST [MASKED]: 1. Lucency around the roots of previously treated [MASKED] 14, with associated left facial cellulitis. No drainable fluid collection. Reactive lymphadenopathy. 2. Mildly enlarged and heterogeneous thyroid gland. No focal nodule identified. 3. Likely dental disease related left maxillary and ethmoid sinus opacification. CHEST XRAY [MASKED]: In comparison with the study of [MASKED], there are lower lung volumes. Cardiomediastinal silhouette is stable and there is no vascular congestion, pleural effusion, or acute focal pneumonia. CARDIAC PERFUSION STUDY [MASKED]: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and systolic function. Compared to the prior study of [MASKED], cavity size and systolic function have normalized. CHEST XRAY [MASKED]: No acute cardiopulmonary process. Brief Hospital Course: TRANSITIONAL ISSUES ====================== [ ] Discharge weight: 251 lbs [ ] Discharge Creatinine: 2.4 [ ] Restart home lisinopril as Cr returns to baseline and K within normal limits [ ] Consider pyrophosphate scan [ ] Discharged on oral Augmentin [ ] Patient discharged to follow up with OMFS at [MASKED] on [MASKED] for tooth extraction. PATIENT SUMMARY AND HOSPITAL COURSE: ====================================== [MASKED] pmhx of HFpEF (EF 55% [MASKED], HTN, DMII c/b peripheral neuropathy, retinopathy, R toe osteo s/p amp, CKD (b/l 1.9-2.3), HLD presenting with chest pain and [MASKED] on CKD. # Sepsis secondary to dental abscess/tooth infection: Patient was noted to have worsening L sided maxillary tooth pain with associated facial swelling. Panorex imaging was obtained and evaluated by dental team. Findings showed extensive caries in left upper single molar with concern for acute exacerbation of chronic apical abscess for which she was started on oral penicillin on [MASKED]. Later that day, patient spiked a fever to 102.9F with associated rigors, sinus tachycardia to the 130s. She was started on IV vancomycin/ceftazidime/metronidazole that was narrowed to vanc/ceftriaxone/metronidazole later. ID and OMFS were consulted. OMFS recommended extraction for source control at close outpatient follow up in dental clinic. At discharge, patient was narrowed to PO Augmentin DS 875-125mg per ID recs for 10 days. # Chest pain Patient initially admitted to the [MASKED] service for chest pain with several cardiac risk factors (HTN, DM, HLD). Chest pain was substernal, sharp, nonradiating, nonexertional, [MASKED] on admission; chest pain stopped [MASKED] evening. Trop 0.02 on admission, <0.01 subsequently. No ecg changes. Given cardiac risk factors, patient underwent perfusion stress study which showed normal myocardial perfusion. Given aspirin 325mg, then continued on aspirin 81mg daily. Home atorvastatin increased to 80mg QHS. Chest pain resolved spontaneously without intervention. # Chronic HFpEF (EF 55% [MASKED]: Patient was admitted with chest pain, felt to be euvolemic to slightly overloaded on exam. On hospital day 1, she received Torsemide 80mg x1 with bump in creatinine. Given her [MASKED] and positive orthostatic hypotension, her diuretics were subsequently held during admission with improvement in creatinine. Of note, home Torsemide was most recently 80mg QAM and 40mg QPM. Given [MASKED] on admission, this was concerning for over-diuresis. Will be discharged on home diuretic dose given improvement in Cr at time of discharge. - Patient continued on home hydralazine, spironolactone, amlodipine, imdur at discharge. Lisinopril held at time of discharge. Discharge weight 251 lbs. Discharge Creatinine 2.4. # Concern for amyloidosis TTE in [MASKED] showed LVH with increased PCWP. Concern for infiltrative process (eg, amyloid). Serum free light chains, SPEP, UPEP negative. Consider pyrophosphate spect as outpatient if suspicion high enough for cardiac amyloidosis. # [MASKED] on CKD (b/l 1.9-2.3): Cr 2.8 on admission. [MASKED] felt likely to be pre-renal secondary to over-diuresis and infection [MASKED] dental abscess. Held home torsemide and gave gentle IVF with improvement. Cr on discharge 2.4. Plan to restart home torsemide on discharge. # HTN Initially held home lisinopril, spironolactone in the setting of [MASKED]. Continued home amlodipine, imdur, and hydralazine. Restarted all home meds except lisinopril on discharge. Lisinopril should be restarted as outpatient as Cr improves and K is confirmed within normal limits (K 5.0 on discharge). Patient refused further lab draws prior to discharge. # DMII ## peripheral neuropathy ## retinopathy Continued home long acting 60 HS, home humalog 15 with dinner, and SSI. Also continued home gabapentin. # CODE: Full # CONTACT/HCP: [MASKED] Relationship: Husband Phone number: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Ferrous Sulfate 325 mg PO DAILY 6. Gabapentin 100 mg PO BID 7. HydrALAZINE 25 mg PO TID 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 9. Lisinopril 10 mg PO DAILY 10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID 11. Spironolactone 25 mg PO DAILY 12. Torsemide 40 mg PO QPM 13. TraZODone 25 mg PO QHS:PRN insomnia 14. Humalog 15 Units Dinner tresiba 60 Units Bedtime 15. Torsemide 80 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth once a day Disp #*10 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth Every 6 hours as needed Disp #*6 Tablet Refills:*0 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Ferrous Sulfate 325 mg PO DAILY 8. Gabapentin 100 mg PO BID 9. HydrALAZINE 25 mg PO TID 10. Humalog 15 Units Dinner Tresiba 60 Units Bedtime 11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID 13. Spironolactone 25 mg PO DAILY 14. Torsemide 80 mg PO DAILY 15. Torsemide 40 mg PO QPM 16. TraZODone 25 mg PO QHS:PRN insomnia 17. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until your creatinine improves Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Sepsis due to dental abscess SECONDARY DIAGNOSIS: ====================== Acute on chronic kidney Disease Orthostatic hypotension Chronic Diastolic Heart Failure Chest Pain 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 chest pain and some kidney damage. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You underwent a stress test which showed normal blood flow to your heart. - You had tooth pain due to an infection around your tooth and needed IV antibiotics. - The dentist saw you and you will need an extraction of your tooth. 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 in one 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: 251 lbs. You should use this as your baseline after you leave the hospital. We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I130", "I5032", "N179", "E1122", "E785", "D509", "Z8673" ]
[ "A419: Sepsis, unspecified organism", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "R079: Chest pain, unspecified", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "K046: Periapical abscess with sinus", "I951: Orthostatic hypotension", "K029: Dental caries, unspecified", "E785: Hyperlipidemia, unspecified", "D509: Iron deficiency anemia, unspecified", "Z89421: Acquired absence of other right toe(s)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,031,575
21,395,590
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: SOB, ___ edema Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ y/o woman with a PMH of HFpEF, HTN, T2DM s/p peripheral neuropathy, retinopathy, R toe osteomyelitis s/p amputation, CKDIII (baseline Cr 1.7-2.0), HLD, who presents as a transfer from ___ with acute, decompensated heart failure. She presented to her PCP's office earlier today with worsening dyspnea on exertion, two-pillow orthopnea, leg swelling, and weight gain of nearly 40 lbs. She denied chest pain at rest or with exertion, but has been limited from a mobility standpoint over the past few months. She had been due to see Dr. ___ as her new cardiologist, but had been unable to owing to transportation issues. She denied nausea, lightheadedness, dizziness, fevers, chills, chest pain, vomiting, diarrhea, or sick contacts. In clinic, her vital signs were notable for BP of 210/100 mmHg P 68, O2 100%, with examination notable for JVP to the level of the earlobe at 30 degrees, decrease breath sounds at the bilateral bases, decreased air movement, and 3+ bilaterally lower extremity edema with warm extremities. She was referred to the ___. Her labs were notable for a normal CBC, BUN/Cr of ___, K 4.3, Mg 1.6, proBNP pending. Upon evaluation in the CDAC, she was deemed to require direct admission to the heart failure service for aggressive diuresis with Lasix 100 mg bolus and drip likely at 10 mg/hr as well as consideration of nitroglycerin gtt. On arrival to the floor, she reports that she has been feeling short of breath for approximately two weeks. This coincides with difficulty that she has had with filling her amlodipine and torsemide over the past two weeks as well, and so she has been unable to take these two medications reliably. She reports dyspnea on exertion, reports that she is still able to "walk pretty far." She always sleeps on two pillows and denies PND. She denies chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria, hematuria, lightheadedness, dizziness, or syncope. She reports waking up with headaches in the morning, but is currently not experiencing a headache. REVIEW OF SYSTEMS: - as above, otherwise negative Past Medical History: - Diastolic CHF, LVEF 55% ___, possibly related to HTN. Diagnosed ___ at ___. - History of CVA - treated at ___, left sided hemiparesis, ___, no residual deficits - Diabetes mellitus, A1C 7.2% (___), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation ___ years ago - CKDIII (baseline Cr 1.7-2.0) - R toe osteomyelitis s/p amputation - iron deficiency anemia Social History: ___ Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age ___. Maternal uncle also with T2DM and ESRD on HD. Children healthy, 1 son with autism. Physical Exam: Admission exam: VS: T 98.1F BP 180/101 mmHg P 74 RR 18 O2 100% RA General: Comfortable, lying in bed, NAD. HEENT: Anicteric sclerae; EOMs intact. MMM, OP clear. Neck: Supple, JVP to earlobe at 30 degrees. CV: RRR, II/VI systolic murmur, best heard over RUSB. Pulm: Diminished breath sounds bilaterally with scant crackles. No wheezes. Abd: Soft, non-tender, non-distended, NABS. Ext: Warm and well-perfused. 2+ edema bilaterally with venous stasis changes. Neuro: A&Ox3; CNs II-XII grossly intact. Discharge exam: ___ 0812 Temp: 97.9 PO BP: 167/96 HR: 52 RR: 18 O2 sat: 100% O2 delivery: Ra FSBG: 286 General: Comfortable, lying in bed, NAD. HEENT: Anicteric sclerae; EOMs intact. MMM, OP clear. Neck: Supple, JVP difficult to assess given body habitus CV: RRR, II/VI systolic murmur, best heard over RUSB. Pulm: Diminished breath sounds bilaterally with scant crackles. No wheezes. Abd: Soft, non-tender, non-distended, NABS. Ext: Warm and well-perfused. 2+ edema bilaterally with venous stasis changes. Neuro: A&Ox3; CNs II-XII grossly intact. finger to nose testing intact Pertinent Results: Admission and notable labs: ___ 02:54PM BLOOD WBC-8.0 RBC-4.16 Hgb-12.1 Hct-36.1 MCV-87 MCH-29.1 MCHC-33.5 RDW-12.7 RDWSD-39.9 Plt ___ ___ 02:54PM BLOOD Neuts-62.4 ___ Monos-6.7 Eos-1.1 Baso-0.5 Im ___ AbsNeut-5.01 AbsLymp-2.34 AbsMono-0.54 AbsEos-0.09 AbsBaso-0.04 ___ 02:54PM BLOOD UreaN-22* Creat-1.7* Na-140 K-4.3 Cl-102 HCO3-25 AnGap-13 ___ 08:10AM BLOOD ALT-10 AST-11 LD(LDH)-260* AlkPhos-137* TotBili-0.2 ___ 02:54PM BLOOD CK-MB-5 cTropnT-0.02* proBNP-1067* ___ 08:10AM BLOOD CK-MB-3 cTropnT-0.02* ___ 02:54PM BLOOD Calcium-9.3 Phos-3.2 Mg-1.6 Cholest-191 ___ 01:00PM BLOOD calTIBC-234* Ferritn-62 TRF-180* ___ 02:54PM BLOOD %HbA1c-14.0* eAG-355* ___ 02:54PM BLOOD Triglyc-157* HDL-52 CHOL/HD-3.7 LDLcalc-108 ___ 07:13PM BLOOD TSH-3.2 ___ 08:38AM BLOOD Lactate-1.2 ___ 12:22AM URINE Blood-TR* Nitrite-NEG Protein-300* Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 12:22AM URINE Color-Straw Appear-Clear Sp ___ ___ 12:22AM URINE RBC-2 WBC-4 Bacteri-NONE Yeast-NONE Epi-5 MICRO: blood culture pending at discharge Discharge labs: ___ 07:45AM BLOOD WBC-8.5 RBC-4.18 Hgb-12.4 Hct-36.5 MCV-87 MCH-29.7 MCHC-34.0 RDW-12.9 RDWSD-40.7 Plt ___ ___ 05:00PM BLOOD Glucose-399* UreaN-32* Creat-2.1* Na-138 K-4.4 Cl-97 HCO3-27 AnGap-14 IMAGING: TTE ___: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. 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%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Preserved biventricular systolic function. Mild mitral and tricuspid regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of ___, the severity of mitral and tricuspid regurgitation has decreased. The pulmonary pressure is lower. Brief Hospital Course: ___ yo woman with history of HFpEF, HTN, T2DM c/b peripheral neuropathy, retinopathy, R toe osteomyelitis s/p amputation, CKDIII (baseline Cr 1.7-2.0), HLD who presented on ___ as a transfer from ___ unit for acute decompensated systolic heart failure. Patient had been at ___ clinic when she was noted to be 40 lbs over dry weight with gross volume overload. She was referred to ___ where she was recommended for IV Lasix and IV nitro gtt for hypertensive urgency and acute decompensated systolic heart failure. ACUTE ISSUES: #Acute decompensated HFpEF: On the CHF service, she was aggressively diuresed with Lasix 100 IV BID + Lasix gtt at 10. She was initiated on hydralazine 10 TID given hypertension and she was placed on isordil 10 TID with plan to uptitrate to a tolerated dose then convert to imdur. The plan over the admission was to diurese off to a dry weight estimated at 107 kg from admission weight of 121 kgs. However, patient has a very challenging social situation as she is the sole caregiver of her son with autism. She felt very strongly about being discharged early, well before completing diuresis. The plan therefore is to continue diuretics at home with close follow up and consideration of returning to ___ on ___ for further assessment and diuresis. Consideration of CDAC admission will be discussed with PCP. She will need labs drawn on ___ to ensure electrolytes are repleted. Her home regimen until she can be seen in clinic again is: - torsemide 100 mg BID - imdur 60 mg daily - hydralazine 10 mg TID - Lisinopril 40 mg daily - dry weight: 107 kg. Discharge weight: 117.9 kg. #Poorly controlled IDDM: Hospital course notable for poorly controlled DM, with new A1c >14. Given this, ___ was consulted and insulin titrated. She was still with inadequately controlled FSG prior to discharge. However, with ___ input, she was initiated on: -glargine 30U qHS -Humalog 10U qAC -she will need follow up with ___ clinic after discharge; this was unable to be arranged due to early and sudden discharge #Sinus bradycardia: Finally, hospital course notable for sinus bradycardia with rates in the ___ and so home metoprolol was discontinued with improved heart rates #Hypertensive urgency: c/b pulmonary edema and HF exacerbation - treated as above with increasing anti-hypertensives and diuresis #Social situation: initial reason for HFpEF decompensation was felt to be due to medication noncompliance (patient was unable to get her meds due to inadequate/confusing refills). She was also experiencing issues getting to appointments which was due to transportation and now is due to difficulty helping her son at home. Please review SW's excellent notes this admission. Going forward: - medications: now enrolled in PACT and please be attentive to refills (written for 1 month's supply for bedside delivery at discharge after discussing that PACT will follow up and ensure proper refills thereafter) - transportation: now arranged with SW input - care for son at home: this will need ongoing consideration and should be addressed in future visits. CHRONIC ISSUES: #HTN: - continued home Lisinopril 40 mg daily - imdur 60 mg daily at discharge as above (was on isordil 10 TID during hospital course) - hydral 10 TID daily #HLD: - asa 81 - atorvastatin 40 mg daily #DM neuropathy: - continued on gabapentin at reduced BID dosing from TID dosing #CKDIII: Creatinine remained near baseline although was rising at the time of discharge. #Fe deficiency anemia: continued on home Fe supplementation TRANSITIONAL ISSUES: - Please ensure follow up in CDAC if possible or at least labs on ___ given that she is being actively diuresed at home on high dose torsemide. - Please ensure that she follow up with PCP, cardiology (HF), and ___ for ongoing management. ___ appointment was unable to be arranged given late and sudden discharge. - follow up TSH; sent in setting of acute HFpEF exacerbation - Discharge weight 117.9 kg from dry weight 107 kg (121 kgs on admission) - please continue to consider optimizing services with special consideration of caring for her son at home as this is the major factor limiting her care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Gabapentin 100 mg PO TID 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Torsemide 60 mg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. Glargine 28 Units Bedtime 10. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Medications: 1. HydrALAZINE 10 mg PO TID RX *hydralazine 10 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*3 2. Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Torsemide 100 mg PO BID RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 5. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3 mL) subcutaneous QHS RX *insulin degludec [Tresiba FlexTouch U-100] 100 unit/mL (3 mL) 30 U qHS at bedtime Disp #*5 Syringe Refills:*0 6. Gabapentin 100 mg PO BID 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) po daily Disp #*30 Tablet Refills:*3 9. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet Refills:*3 10. Ferrous Sulfate 325 mg PO DAILY 11. Lisinopril 40 mg PO DAILY 12.Outpatient Lab Work Please collect chem10 and fax to ___ on ___. ICD 10 I50.33 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Acute decompensated heart failure with preserved ejection fraction Secondary diagnosis: Insulin dependent diabetes mellitus complicated by neuropathy and retinopathy Sinus bradycardia Hypertension Chronic kidney disease III (baseline Cr 1.7-2.0) Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, Why were you were seen in the hospital? - You were seen in the hospital due to a condition called heart failure. You had too much volume on and so had swelling in your legs (edema) as well as fluid in your lungs. - You were seen by your primary care doctor who referred you urgently to our cardiac monitoring unit. It was felt that you needed to be admitted to the hospital. What happened when you were in the hospital? - You underwent diuresis, which is when we give you medications to make you pee off the extra fluid. - Your diabetes was shown to be poorly controlled on our labs. Given this, we had our diabetes experts from the ___ ___ evaluate you. We adjusted your insulin. - You had dizziness while you were here and so we discontinued your medications. What should you do when you leave the hospital? - Weigh yourself every day in the morning. Please call the cardiology clinic if your weight is decreasing or increasing more than 3 pounds in a given day: ___. - Please follow up with ___ at your appointment below for changing your diabetes medications - Please have your labs checked on ___ if you are not seen in ___. It was a pleasure taking care of you at ___. Sincerely, Your ___ care team Followup Instructions: ___
[ "I130", "I5023", "E1122", "E1142", "I69354", "N183", "E11319", "E785", "Z89421", "D509", "Z794", "E1165", "R001", "I160" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: SOB, [MASKED] edema Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] y/o woman with a PMH of HFpEF, HTN, T2DM s/p peripheral neuropathy, retinopathy, R toe osteomyelitis s/p amputation, CKDIII (baseline Cr 1.7-2.0), HLD, who presents as a transfer from [MASKED] with acute, decompensated heart failure. She presented to her PCP's office earlier today with worsening dyspnea on exertion, two-pillow orthopnea, leg swelling, and weight gain of nearly 40 lbs. She denied chest pain at rest or with exertion, but has been limited from a mobility standpoint over the past few months. She had been due to see Dr. [MASKED] as her new cardiologist, but had been unable to owing to transportation issues. She denied nausea, lightheadedness, dizziness, fevers, chills, chest pain, vomiting, diarrhea, or sick contacts. In clinic, her vital signs were notable for BP of 210/100 mmHg P 68, O2 100%, with examination notable for JVP to the level of the earlobe at 30 degrees, decrease breath sounds at the bilateral bases, decreased air movement, and 3+ bilaterally lower extremity edema with warm extremities. She was referred to the [MASKED]. Her labs were notable for a normal CBC, BUN/Cr of [MASKED], K 4.3, Mg 1.6, proBNP pending. Upon evaluation in the CDAC, she was deemed to require direct admission to the heart failure service for aggressive diuresis with Lasix 100 mg bolus and drip likely at 10 mg/hr as well as consideration of nitroglycerin gtt. On arrival to the floor, she reports that she has been feeling short of breath for approximately two weeks. This coincides with difficulty that she has had with filling her amlodipine and torsemide over the past two weeks as well, and so she has been unable to take these two medications reliably. She reports dyspnea on exertion, reports that she is still able to "walk pretty far." She always sleeps on two pillows and denies PND. She denies chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria, hematuria, lightheadedness, dizziness, or syncope. She reports waking up with headaches in the morning, but is currently not experiencing a headache. REVIEW OF SYSTEMS: - as above, otherwise negative Past Medical History: - Diastolic CHF, LVEF 55% [MASKED], possibly related to HTN. Diagnosed [MASKED] at [MASKED]. - History of CVA - treated at [MASKED], left sided hemiparesis, [MASKED], no residual deficits - Diabetes mellitus, A1C 7.2% ([MASKED]), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation [MASKED] years ago - CKDIII (baseline Cr 1.7-2.0) - R toe osteomyelitis s/p amputation - iron deficiency anemia Social History: [MASKED] Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age [MASKED]. Maternal uncle also with T2DM and ESRD on HD. Children healthy, 1 son with autism. Physical Exam: Admission exam: VS: T 98.1F BP 180/101 mmHg P 74 RR 18 O2 100% RA General: Comfortable, lying in bed, NAD. HEENT: Anicteric sclerae; EOMs intact. MMM, OP clear. Neck: Supple, JVP to earlobe at 30 degrees. CV: RRR, II/VI systolic murmur, best heard over RUSB. Pulm: Diminished breath sounds bilaterally with scant crackles. No wheezes. Abd: Soft, non-tender, non-distended, NABS. Ext: Warm and well-perfused. 2+ edema bilaterally with venous stasis changes. Neuro: A&Ox3; CNs II-XII grossly intact. Discharge exam: [MASKED] 0812 Temp: 97.9 PO BP: 167/96 HR: 52 RR: 18 O2 sat: 100% O2 delivery: Ra FSBG: 286 General: Comfortable, lying in bed, NAD. HEENT: Anicteric sclerae; EOMs intact. MMM, OP clear. Neck: Supple, JVP difficult to assess given body habitus CV: RRR, II/VI systolic murmur, best heard over RUSB. Pulm: Diminished breath sounds bilaterally with scant crackles. No wheezes. Abd: Soft, non-tender, non-distended, NABS. Ext: Warm and well-perfused. 2+ edema bilaterally with venous stasis changes. Neuro: A&Ox3; CNs II-XII grossly intact. finger to nose testing intact Pertinent Results: Admission and notable labs: [MASKED] 02:54PM BLOOD WBC-8.0 RBC-4.16 Hgb-12.1 Hct-36.1 MCV-87 MCH-29.1 MCHC-33.5 RDW-12.7 RDWSD-39.9 Plt [MASKED] [MASKED] 02:54PM BLOOD Neuts-62.4 [MASKED] Monos-6.7 Eos-1.1 Baso-0.5 Im [MASKED] AbsNeut-5.01 AbsLymp-2.34 AbsMono-0.54 AbsEos-0.09 AbsBaso-0.04 [MASKED] 02:54PM BLOOD UreaN-22* Creat-1.7* Na-140 K-4.3 Cl-102 HCO3-25 AnGap-13 [MASKED] 08:10AM BLOOD ALT-10 AST-11 LD(LDH)-260* AlkPhos-137* TotBili-0.2 [MASKED] 02:54PM BLOOD CK-MB-5 cTropnT-0.02* proBNP-1067* [MASKED] 08:10AM BLOOD CK-MB-3 cTropnT-0.02* [MASKED] 02:54PM BLOOD Calcium-9.3 Phos-3.2 Mg-1.6 Cholest-191 [MASKED] 01:00PM BLOOD calTIBC-234* Ferritn-62 TRF-180* [MASKED] 02:54PM BLOOD %HbA1c-14.0* eAG-355* [MASKED] 02:54PM BLOOD Triglyc-157* HDL-52 CHOL/HD-3.7 LDLcalc-108 [MASKED] 07:13PM BLOOD TSH-3.2 [MASKED] 08:38AM BLOOD Lactate-1.2 [MASKED] 12:22AM URINE Blood-TR* Nitrite-NEG Protein-300* Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 12:22AM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 12:22AM URINE RBC-2 WBC-4 Bacteri-NONE Yeast-NONE Epi-5 MICRO: blood culture pending at discharge Discharge labs: [MASKED] 07:45AM BLOOD WBC-8.5 RBC-4.18 Hgb-12.4 Hct-36.5 MCV-87 MCH-29.7 MCHC-34.0 RDW-12.9 RDWSD-40.7 Plt [MASKED] [MASKED] 05:00PM BLOOD Glucose-399* UreaN-32* Creat-2.1* Na-138 K-4.4 Cl-97 HCO3-27 AnGap-14 IMAGING: TTE [MASKED]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. 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%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Preserved biventricular systolic function. Mild mitral and tricuspid regurgitation. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [MASKED], the severity of mitral and tricuspid regurgitation has decreased. The pulmonary pressure is lower. Brief Hospital Course: [MASKED] yo woman with history of HFpEF, HTN, T2DM c/b peripheral neuropathy, retinopathy, R toe osteomyelitis s/p amputation, CKDIII (baseline Cr 1.7-2.0), HLD who presented on [MASKED] as a transfer from [MASKED] unit for acute decompensated systolic heart failure. Patient had been at [MASKED] clinic when she was noted to be 40 lbs over dry weight with gross volume overload. She was referred to [MASKED] where she was recommended for IV Lasix and IV nitro gtt for hypertensive urgency and acute decompensated systolic heart failure. ACUTE ISSUES: #Acute decompensated HFpEF: On the CHF service, she was aggressively diuresed with Lasix 100 IV BID + Lasix gtt at 10. She was initiated on hydralazine 10 TID given hypertension and she was placed on isordil 10 TID with plan to uptitrate to a tolerated dose then convert to imdur. The plan over the admission was to diurese off to a dry weight estimated at 107 kg from admission weight of 121 kgs. However, patient has a very challenging social situation as she is the sole caregiver of her son with autism. She felt very strongly about being discharged early, well before completing diuresis. The plan therefore is to continue diuretics at home with close follow up and consideration of returning to [MASKED] on [MASKED] for further assessment and diuresis. Consideration of CDAC admission will be discussed with PCP. She will need labs drawn on [MASKED] to ensure electrolytes are repleted. Her home regimen until she can be seen in clinic again is: - torsemide 100 mg BID - imdur 60 mg daily - hydralazine 10 mg TID - Lisinopril 40 mg daily - dry weight: 107 kg. Discharge weight: 117.9 kg. #Poorly controlled IDDM: Hospital course notable for poorly controlled DM, with new A1c >14. Given this, [MASKED] was consulted and insulin titrated. She was still with inadequately controlled FSG prior to discharge. However, with [MASKED] input, she was initiated on: -glargine 30U qHS -Humalog 10U qAC -she will need follow up with [MASKED] clinic after discharge; this was unable to be arranged due to early and sudden discharge #Sinus bradycardia: Finally, hospital course notable for sinus bradycardia with rates in the [MASKED] and so home metoprolol was discontinued with improved heart rates #Hypertensive urgency: c/b pulmonary edema and HF exacerbation - treated as above with increasing anti-hypertensives and diuresis #Social situation: initial reason for HFpEF decompensation was felt to be due to medication noncompliance (patient was unable to get her meds due to inadequate/confusing refills). She was also experiencing issues getting to appointments which was due to transportation and now is due to difficulty helping her son at home. Please review SW's excellent notes this admission. Going forward: - medications: now enrolled in PACT and please be attentive to refills (written for 1 month's supply for bedside delivery at discharge after discussing that PACT will follow up and ensure proper refills thereafter) - transportation: now arranged with SW input - care for son at home: this will need ongoing consideration and should be addressed in future visits. CHRONIC ISSUES: #HTN: - continued home Lisinopril 40 mg daily - imdur 60 mg daily at discharge as above (was on isordil 10 TID during hospital course) - hydral 10 TID daily #HLD: - asa 81 - atorvastatin 40 mg daily #DM neuropathy: - continued on gabapentin at reduced BID dosing from TID dosing #CKDIII: Creatinine remained near baseline although was rising at the time of discharge. #Fe deficiency anemia: continued on home Fe supplementation TRANSITIONAL ISSUES: - Please ensure follow up in CDAC if possible or at least labs on [MASKED] given that she is being actively diuresed at home on high dose torsemide. - Please ensure that she follow up with PCP, cardiology (HF), and [MASKED] for ongoing management. [MASKED] appointment was unable to be arranged given late and sudden discharge. - follow up TSH; sent in setting of acute HFpEF exacerbation - Discharge weight 117.9 kg from dry weight 107 kg (121 kgs on admission) - please continue to consider optimizing services with special consideration of caring for her son at home as this is the major factor limiting her care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Gabapentin 100 mg PO TID 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Torsemide 60 mg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. Glargine 28 Units Bedtime 10. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Medications: 1. HydrALAZINE 10 mg PO TID RX *hydralazine 10 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*3 2. Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Torsemide 100 mg PO BID RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 5. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3 mL) subcutaneous QHS RX *insulin degludec [Tresiba FlexTouch U-100] 100 unit/mL (3 mL) 30 U qHS at bedtime Disp #*5 Syringe Refills:*0 6. Gabapentin 100 mg PO BID 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) po daily Disp #*30 Tablet Refills:*3 9. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet Refills:*3 10. Ferrous Sulfate 325 mg PO DAILY 11. Lisinopril 40 mg PO DAILY 12.Outpatient Lab Work Please collect chem10 and fax to [MASKED] on [MASKED]. ICD 10 I50.33 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: Acute decompensated heart failure with preserved ejection fraction Secondary diagnosis: Insulin dependent diabetes mellitus complicated by neuropathy and retinopathy Sinus bradycardia Hypertension Chronic kidney disease III (baseline Cr 1.7-2.0) Hyperlipidemia 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 were seen in the hospital? - You were seen in the hospital due to a condition called heart failure. You had too much volume on and so had swelling in your legs (edema) as well as fluid in your lungs. - You were seen by your primary care doctor who referred you urgently to our cardiac monitoring unit. It was felt that you needed to be admitted to the hospital. What happened when you were in the hospital? - You underwent diuresis, which is when we give you medications to make you pee off the extra fluid. - Your diabetes was shown to be poorly controlled on our labs. Given this, we had our diabetes experts from the [MASKED] [MASKED] evaluate you. We adjusted your insulin. - You had dizziness while you were here and so we discontinued your medications. What should you do when you leave the hospital? - Weigh yourself every day in the morning. Please call the cardiology clinic if your weight is decreasing or increasing more than 3 pounds in a given day: [MASKED]. - Please follow up with [MASKED] at your appointment below for changing your diabetes medications - Please have your labs checked on [MASKED] if you are not seen in [MASKED]. It was a pleasure taking care of you at [MASKED]. Sincerely, Your [MASKED] care team Followup Instructions: [MASKED]
[]
[ "I130", "E1122", "E785", "D509", "Z794", "E1165" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "N183: Chronic kidney disease, stage 3 (moderate)", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E785: Hyperlipidemia, unspecified", "Z89421: Acquired absence of other right toe(s)", "D509: Iron deficiency anemia, unspecified", "Z794: Long term (current) use of insulin", "E1165: Type 2 diabetes mellitus with hyperglycemia", "R001: Bradycardia, unspecified", "I160: Hypertensive urgency" ]
10,031,575
23,640,913
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 weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o woman with a PMH of HFpEF, HTN, T2DM s/p peripheral neuropathy, retinopathy, R toe osteomyelitis s/p amputation, CKDIII (baseline Cr 1.7-2.0), HLD, who presents with chest pain, cough, diarrhea, and hypotension, admitted for ___. Patient recently presented to ___ for 1 week of malaise, cough, pleuritic chest pain, and hypotension. She was checked for flu (negative) and RSV, RSV noted to be positive. She was discharged with Rx for Benadryl and ibuprofen. Since then she has continued to feel unwell with malaise, cough, and pleuritic chest pain. She also developed nausea and diarrhea several days ago. Notes watery BMs ___ times a day. Has had poor PO intake. Denies recent travel, new or unusual foods, no recent abx. Mother has had C. Diff several times, last episode ___ months ago. Has continued to taker her medications despite feeling unwell, including her torsemide. Her husband now has similar symptoms. She notes her cough previously was productive of yellow sputum, now has become thinner, white, and is less bothersome. She continues to have pleuritic chest pain with deep breaths that is unchanged from last week. In the ___, the patient's vitals were as follows: T 96, HR 70, RR 14, BP 114/73 --> 93/49, SpO2 100% on RA. CBC without leukocytosis, BMP with hyperkalemia and ___ to 3.9. Troponin 0.11--> 0.10. UA c/w contamination. CXR negative for acute process. She was given ASA 325, 500 cc NS bolus. She was admitted to medicine for further work up and management. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. PAST MEDICAL/SURGICAL HISTORY: HFpEF HTN Dm2 CKD R toe osteo s/p amputation SOCIAL HISTORY: ___ FAMILY HISTORY: Reviewed and found to be not relevant to this illness/reason for hospitalization. ALLERGIES/ADR: See webOMR PREADMISSION MEDICATIONS: * Document and also communicate any unresolved medication reconciliation issues to the next provider of care. --------------- --------------- --------------- --------------- Active Medication list as of ___: Medications - Prescription AMLODIPINE - amlodipine 10 mg tablet. 1 tablet(s) by mouth daily am ATORVASTATIN - atorvastatin 40 mg tablet. 1 tablet(s) by mouth daily at hs - (Prescribed by Other Provider) GABAPENTIN - gabapentin 100 mg capsule. 1 capsule(s) by mouth two times per day HYDRALAZINE - hydralazine 10 mg tablet. 1 tablet(s) by mouth three times a day INSULIN DEGLUDEC [TRESIBA FLEXTOUCH U-100] - Tresiba FlexTouch U-100 insulin 100 unit/mL (3 mL) subcutaneous pen. 35 units sc hs INSULIN LISPRO ___ INSULIN] - ___ (U-100) Insulin 100 unit/mL subcutaneous. ___ units SC as directed before meals and at bedtime as needed for sliding scale directions ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 60 mg tablet,extended release 24 hr. 1 tablet(s) by mouth daily am LISINOPRIL - lisinopril 40 mg tablet. 1 tablet(s) by mouth once a day at hs - (Prescribed by Other Provider) METOLAZONE - metolazone 5 mg tablet. 1 (One) tablet(s) by mouth once daily as needed for for weight gain and leg swelling ONLY as instructed by cardiology TORSEMIDE - torsemide 100 mg tablet. 1 tablet(s) by mouth once a day ___ and ___ 50 mg - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 81 mg chewable tablet. 1 tablet(s) by mouth daily am BLOOD SUGAR DIAGNOSTIC [FREESTYLE TEST] - FreeStyle Test strips. Use ad directed to test blood glucose up to four times a day BLOOD-GLUCOSE METER [FREESTYLE SYSTEM KIT] - FreeStyle System Kit. Use as directed to test blood glucose up to four times a day Please provide which ever freestyle meter is covered FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth daily LANCETS [FREESTYLE LANCETS] - FreeStyle Lancets 28 gauge. Use as directed to test blood glucose up to four times a day PEN NEEDLE, DIABETIC [BD ULTRA-FINE SHORT PEN NEEDLE] - BD Ultra-Fine Short Pen Needle 31 gauge x ___. use as directed up to 5x/day for insulin injection --------------- --------------- --------------- --------------- Past Medical History: - Diastolic CHF, LVEF 55% ___, possibly related to HTN. Diagnosed ___ at ___. - History of CVA - treated at ___, left sided hemiparesis, ___, no residual deficits - Diabetes mellitus, A1C 7.2% (___), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation ___ years ago - CKDIII (baseline Cr 1.7-2.0) - R toe osteomyelitis s/p amputation - iron deficiency anemia Social History: ___ Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age ___. Maternal uncle also with T2DM and ESRD on HD. Children healthy, 1 son with autism. Physical Exam: EXAM(8) ___ 0817 Temp: 98.4 PO BP: 140/77 R Lying HR: 65 RR: 16 O2 sat: 100% O2 delivery: RA Weight 250lbs JVP flat regular s1 and s2 without audible murmur CTAB no crackles or wheezes no focal abd tenderness to palpation no peripheral edema Pertinent Results: ___ 02:05AM BLOOD WBC-9.3 RBC-3.73* Hgb-11.0* Hct-34.4 MCV-92 MCH-29.5 MCHC-32.0 RDW-12.9 RDWSD-43.7 Plt ___ ___ 07:12AM BLOOD WBC-8.5 RBC-3.72* Hgb-11.0* Hct-33.7* MCV-91 MCH-29.6 MCHC-32.6 RDW-12.7 RDWSD-41.9 Plt ___ ___ 02:05AM BLOOD Glucose-197* UreaN-117* Creat-3.9*# Na-140 K-6.3* Cl-110* HCO3-17* AnGap-13 ___ 07:12AM BLOOD Glucose-129* UreaN-94* Creat-2.4*# Na-142 K-5.5* Cl-110* HCO3-18* AnGap-14 ___ 04:45AM BLOOD cTropnT-0.10* FINDINGS: Lung volumes are low. There are no focal consolidations. The cardiomediastinal and hilar silhouettes are within normal limits. No pulmonary edema. No pleural effusions. No pneumothorax. IMPRESSION: No acute intrathoracic process. ___ 05:55AM BLOOD WBC-8.3 RBC-3.69* Hgb-11.0* Hct-33.6* MCV-91 MCH-29.8 MCHC-32.7 RDW-12.8 RDWSD-41.9 Plt ___ ___ 09:20AM BLOOD Glucose-196* UreaN-45* Creat-2.0* Na-137 K-5.8* Cl-104 HCO3-20* AnGap-13 ___ 11:12AM BLOOD Glucose-181* UreaN-53* Creat-2.1* Na-141 K-5.8* Cl-109* HCO3-20* AnGap-12 ___ 05:55AM BLOOD Glucose-127* UreaN-55* Creat-2.1* Na-141 K-6.1* Cl-109* HCO3-20* AnGap-12 ___ 10:50AM BLOOD Glucose-174* UreaN-64* Creat-2.3* Na-139 K-5.3 Cl-109* HCO3-20* AnGap-10 ___ 06:10AM BLOOD Glucose-146* UreaN-68* Creat-2.4* Na-140 K-6.3* Cl-108 HCO3-20* AnGap-12 ___ 10:20AM BLOOD Glucose-164* UreaN-72* Creat-2.2* Na-140 K-5.7* Cl-108 HCO3-18* AnGap-14 ___ 05:15AM BLOOD Glucose-174* UreaN-76* Creat-2.1* Na-139 K-6.9* Cl-108 HCO3-18* AnGap-___ woman with a history of heart failure with preserved ejection fraction hypertension type 2 diabetes known to the congestive heart failure cardiology service at ___ with stage III chronic kidney disease who presents with cough diarrhea lower blood pressure. She was diagnosed with acute renal failure with a creatinine of 3.9 which was felt to be prerenal in the etiology and he began to improve. She was also diagnosed with C. difficile colitis based on stool testing of her diarrhea and started on oral vancomycin. #ARF- likely from hypovolemia in the context of diarrhea and continued diuretic dosing. Patient presented significantly below dry weight. ___ improved to 2.0 on discharge and home diuretics were resumed. #Hyperkalemia- Had several episodes of hyperkalemia as high as 7.0 without accompanying ECG changes or telemetry events. Corrected with insulin/glucose and IV Lasix. Suspect this is from diuretic cessation and RTA from ATN. Improving at the time of discharge. Lisinopril held. Discussed risks hyperkalemia with patient and she wished to be discharged home to take care of her son despite ongoing mild hyperkalemia (5.8). -Hold Lisinopril -Resume home torsemide dosing as this should help with hyperkalemia -Discharge weight was 253 lbs #Cdiff colitis: d1 oral vanco ___, treated for severe manifestation given associated acute renal failure with creatinine greater than 1.5 but symptomatically fairly mild going no more than 3 times a day and there is lack of abdominal pain. She was abdominal pain free and without diarrhea at the time of discharge. Cre 2.0 (appears near baseline of (1.8-2.0) #HFpEF: dry to euvolemic, no pulm edema on CXR: anti-HTN meds held initially as well as holding metolazone and torsemide 100mg as of ___. Patient received PRN Lasix IV to correct hyperkalemia and was 253 lbs on discharge. She has HF f/u on ___ at 9am. She was told to resume her home diuretics and weight herself daily. #DM2: was seen by ___ service on prior admission due to poorly controlled DM -glargine 30 units qhs in patient -resumed home regimen on discharge #HTN: HELD Lisinopril due to hyperkalemia otherwise continued amlodipine/hydralazine on discharge. #HLD: asa 81 atorvastatin 40 mg daily #DM neuropathy: held gabapentin for ___ to avoid toxicity, can resume when creat improves prior to discharge ___ - on PO iron at home, holding for nausea and diarrhea. Can resume outpatient when off C. Diff medication. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Ferrous Sulfate 325 mg PO DAILY 5. Gabapentin 100 mg PO BID 6. ___ U-100 (insulin lispro) 100 unit/mL subcutaneous ASDIR 7. HydrALAZINE 10 mg PO TID 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. Metolazone 5 mg PO DAILY:PRN leg swelling 11. Metoprolol Succinate XL 12.5 mg PO DAILY 12. Torsemide 100 mg PO DAILY 13. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3 mL) subcutaneous QHS Discharge Medications: 1. Vancomycin Oral Liquid ___ mg PO QID RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day Disp #*40 Capsule Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Ferrous Sulfate 325 mg PO DAILY 6. Gabapentin 100 mg PO BID 7. ___ U-100 (insulin lispro) 100 unit/mL subcutaneous ASDIR 8. HydrALAZINE 10 mg PO TID 9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 10. Metolazone 5 mg PO DAILY:PRN leg swelling 11. Torsemide 100 mg PO 5X/WEEK (___) 12. Torsemide 50 mg PO 2X/WEEK (___) 13. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3 mL) subcutaneous QHS 14. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until you see Dr. ___ ___ Disposition: Home Discharge Diagnosis: C. difficile colitis Acute kidney failure Chronic diastolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized because of dehydration causing acute kidney injury as well as the diagnosis of C. difficile colitis diagnosed during workup of diarrhea. we adjusted your cardiac meds including adjusting the doses of some of your diuretics and holding your blood pressure medicines while hospitalized . When we held your diuretic because you were dehydrated you had high potassium levels in the blood. This improved with resuming your diuretic. You SHOULD STOP YOUR LISINOPRIL UNTIL you see your cardiologist. Otherwise you can resume your diuretics as normal. We also started an antibiotic for C. difficile called vancomycin which she should take to complete therapy . If you develop any severe abdominal pain or worsened diarrhea or fever or new weakness please let your doctor know right away . Symptoms of worsening congestive heart failure include shortness of breath with activity increased fatigue and lower leg swelling and weight gain weigh yourself every morning, call MD if weight goes up more than 3 lbs. It was a pleasure taking care of you. ___ Care Team Followup Instructions: ___
[ "A0472", "N179", "I130", "I5032", "E1122", "N183", "Z794", "E1142", "E11319", "E861", "D509", "E875", "Z9114", "E785" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: diarrhea weakness Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o woman with a PMH of HFpEF, HTN, T2DM s/p peripheral neuropathy, retinopathy, R toe osteomyelitis s/p amputation, CKDIII (baseline Cr 1.7-2.0), HLD, who presents with chest pain, cough, diarrhea, and hypotension, admitted for [MASKED]. Patient recently presented to [MASKED] for 1 week of malaise, cough, pleuritic chest pain, and hypotension. She was checked for flu (negative) and RSV, RSV noted to be positive. She was discharged with Rx for Benadryl and ibuprofen. Since then she has continued to feel unwell with malaise, cough, and pleuritic chest pain. She also developed nausea and diarrhea several days ago. Notes watery BMs [MASKED] times a day. Has had poor PO intake. Denies recent travel, new or unusual foods, no recent abx. Mother has had C. Diff several times, last episode [MASKED] months ago. Has continued to taker her medications despite feeling unwell, including her torsemide. Her husband now has similar symptoms. She notes her cough previously was productive of yellow sputum, now has become thinner, white, and is less bothersome. She continues to have pleuritic chest pain with deep breaths that is unchanged from last week. In the [MASKED], the patient's vitals were as follows: T 96, HR 70, RR 14, BP 114/73 --> 93/49, SpO2 100% on RA. CBC without leukocytosis, BMP with hyperkalemia and [MASKED] to 3.9. Troponin 0.11--> 0.10. UA c/w contamination. CXR negative for acute process. She was given ASA 325, 500 cc NS bolus. She was admitted to medicine for further work up and management. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. PAST MEDICAL/SURGICAL HISTORY: HFpEF HTN Dm2 CKD R toe osteo s/p amputation SOCIAL HISTORY: [MASKED] FAMILY HISTORY: Reviewed and found to be not relevant to this illness/reason for hospitalization. ALLERGIES/ADR: See webOMR PREADMISSION MEDICATIONS: * Document and also communicate any unresolved medication reconciliation issues to the next provider of care. --------------- --------------- --------------- --------------- Active Medication list as of [MASKED]: Medications - Prescription AMLODIPINE - amlodipine 10 mg tablet. 1 tablet(s) by mouth daily am ATORVASTATIN - atorvastatin 40 mg tablet. 1 tablet(s) by mouth daily at hs - (Prescribed by Other Provider) GABAPENTIN - gabapentin 100 mg capsule. 1 capsule(s) by mouth two times per day HYDRALAZINE - hydralazine 10 mg tablet. 1 tablet(s) by mouth three times a day INSULIN DEGLUDEC [TRESIBA FLEXTOUCH U-100] - Tresiba FlexTouch U-100 insulin 100 unit/mL (3 mL) subcutaneous pen. 35 units sc hs INSULIN LISPRO [MASKED] INSULIN] - [MASKED] (U-100) Insulin 100 unit/mL subcutaneous. [MASKED] units SC as directed before meals and at bedtime as needed for sliding scale directions ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 60 mg tablet,extended release 24 hr. 1 tablet(s) by mouth daily am LISINOPRIL - lisinopril 40 mg tablet. 1 tablet(s) by mouth once a day at hs - (Prescribed by Other Provider) METOLAZONE - metolazone 5 mg tablet. 1 (One) tablet(s) by mouth once daily as needed for for weight gain and leg swelling ONLY as instructed by cardiology TORSEMIDE - torsemide 100 mg tablet. 1 tablet(s) by mouth once a day [MASKED] and [MASKED] 50 mg - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 81 mg chewable tablet. 1 tablet(s) by mouth daily am BLOOD SUGAR DIAGNOSTIC [FREESTYLE TEST] - FreeStyle Test strips. Use ad directed to test blood glucose up to four times a day BLOOD-GLUCOSE METER [FREESTYLE SYSTEM KIT] - FreeStyle System Kit. Use as directed to test blood glucose up to four times a day Please provide which ever freestyle meter is covered FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth daily LANCETS [FREESTYLE LANCETS] - FreeStyle Lancets 28 gauge. Use as directed to test blood glucose up to four times a day PEN NEEDLE, DIABETIC [BD ULTRA-FINE SHORT PEN NEEDLE] - BD Ultra-Fine Short Pen Needle 31 gauge x [MASKED]. use as directed up to 5x/day for insulin injection --------------- --------------- --------------- --------------- Past Medical History: - Diastolic CHF, LVEF 55% [MASKED], possibly related to HTN. Diagnosed [MASKED] at [MASKED]. - History of CVA - treated at [MASKED], left sided hemiparesis, [MASKED], no residual deficits - Diabetes mellitus, A1C 7.2% ([MASKED]), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation [MASKED] years ago - CKDIII (baseline Cr 1.7-2.0) - R toe osteomyelitis s/p amputation - iron deficiency anemia Social History: [MASKED] Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age [MASKED]. Maternal uncle also with T2DM and ESRD on HD. Children healthy, 1 son with autism. Physical Exam: EXAM(8) [MASKED] 0817 Temp: 98.4 PO BP: 140/77 R Lying HR: 65 RR: 16 O2 sat: 100% O2 delivery: RA Weight 250lbs JVP flat regular s1 and s2 without audible murmur CTAB no crackles or wheezes no focal abd tenderness to palpation no peripheral edema Pertinent Results: [MASKED] 02:05AM BLOOD WBC-9.3 RBC-3.73* Hgb-11.0* Hct-34.4 MCV-92 MCH-29.5 MCHC-32.0 RDW-12.9 RDWSD-43.7 Plt [MASKED] [MASKED] 07:12AM BLOOD WBC-8.5 RBC-3.72* Hgb-11.0* Hct-33.7* MCV-91 MCH-29.6 MCHC-32.6 RDW-12.7 RDWSD-41.9 Plt [MASKED] [MASKED] 02:05AM BLOOD Glucose-197* UreaN-117* Creat-3.9*# Na-140 K-6.3* Cl-110* HCO3-17* AnGap-13 [MASKED] 07:12AM BLOOD Glucose-129* UreaN-94* Creat-2.4*# Na-142 K-5.5* Cl-110* HCO3-18* AnGap-14 [MASKED] 04:45AM BLOOD cTropnT-0.10* FINDINGS: Lung volumes are low. There are no focal consolidations. The cardiomediastinal and hilar silhouettes are within normal limits. No pulmonary edema. No pleural effusions. No pneumothorax. IMPRESSION: No acute intrathoracic process. [MASKED] 05:55AM BLOOD WBC-8.3 RBC-3.69* Hgb-11.0* Hct-33.6* MCV-91 MCH-29.8 MCHC-32.7 RDW-12.8 RDWSD-41.9 Plt [MASKED] [MASKED] 09:20AM BLOOD Glucose-196* UreaN-45* Creat-2.0* Na-137 K-5.8* Cl-104 HCO3-20* AnGap-13 [MASKED] 11:12AM BLOOD Glucose-181* UreaN-53* Creat-2.1* Na-141 K-5.8* Cl-109* HCO3-20* AnGap-12 [MASKED] 05:55AM BLOOD Glucose-127* UreaN-55* Creat-2.1* Na-141 K-6.1* Cl-109* HCO3-20* AnGap-12 [MASKED] 10:50AM BLOOD Glucose-174* UreaN-64* Creat-2.3* Na-139 K-5.3 Cl-109* HCO3-20* AnGap-10 [MASKED] 06:10AM BLOOD Glucose-146* UreaN-68* Creat-2.4* Na-140 K-6.3* Cl-108 HCO3-20* AnGap-12 [MASKED] 10:20AM BLOOD Glucose-164* UreaN-72* Creat-2.2* Na-140 K-5.7* Cl-108 HCO3-18* AnGap-14 [MASKED] 05:15AM BLOOD Glucose-174* UreaN-76* Creat-2.1* Na-139 K-6.9* Cl-108 HCO3-18* AnGap-[MASKED] woman with a history of heart failure with preserved ejection fraction hypertension type 2 diabetes known to the congestive heart failure cardiology service at [MASKED] with stage III chronic kidney disease who presents with cough diarrhea lower blood pressure. She was diagnosed with acute renal failure with a creatinine of 3.9 which was felt to be prerenal in the etiology and he began to improve. She was also diagnosed with C. difficile colitis based on stool testing of her diarrhea and started on oral vancomycin. #ARF- likely from hypovolemia in the context of diarrhea and continued diuretic dosing. Patient presented significantly below dry weight. [MASKED] improved to 2.0 on discharge and home diuretics were resumed. #Hyperkalemia- Had several episodes of hyperkalemia as high as 7.0 without accompanying ECG changes or telemetry events. Corrected with insulin/glucose and IV Lasix. Suspect this is from diuretic cessation and RTA from ATN. Improving at the time of discharge. Lisinopril held. Discussed risks hyperkalemia with patient and she wished to be discharged home to take care of her son despite ongoing mild hyperkalemia (5.8). -Hold Lisinopril -Resume home torsemide dosing as this should help with hyperkalemia -Discharge weight was 253 lbs #Cdiff colitis: d1 oral vanco [MASKED], treated for severe manifestation given associated acute renal failure with creatinine greater than 1.5 but symptomatically fairly mild going no more than 3 times a day and there is lack of abdominal pain. She was abdominal pain free and without diarrhea at the time of discharge. Cre 2.0 (appears near baseline of (1.8-2.0) #HFpEF: dry to euvolemic, no pulm edema on CXR: anti-HTN meds held initially as well as holding metolazone and torsemide 100mg as of [MASKED]. Patient received PRN Lasix IV to correct hyperkalemia and was 253 lbs on discharge. She has HF f/u on [MASKED] at 9am. She was told to resume her home diuretics and weight herself daily. #DM2: was seen by [MASKED] service on prior admission due to poorly controlled DM -glargine 30 units qhs in patient -resumed home regimen on discharge #HTN: HELD Lisinopril due to hyperkalemia otherwise continued amlodipine/hydralazine on discharge. #HLD: asa 81 atorvastatin 40 mg daily #DM neuropathy: held gabapentin for [MASKED] to avoid toxicity, can resume when creat improves prior to discharge [MASKED] - on PO iron at home, holding for nausea and diarrhea. Can resume outpatient when off C. Diff medication. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Ferrous Sulfate 325 mg PO DAILY 5. Gabapentin 100 mg PO BID 6. [MASKED] U-100 (insulin lispro) 100 unit/mL subcutaneous ASDIR 7. HydrALAZINE 10 mg PO TID 8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. Metolazone 5 mg PO DAILY:PRN leg swelling 11. Metoprolol Succinate XL 12.5 mg PO DAILY 12. Torsemide 100 mg PO DAILY 13. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3 mL) subcutaneous QHS Discharge Medications: 1. Vancomycin Oral Liquid [MASKED] mg PO QID RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day Disp #*40 Capsule Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Ferrous Sulfate 325 mg PO DAILY 6. Gabapentin 100 mg PO BID 7. [MASKED] U-100 (insulin lispro) 100 unit/mL subcutaneous ASDIR 8. HydrALAZINE 10 mg PO TID 9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 10. Metolazone 5 mg PO DAILY:PRN leg swelling 11. Torsemide 100 mg PO 5X/WEEK ([MASKED]) 12. Torsemide 50 mg PO 2X/WEEK ([MASKED]) 13. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3 mL) subcutaneous QHS 14. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until you see Dr. [MASKED] [MASKED] Disposition: Home Discharge Diagnosis: C. difficile colitis Acute kidney failure Chronic diastolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized because of dehydration causing acute kidney injury as well as the diagnosis of C. difficile colitis diagnosed during workup of diarrhea. we adjusted your cardiac meds including adjusting the doses of some of your diuretics and holding your blood pressure medicines while hospitalized . When we held your diuretic because you were dehydrated you had high potassium levels in the blood. This improved with resuming your diuretic. You SHOULD STOP YOUR LISINOPRIL UNTIL you see your cardiologist. Otherwise you can resume your diuretics as normal. We also started an antibiotic for C. difficile called vancomycin which she should take to complete therapy . If you develop any severe abdominal pain or worsened diarrhea or fever or new weakness please let your doctor know right away . Symptoms of worsening congestive heart failure include shortness of breath with activity increased fatigue and lower leg swelling and weight gain weigh yourself every morning, call MD if weight goes up more than 3 lbs. It was a pleasure taking care of you. [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "I130", "I5032", "E1122", "Z794", "D509", "E785" ]
[ "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "N179: Acute kidney failure, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "Z794: Long term (current) use of insulin", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E861: Hypovolemia", "D509: Iron deficiency anemia, unspecified", "E875: Hyperkalemia", "Z9114: Patient's other noncompliance with medication regimen", "E785: Hyperlipidemia, unspecified" ]
10,031,575
24,907,346
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Foot pain, swelling Major Surgical or Invasive Procedure: ___ Bedside I&D, right foot ___ Open right ___ toe amputation ___ Right foot debridement with wound vac placement History of Present Illness: ___ year old woman with IDDM2, diastolic CHF (likely related to HTN), HTN, HLD, and recent ___ admission for CHF exacerbation with recent admissions for CHF exacerbation (___) and orthostasis ___ setting of diuresis (___) who presents with worsened R foot pain. Per ED documentation, pt has diabetic foot ulcer on right foot for months, initially followed at ___. She has had increasing swelling of the dorsum of the foot for 4 days with increasing difficulty walking. No h/o dvt/pe malignancy, chest pain/dyspnea, no recent long plane flights or car rides or surgeries. She was seen at ___ clinic where she was sent ___ for ultrasound to rule out dvt and for further evaluation of suspected infection. ___ the ED, initial VS were: 98.3 82 142/73 18 95% RA Exam notable for: ___ edema Labs showed: WBC 21.1 HgB 10.9 Glu off Chem-7 189, AG = 12 FSBG 319 Imaging showed: ___ R foot XR IMPRESSION: No overt evidence of osteomyelitis, however if there is concern for osteomyelitis, MRI would be more sensitive. ___ ___ IMPRESSION: No evidence of deep venous thrombosis ___ the imaged portion of the right lower extremity veins. Received: ___ 17:15 IV Fentanyl Citrate 50 mcg ___ 20:17 IV Piperacillin-Tazobactam 4.5 g ___ 22:07 PO/NG OxyCODONE (Immediate Release) 5 mg ___ 22:07 PO/NG Acetaminophen 1000 mg ___ 22:48 IV Vancomycin ___ m ___ 22:55 SC Lantus Insulin 20 Units ___ 22:55 SC Humalog Insulin 4 Units Podiatry consulted and bedside I+D performed c cultures sent with plan to go to the OR for I+D ___. Patient admitted to medicine with podiatry consult given medical complexity. Transfer VS were: 98.6 67 144/79 17 100% RA On arrival to the floor, patient reports generally feeling well. Reports foot has been more painful since prior weekend resulting ___ difficulty ___ ambulation. Denies N/V. Reports subjective fever 1 day PTA but no measured temperature. Denies issues with prior anesthesia. Past Medical History: - Diastolic CHF, LVEF 55% ___, possibly related to HTN. Diagnosed ___ at ___. - History of CVA - treated at ___, left sided hemiparesis, ___, no residual deficits - Diabetes mellitus, A1C 7.2% on admission (___), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation ___ years ago Social History: ___ Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age ___. Maternal uncle also with T2DM and ESRD on HD. Children healthy, 1 son with autism. Physical Exam: ON ADMISSION ============ VS: 99.5 PO 124 / 72 R Lying 81 20 100 Ra wt: 107.68 kg (237.39 lb) (last dry weight 102.1 kg) GENERAL: Well developed, well nourished woman ___ NAD. Oriented x3. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI NECK: Supple. JVP flat. CARDIAC: RRR, normal S1, S2, systolic murmur loudest at LSB. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Trace lower extremity edema with venous stasis changes. Right foot dressed NEURO: grossly intact, moving all extremities ON DISCHARGE ============ VS: 98.1 PO 135 / 64 L Lying 55 18 100 Ra GENERAL: Well appearing, ___ NAD. Oriented x3. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI NECK: Supple. JVP flat. CARDIAC: RRR, normal S1, S2, systolic murmur loudest at LSB. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Trace lower extremity edema with venous stasis changes. Right foot dressed NEURO: grossly intact, moving all extremities Pertinent Results: ADMISSION LABS ============== ___ 03:55PM BLOOD WBC-21.1*# RBC-3.97 Hgb-10.9* Hct-34.3 MCV-86 MCH-27.5 MCHC-31.8* RDW-13.6 RDWSD-42.7 Plt ___ ___ 03:55PM BLOOD Neuts-80.4* Lymphs-11.4* Monos-6.4 Eos-0.5* Baso-0.5 Im ___ AbsNeut-16.93*# AbsLymp-2.41 AbsMono-1.35* AbsEos-0.10 AbsBaso-0.10* ___ 03:55PM BLOOD Glucose-189* UreaN-28* Creat-2.0* Na-134 K-5.0 Cl-100 HCO3-22 AnGap-17 ___ 06:15AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.0 ___ 04:20PM BLOOD Lactate-1.5 DISCHARGE LABS ============== ___ 06:50AM BLOOD WBC-10.7* RBC-3.62* Hgb-10.3* Hct-32.2* MCV-89 MCH-28.5 MCHC-32.0 RDW-14.2 RDWSD-45.8 Plt ___ ___ 06:50AM BLOOD Glucose-153* UreaN-40* Creat-2.0* Na-137 K-4.9 Cl-100 HCO3-27 AnGap-15 ___ 06:50AM BLOOD Calcium-9.1 Phos-5.0* Mg-1.9 MICROBIOLOGY ============ ___ 2:12 pm SWAB Source: Right foot. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: CITROBACTER KOSERI. MODERATE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 5:36 pm SWAB Source: right foot . GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final ___: CITROBACTER KOSERI. MODERATE GROWTH. STAPH AUREUS COAG +. MODERATE 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. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ CITROBACTER KOSERI | STAPH AUREUS COAG + | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- 0.5 S GENTAMICIN------------ <=1 S <=0.5 S LEVOFLOXACIN---------- 0.25 S MEROPENEM-------------<=0.25 S OXACILLIN------------- 0.5 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S ANAEROBIC CULTURE (Final ___: ANAEROBIC GRAM POSITIVE COCCUS(I). SPARSE GROWTH. (formerly Peptostreptococcus species). NO FURTHER WORKUP WILL BE PERFORMED. ___ 11:18 am TISSUE Site: FOOT ___ TOE RIGHT FOOT. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). TISSUE (Final ___: CITROBACTER KOSERI. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. IMAGING ======= ___ R foot XR IMPRESSION: No overt evidence of osteomyelitis, however if there is concern for osteomyelitis, MRI would be more sensitive. ___ ___ IMPRESSION: No evidence of deep venous thrombosis ___ the imaged portion of the right lower extremity veins. ___ R foot XR IMPRESSION: ___ comparison with the study of ___, there has been amputation of the phalanges of the fifth digit. Postoperative changes are seen ___ soft tissues. Further information can be gathered from the operative report. ___ Bone Pathology: PATHOLOGIC DIAGNOSIS: ___ Department of Pathology ___ Main: ___ Facsimile: ___ Patient: ___ MRN: ___ Birth Date: ___ Age: ___ Y Sex:F ___ #: ___ Patient Location: ___ Med/Sur___ SURGICAL PATHOLOGY REPORT - Final Fifth toe right foot, amputation: - Acute osteomyelitis with associated fat necrosis and lipid laden macrophages; multiple levels are examined. Brief Hospital Course: ___ year old woman with IDDM2, diastolic CHF (likely related to HTN), HTN, HLD, and recent ___ admission for CHF exacerbation with recent admissions for CHF exacerbation (___) and orthostasis ___ setting of diuresis (___) who presents with worsened R foot pain ___ the setting of known diabetic foot ulcer with overlying superinfection, now s/p bedside I+D as well as open ___ digit amputation ___. #Diabetic foot ulcer c/b suprainfection and osteomyelitis: Pt presented with erythematous, edematous foot that was significantly painful/tender, with serous drainage. Had a leukocytosis to 21 on admission. She underwent bedside debridement ___ ___ ED by Podiatry, then ___ digit amputation ___ OR on ___. She then went back to the OR on ___ for debridement and wound vac placement. She was treated initially with IV Vancomycin, Ceftazidime, and Metronidazole. This was narrowed to Ciprofloxacin and clindamycin on ___, based on sensitivities on microbiology data. Bone pathology showed evidence of acute osteomyelitis. Infectious disease was consulted and recommended a course of oral ciprofloxacin and clindamycin with OPAT follow up. #Type 2 Diabetes, insulin dependent: Home Lantus reduced to 20u QHS during admission, then eventually increased to home dose nightly. She was also on sliding scale and scheduled 3 units at lunch and dinner. She had hyperglycemia to 290's nightly and her diabetes management requires outpatient titration. #Acute on Chronic kidney disease, stage III: Recent baseline 1.6-2.0. CKD likely due to longstanding diabetes and HTN. Creatinine on admission at upper limit of recent baseline, likely due to poor PO intake given infection/NPO status, vs intravascular depletion from holding diuretic. Torsemide was held prior to surgery, then subsequently resumed. Lisinopril was held given initial ___, then resumed on ___. #Chronic Diastolic CHF: EF 55%. Most likely diastolic CHF secondary to hypertension. She was slightly above her dry weight on admission, with trace peripheral edema, but otherwise no signs of volume overload. As above, diuresis was held prior to surgery, but subsequently resumed. #Iron deficiency: Hgb stable this admission. Received IV iron during ___ admission. #HLD/CAD: Patient with no diagnosed structural ischemic disease, but suffered from demand ischemia during recent admission. Continued home Atorvastatin, ASA, Imdur. #HTN: Continued Amlodipine. Lisinopril held prior to surgery, then resumed. TRANSITIONAL ISSUES: ================== -discharge weight 103.7 kg -diabetes management requires outpatient titration. -Would recommend EGD and colonoscopy as outpatient, given iron deficiency anemia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Ferrous Sulfate 325 mg PO DAILY 5. Gabapentin 100 mg PO TID 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Torsemide 60 mg PO DAILY 8. Lisinopril 40 mg PO DAILY 9. Glargine 28 Units Bedtime Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 3. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a day Disp #*56 Capsule Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 5. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #*30 Tablet Refills:*0 6. amLODIPine 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Ferrous Sulfate 325 mg PO DAILY 10. Gabapentin 100 mg PO TID 11. Glargine 28 Units Bedtime 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 13. Lisinopril 40 mg PO DAILY 14. Torsemide 60 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Complicated skin/soft tissue infection, osteomyelitis SECONDARY: Chronic kidney disease (stage III), Chronic diastolic heart failure, Diabetes mellitus type 2, Iron deficiency anemia, Hyperlipidemia, Hypertension, Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms ___, It was a pleasure taking ___ of you at ___ ___. You were ___ the hospital because you had an infected ulcer on your foot. This infection had spread to the bone You had a bedside procedure and then a surgery to remove infected tissue. We also gave you IV antibiotics to treat the infection. These were transitioned to oral antibiotics. When you leave the hospital, you will continue to get antibiotics. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. Best wishes, Your ___ team Followup Instructions: ___
[ "E1169", "L03115", "E1122", "M86171", "N179", "I130", "N183", "I5032", "I272", "E11621", "L97514", "E11628", "E1140", "Z794", "D500", "E785", "I2510", "Z8673", "E1165", "I340", "E11319", "E669", "Z6837", "B9561", "B9689" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Foot pain, swelling Major Surgical or Invasive Procedure: [MASKED] Bedside I&D, right foot [MASKED] Open right [MASKED] toe amputation [MASKED] Right foot debridement with wound vac placement History of Present Illness: [MASKED] year old woman with IDDM2, diastolic CHF (likely related to HTN), HTN, HLD, and recent [MASKED] admission for CHF exacerbation with recent admissions for CHF exacerbation ([MASKED]) and orthostasis [MASKED] setting of diuresis ([MASKED]) who presents with worsened R foot pain. Per ED documentation, pt has diabetic foot ulcer on right foot for months, initially followed at [MASKED]. She has had increasing swelling of the dorsum of the foot for 4 days with increasing difficulty walking. No h/o dvt/pe malignancy, chest pain/dyspnea, no recent long plane flights or car rides or surgeries. She was seen at [MASKED] clinic where she was sent [MASKED] for ultrasound to rule out dvt and for further evaluation of suspected infection. [MASKED] the ED, initial VS were: 98.3 82 142/73 18 95% RA Exam notable for: [MASKED] edema Labs showed: WBC 21.1 HgB 10.9 Glu off Chem-7 189, AG = 12 FSBG 319 Imaging showed: [MASKED] R foot XR IMPRESSION: No overt evidence of osteomyelitis, however if there is concern for osteomyelitis, MRI would be more sensitive. [MASKED] [MASKED] IMPRESSION: No evidence of deep venous thrombosis [MASKED] the imaged portion of the right lower extremity veins. Received: [MASKED] 17:15 IV Fentanyl Citrate 50 mcg [MASKED] 20:17 IV Piperacillin-Tazobactam 4.5 g [MASKED] 22:07 PO/NG OxyCODONE (Immediate Release) 5 mg [MASKED] 22:07 PO/NG Acetaminophen 1000 mg [MASKED] 22:48 IV Vancomycin [MASKED] m [MASKED] 22:55 SC Lantus Insulin 20 Units [MASKED] 22:55 SC Humalog Insulin 4 Units Podiatry consulted and bedside I+D performed c cultures sent with plan to go to the OR for I+D [MASKED]. Patient admitted to medicine with podiatry consult given medical complexity. Transfer VS were: 98.6 67 144/79 17 100% RA On arrival to the floor, patient reports generally feeling well. Reports foot has been more painful since prior weekend resulting [MASKED] difficulty [MASKED] ambulation. Denies N/V. Reports subjective fever 1 day PTA but no measured temperature. Denies issues with prior anesthesia. Past Medical History: - Diastolic CHF, LVEF 55% [MASKED], possibly related to HTN. Diagnosed [MASKED] at [MASKED]. - History of CVA - treated at [MASKED], left sided hemiparesis, [MASKED], no residual deficits - Diabetes mellitus, A1C 7.2% on admission ([MASKED]), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation [MASKED] years ago Social History: [MASKED] Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age [MASKED]. Maternal uncle also with T2DM and ESRD on HD. Children healthy, 1 son with autism. Physical Exam: ON ADMISSION ============ VS: 99.5 PO 124 / 72 R Lying 81 20 100 Ra wt: 107.68 kg (237.39 lb) (last dry weight 102.1 kg) GENERAL: Well developed, well nourished woman [MASKED] NAD. Oriented x3. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI NECK: Supple. JVP flat. CARDIAC: RRR, normal S1, S2, systolic murmur loudest at LSB. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Trace lower extremity edema with venous stasis changes. Right foot dressed NEURO: grossly intact, moving all extremities ON DISCHARGE ============ VS: 98.1 PO 135 / 64 L Lying 55 18 100 Ra GENERAL: Well appearing, [MASKED] NAD. Oriented x3. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI NECK: Supple. JVP flat. CARDIAC: RRR, normal S1, S2, systolic murmur loudest at LSB. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Trace lower extremity edema with venous stasis changes. Right foot dressed NEURO: grossly intact, moving all extremities Pertinent Results: ADMISSION LABS ============== [MASKED] 03:55PM BLOOD WBC-21.1*# RBC-3.97 Hgb-10.9* Hct-34.3 MCV-86 MCH-27.5 MCHC-31.8* RDW-13.6 RDWSD-42.7 Plt [MASKED] [MASKED] 03:55PM BLOOD Neuts-80.4* Lymphs-11.4* Monos-6.4 Eos-0.5* Baso-0.5 Im [MASKED] AbsNeut-16.93*# AbsLymp-2.41 AbsMono-1.35* AbsEos-0.10 AbsBaso-0.10* [MASKED] 03:55PM BLOOD Glucose-189* UreaN-28* Creat-2.0* Na-134 K-5.0 Cl-100 HCO3-22 AnGap-17 [MASKED] 06:15AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.0 [MASKED] 04:20PM BLOOD Lactate-1.5 DISCHARGE LABS ============== [MASKED] 06:50AM BLOOD WBC-10.7* RBC-3.62* Hgb-10.3* Hct-32.2* MCV-89 MCH-28.5 MCHC-32.0 RDW-14.2 RDWSD-45.8 Plt [MASKED] [MASKED] 06:50AM BLOOD Glucose-153* UreaN-40* Creat-2.0* Na-137 K-4.9 Cl-100 HCO3-27 AnGap-15 [MASKED] 06:50AM BLOOD Calcium-9.1 Phos-5.0* Mg-1.9 MICROBIOLOGY ============ [MASKED] 2:12 pm SWAB Source: Right foot. GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [MASKED]: CITROBACTER KOSERI. MODERATE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [MASKED] [MASKED]. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # [MASKED] [MASKED]. ANAEROBIC CULTURE (Final [MASKED]: NO ANAEROBES ISOLATED. [MASKED] 5:36 pm SWAB Source: right foot . GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND SINGLY. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [MASKED]: CITROBACTER KOSERI. MODERATE GROWTH. STAPH AUREUS COAG +. MODERATE 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. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] CITROBACTER KOSERI | STAPH AUREUS COAG + | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- 0.5 S GENTAMICIN------------ <=1 S <=0.5 S LEVOFLOXACIN---------- 0.25 S MEROPENEM-------------<=0.25 S OXACILLIN------------- 0.5 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S ANAEROBIC CULTURE (Final [MASKED]: ANAEROBIC GRAM POSITIVE COCCUS(I). SPARSE GROWTH. (formerly Peptostreptococcus species). NO FURTHER WORKUP WILL BE PERFORMED. [MASKED] 11:18 am TISSUE Site: FOOT [MASKED] TOE RIGHT FOOT. GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). TISSUE (Final [MASKED]: CITROBACTER KOSERI. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [MASKED] [MASKED]. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # [MASKED] [MASKED]. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. IMAGING ======= [MASKED] R foot XR IMPRESSION: No overt evidence of osteomyelitis, however if there is concern for osteomyelitis, MRI would be more sensitive. [MASKED] [MASKED] IMPRESSION: No evidence of deep venous thrombosis [MASKED] the imaged portion of the right lower extremity veins. [MASKED] R foot XR IMPRESSION: [MASKED] comparison with the study of [MASKED], there has been amputation of the phalanges of the fifth digit. Postoperative changes are seen [MASKED] soft tissues. Further information can be gathered from the operative report. [MASKED] Bone Pathology: PATHOLOGIC DIAGNOSIS: [MASKED] Department of Pathology [MASKED] Main: [MASKED] Facsimile: [MASKED] Patient: [MASKED] MRN: [MASKED] Birth Date: [MASKED] Age: [MASKED] Y [MASKED] #: [MASKED] Patient Location: [MASKED] Med/Sur SURGICAL PATHOLOGY REPORT - Final Fifth toe right foot, amputation: - Acute osteomyelitis with associated fat necrosis and lipid laden macrophages; multiple levels are examined. Brief Hospital Course: [MASKED] year old woman with IDDM2, diastolic CHF (likely related to HTN), HTN, HLD, and recent [MASKED] admission for CHF exacerbation with recent admissions for CHF exacerbation ([MASKED]) and orthostasis [MASKED] setting of diuresis ([MASKED]) who presents with worsened R foot pain [MASKED] the setting of known diabetic foot ulcer with overlying superinfection, now s/p bedside I+D as well as open [MASKED] digit amputation [MASKED]. #Diabetic foot ulcer c/b suprainfection and osteomyelitis: Pt presented with erythematous, edematous foot that was significantly painful/tender, with serous drainage. Had a leukocytosis to 21 on admission. She underwent bedside debridement [MASKED] [MASKED] ED by Podiatry, then [MASKED] digit amputation [MASKED] OR on [MASKED]. She then went back to the OR on [MASKED] for debridement and wound vac placement. She was treated initially with IV Vancomycin, Ceftazidime, and Metronidazole. This was narrowed to Ciprofloxacin and clindamycin on [MASKED], based on sensitivities on microbiology data. Bone pathology showed evidence of acute osteomyelitis. Infectious disease was consulted and recommended a course of oral ciprofloxacin and clindamycin with OPAT follow up. #Type 2 Diabetes, insulin dependent: Home Lantus reduced to 20u QHS during admission, then eventually increased to home dose nightly. She was also on sliding scale and scheduled 3 units at lunch and dinner. She had hyperglycemia to 290's nightly and her diabetes management requires outpatient titration. #Acute on Chronic kidney disease, stage III: Recent baseline 1.6-2.0. CKD likely due to longstanding diabetes and HTN. Creatinine on admission at upper limit of recent baseline, likely due to poor PO intake given infection/NPO status, vs intravascular depletion from holding diuretic. Torsemide was held prior to surgery, then subsequently resumed. Lisinopril was held given initial [MASKED], then resumed on [MASKED]. #Chronic Diastolic CHF: EF 55%. Most likely diastolic CHF secondary to hypertension. She was slightly above her dry weight on admission, with trace peripheral edema, but otherwise no signs of volume overload. As above, diuresis was held prior to surgery, but subsequently resumed. #Iron deficiency: Hgb stable this admission. Received IV iron during [MASKED] admission. #HLD/CAD: Patient with no diagnosed structural ischemic disease, but suffered from demand ischemia during recent admission. Continued home Atorvastatin, ASA, Imdur. #HTN: Continued Amlodipine. Lisinopril held prior to surgery, then resumed. TRANSITIONAL ISSUES: ================== -discharge weight 103.7 kg -diabetes management requires outpatient titration. -Would recommend EGD and colonoscopy as outpatient, given iron deficiency anemia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Ferrous Sulfate 325 mg PO DAILY 5. Gabapentin 100 mg PO TID 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Torsemide 60 mg PO DAILY 8. Lisinopril 40 mg PO DAILY 9. Glargine 28 Units Bedtime Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 3. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a day Disp #*56 Capsule Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 5. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #*30 Tablet Refills:*0 6. amLODIPine 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Ferrous Sulfate 325 mg PO DAILY 10. Gabapentin 100 mg PO TID 11. Glargine 28 Units Bedtime 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 13. Lisinopril 40 mg PO DAILY 14. Torsemide 60 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY: Complicated skin/soft tissue infection, osteomyelitis SECONDARY: Chronic kidney disease (stage III), Chronic diastolic heart failure, Diabetes mellitus type 2, Iron deficiency anemia, Hyperlipidemia, Hypertension, Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms [MASKED], It was a pleasure taking [MASKED] of you at [MASKED] [MASKED]. You were [MASKED] the hospital because you had an infected ulcer on your foot. This infection had spread to the bone You had a bedside procedure and then a surgery to remove infected tissue. We also gave you IV antibiotics to treat the infection. These were transitioned to oral antibiotics. When you leave the hospital, you will continue to get antibiotics. Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. Best wishes, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "E1122", "N179", "I130", "I5032", "Z794", "E785", "I2510", "Z8673", "E1165", "E669" ]
[ "E1169: Type 2 diabetes mellitus with other specified complication", "L03115: Cellulitis of right lower limb", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "M86171: Other acute osteomyelitis, right ankle and foot", "N179: Acute kidney failure, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "I5032: Chronic diastolic (congestive) heart failure", "I272: Other secondary pulmonary hypertension", "E11621: Type 2 diabetes mellitus with foot ulcer", "L97514: Non-pressure chronic ulcer of other part of right foot with necrosis of bone", "E11628: Type 2 diabetes mellitus with other skin complications", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "Z794: Long term (current) use of insulin", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I340: Nonrheumatic mitral (valve) insufficiency", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere" ]
10,031,575
25,549,462
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weight loss, fatigue, dizziness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year old woman with a ___ diastolic CHF (likely related to HTN), HTN, HLD, T2DM, and recent ___ admission for CHF exacerbation discharged ___, who presented to clinic today with 2 days of presyncope, fatigue, and weight loss. The patient initially presented to ___ ___ and was diagnosed with heart failure. She was diuresed, but did not reliably take her diuretics post-discharge per chart review. Per patient she says she was unhappy with the care she was receiving there. She then presented to ___ with a repeat heart failure exacerbation ___. Cardiac MRI showed dilated cardiomyopathy with no evidence of infiltrative disease, and TTE showed preserved ejection fraction. She was treated with a Lasix drip, and transitioned to torsemide. She was discharged on torsemide 80 mg BID with a discharge weight of 106.5 kg/234.8 lbs and creatinine 2.1. Of note, that hospitalization was complicated by type II NSTEMI, secondary to demand from volume overload. Aspirin and atorvastatin were initiated. Her discharge medication regimen also included lisinopril 10 mg daily, amlodipine 10 mg daily, and Imdur 30 mg daily. The patient presented to her appointment today, and was complaining of dizziness. She reported that two days she had an episode dizziness when using the bathroom. She describes this as feeling like the room was spinning around her and she was off balance. She fell off of the toilet, but did not lose consciousness. She shares that actually since the day after leaving the hospital she had been experiencing intermittent dizziness, worse with standing and walking. She occasionally would also have shortness of breath and hot flashes. She has been taking her medication as prescribed, and her blood sugars have been in the 100s. She has not been eating or drinking much since leaving the hospital, which she attributes to generally feeling poorly. She denies any post-discharge depression or anxiety. In clinic her vitals were notable for weight 224 lbs, HR 79, BP 106/65 (despite not taking BP meds today), HR 79, T97.3. Labs were notable for Cr 2.8, K 5.3, and glucose 304.She was sent to the CDACU, where here initial BP was 90/60. The BP improved to 135 systolic with 500cc of IV fluids. The decision was made to transfer the patient from the CDACU to CHF service. Upon arrival to the floor, the patient gives the above history. She says she is feeling somewhat better since getting IV fluid, but is still a little dizzy. She adds she had some diffuse abdominal two days ago, but this improved after having a bowel movement. Past Medical History: - Diastolic CHF, LVEF 55% ___, possibly related to HTN. Diagnosed ___ at ___. - History of CVA - treated at ___, left sided hemiparesis, ___, no residual deficits - Diabetes mellitus, A1C 7.2% on admission (___), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation ___ years ago Social History: ___ Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age ___. Maternal uncle also with T2DM and ESRD on HD. Children health, 1 son with autism. Physical Exam: ADMISSION EXAM ==================== VS: T98.1 BP/HR sitting 119/71 81 BP/HR standing 86/56 96 RR O296 RA GENERAL: Well developed, well nourished woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP flat. CARDIAC: RRR, normal S1, S2; S4; systolic murmur loudest at LSB. 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: No lower extremity edema. Right foot wrapped in gauze. NEURO: grossly intact, moving all extremities, finger to nose test intact. DISCHARGE EXAM =================== VS: 98.2, HR 60-70's, BP 151/82 (SBP range 128-160's), RR 18, 98% RA Weight: 102.1kg (103kg) I/O: ___ GENERAL: Well developed, well nourished woman in NAD. Oriented x3. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI NECK: Supple. JVP flat. CARDIAC: RRR, normal S1, S2, systolic murmur loudest at LSB. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Trace lower extremity edema with venous stasis changes. Right foot dressed NEURO: grossly intact, moving all extremities Pertinent Results: ADMISSION LABS ===================== ___ 07:12PM BLOOD WBC-8.3 RBC-4.16 Hgb-11.3 Hct-35.9 MCV-86 MCH-27.2 MCHC-31.5* RDW-13.8 RDWSD-42.9 Plt ___ ___ 07:12PM BLOOD Neuts-57.8 ___ Monos-6.9 Eos-2.7 Baso-0.4 Im ___ AbsNeut-4.80 AbsLymp-2.66 AbsMono-0.57 AbsEos-0.22 AbsBaso-0.03 ___ 10:50AM BLOOD Glucose-304* UreaN-60* Creat-2.8* Na-134 K-5.3* Cl-96 HCO3-29 AnGap-14 ___ 07:12PM BLOOD ALT-19 AST-13 AlkPhos-126* TotBili-0.2 ___ 07:12PM BLOOD CK-MB-2 cTropnT-0.06* proBNP-338* ___ 05:30AM BLOOD CK-MB-2 cTropnT-0.04* ___ 07:12PM BLOOD Albumin-2.8* Calcium-8.9 Phos-4.0 Mg-1.8 ___ 07:12PM BLOOD TSH-3.0 ___ 07:12PM BLOOD T4-8.1 ___ 07:12PM BLOOD CRP-3.8 ___ 08:33PM URINE Blood-TR Nitrite-NEG Protein-300 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 08:33PM URINE RBC-5* WBC-3 Bacteri-NONE Yeast-NONE Epi-2 ___ 08:33PM URINE Hours-RANDOM UreaN-644 Creat-112 Na-61 TotProt-411 Prot/Cr-3.7* DISCHARGE LABS ==================== ___ 07:25AM BLOOD WBC-6.0 RBC-4.03 Hgb-11.0* Hct-35.0 MCV-87 MCH-27.3 MCHC-31.4* RDW-13.7 RDWSD-42.7 Plt ___ ___ 07:25AM BLOOD Glucose-146* UreaN-45* Creat-2.0* Na-137 K-5.6* Cl-104 HCO3-25 AnGap-14 ___ 07:25AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.0 REPORTS ==================== CXR ___ No acute change. CT Head ___ Right frontal lobe low-attenuation change at the vertex, with associated volume loss, likely sequela of chronic infarct. Small focus of cortical and subcortical low-attenuation left parietal lobe may represent subacute or chronic infarct, consider MRI if clinically indicated.. Chronic bilateral lacunar infarcts basal ganglia. Renal US with Doppler ___ Normal renal ultrasound. Mildly elevated resistive indices of the intrarenal arteries but no sonographically specific evidence of renal artery stenosis. Brief Hospital Course: Ms. ___ is a ___ year old woman with a PMH diastolic CHF (likely related to HTN), HTN, HLD, T2DM, and recent ___ admission for CHF exacerbation discharged ___, who presents with presyncope, orthostasis, and ___, likely in the setting of overdiuresis. # Dizziness, Orthostasis: Patient presented with dizziness and presyncope leading to fall, likely secondary to over-diuresis. After receiving 1L IVF, she felt improved and is no longer orthostatic. After holding, Torsemide was resumed at a lower dose, 60mg daily, from prior 80mg BID. Amlodipine and Imdur and Lisinopril were all initially held. Imdur and Amlodipine were resumed prior to discharge. Lisinopril was held on discharge due to mild hyperkalemia, and can be restarted as an outpatient. #Acute Kidney Injury on stage III-IV CKD Improved from Cr 2.8 to Cr 2.0 with IVF and diuretic cessation, c/w discharge Cr from last hospitalization. ___ likely related to overdiuresis. CKD likely due to longstanding diabetes and HTN. Renal u/s was normal with elevated resistive indices of the intrarenal arteries but no renal artery stenosis. Should follow-up outpatient non-urgently with a Nephrologist. #Chronic Diastolic CHF: Most likely diastolic CHF secondary to hypertension, workup for other causes negative last admission. She was admitted at 10 lbs below her prior dry weight. Torsemide reduced from 80mg BID to 60mg once daily. # Prior CVA: CT head was done on admission because of report of a fall with headstrike. This showed findings concerning for sequela of chronic infarct. At this point more history was gathered and the patient endorsed a prior stroke, treated and diagnosed at ___, with no residual deficits. An MRI was ordered to evaluate this further, but the patient declined getting the study due to anxiety and fatigue. She had no active neurologic issues and a normal Neuro exam, so decision was made to defer MRI to outpatient setting. #Type 2 Diabetes, insulin dependent: - Continue home Lantus - Continue home Humalog sliding scale - Continue home Gabapentin for diabetic nephropathy #Iron deficiency: Received IV iron last admission. - EGD and ___ as outpatient - Continue home ferrous sulfate #HLD/CAD Patient with no diagnosed structural ischemic disease, but suffered from demand ischemia at last admission. - Continue home Atorvastatin, ASA #Diabetic foot ulcer: Seen by podiatry last admission, and as an outpatient earlier this week - Continue dressing changes per Podiatry notes TRANSITIONAL ISSUES =================== - Discharge weight: 102.1kg - Discharge diuretic: Torsemide 60mg once daily (prior dose 80mg BID) - Please check electrolytes and renal function at upcoming primary care and cardiology visits this week. If potassium has normalized, can restart Lisinopril (prior dose was 40mg once daily) - Have emailed ___ clinic scheduling department to arrange a clinic visit with a Nurse Practitioner this week. Unable to be arranged over weekend. Long term, she will follow-up with Dr. ___ CHF as well. - Should non-urgently see a Nephrologist for CKD - Recommend outpatient ___ to evaluate iron deficiency anemia - She has never had a mammogram - Outpatient Endocrine follow up for thyroiditis (noted on ultrasound during prior admission) has already been scheduled - Consider MRI Brain as outpatient to better evaluate prior CVA Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Gabapentin 100 mg PO TID 5. Lisinopril 40 mg PO DAILY 6. amLODIPine 10 mg PO DAILY 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Torsemide 80 mg PO BID 9. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine 5 % apply to painful area once daily in the morning Disp #*15 Patch Refills:*0 2. Torsemide 60 mg PO DAILY RX *torsemide 20 mg 3 tablet(s) by mouth once daily Disp #*90 Tablet Refills:*0 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Ferrous Sulfate 325 mg PO DAILY 7. Gabapentin 100 mg PO TID 8. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 10. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until you get labs rechecked at your PCP or ___ visit Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute kidney injury on chronic kidney disease Pre-syncope due to overdiuresis Volume depletion Chronic diastolic CHF Type 2 diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. ___, You were admitted because of dizziness and lightheadedness. Your blood pressure was low. Based on our test results, this was likely because the dose of your diuretic (water pill - Torsemide) was too high. We gave you intravenous fluids and your blood pressure, kidney function, and symptoms all improved. Your Torsemide (water pill) dose is now 60mg, only ONCE PER DAY. Also, your potassium level was mildly high. Your Lisinopril can make this worse. Thus please DO NOT TAKE YOUR LISINOPRIL until your potassium is rechecked by either your new PCP or your ___. Please be sure to see all your doctors, including your new PCP, ___. The Cardiology department will call you on ___ to schedule the next appointment with the heart failure team. It was a pleasure, we wish you all the best. - ___ Cardiology Team Followup Instructions: ___
[ "N179", "I214", "I130", "I5032", "T501X5A", "E1122", "E875", "E11621", "E11319", "L97519", "E1140", "E785", "I951", "Z794", "E869", "N184", "Z8673", "Y929", "D509", "E069", "I2510", "R319", "Z9181", "E6601", "Z6835" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weight loss, fatigue, dizziness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with a [MASKED] diastolic CHF (likely related to HTN), HTN, HLD, T2DM, and recent [MASKED] admission for CHF exacerbation discharged [MASKED], who presented to clinic today with 2 days of presyncope, fatigue, and weight loss. The patient initially presented to [MASKED] [MASKED] and was diagnosed with heart failure. She was diuresed, but did not reliably take her diuretics post-discharge per chart review. Per patient she says she was unhappy with the care she was receiving there. She then presented to [MASKED] with a repeat heart failure exacerbation [MASKED]. Cardiac MRI showed dilated cardiomyopathy with no evidence of infiltrative disease, and TTE showed preserved ejection fraction. She was treated with a Lasix drip, and transitioned to torsemide. She was discharged on torsemide 80 mg BID with a discharge weight of 106.5 kg/234.8 lbs and creatinine 2.1. Of note, that hospitalization was complicated by type II NSTEMI, secondary to demand from volume overload. Aspirin and atorvastatin were initiated. Her discharge medication regimen also included lisinopril 10 mg daily, amlodipine 10 mg daily, and Imdur 30 mg daily. The patient presented to her appointment today, and was complaining of dizziness. She reported that two days she had an episode dizziness when using the bathroom. She describes this as feeling like the room was spinning around her and she was off balance. She fell off of the toilet, but did not lose consciousness. She shares that actually since the day after leaving the hospital she had been experiencing intermittent dizziness, worse with standing and walking. She occasionally would also have shortness of breath and hot flashes. She has been taking her medication as prescribed, and her blood sugars have been in the 100s. She has not been eating or drinking much since leaving the hospital, which she attributes to generally feeling poorly. She denies any post-discharge depression or anxiety. In clinic her vitals were notable for weight 224 lbs, HR 79, BP 106/65 (despite not taking BP meds today), HR 79, T97.3. Labs were notable for Cr 2.8, K 5.3, and glucose 304.She was sent to the CDACU, where here initial BP was 90/60. The BP improved to 135 systolic with 500cc of IV fluids. The decision was made to transfer the patient from the CDACU to CHF service. Upon arrival to the floor, the patient gives the above history. She says she is feeling somewhat better since getting IV fluid, but is still a little dizzy. She adds she had some diffuse abdominal two days ago, but this improved after having a bowel movement. Past Medical History: - Diastolic CHF, LVEF 55% [MASKED], possibly related to HTN. Diagnosed [MASKED] at [MASKED]. - History of CVA - treated at [MASKED], left sided hemiparesis, [MASKED], no residual deficits - Diabetes mellitus, A1C 7.2% on admission ([MASKED]), complicated by neuropathy - Hypertension - Hyperlipidemia - R foot ulcer, followed by podiatry - S/p tubal ligation [MASKED] years ago Social History: [MASKED] Family History: Mother with T2DM and ESRD on HD. Mother has been on HD since about age [MASKED]. Maternal uncle also with T2DM and ESRD on HD. Children health, 1 son with autism. Physical Exam: ADMISSION EXAM ==================== VS: T98.1 BP/HR sitting 119/71 81 BP/HR standing 86/56 96 RR O296 RA GENERAL: Well developed, well nourished woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP flat. CARDIAC: RRR, normal S1, S2; S4; systolic murmur loudest at LSB. 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: No lower extremity edema. Right foot wrapped in gauze. NEURO: grossly intact, moving all extremities, finger to nose test intact. DISCHARGE EXAM =================== VS: 98.2, HR 60-70's, BP 151/82 (SBP range 128-160's), RR 18, 98% RA Weight: 102.1kg (103kg) I/O: [MASKED] GENERAL: Well developed, well nourished woman in NAD. Oriented x3. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI NECK: Supple. JVP flat. CARDIAC: RRR, normal S1, S2, systolic murmur loudest at LSB. LUNGS: Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Trace lower extremity edema with venous stasis changes. Right foot dressed NEURO: grossly intact, moving all extremities Pertinent Results: ADMISSION LABS ===================== [MASKED] 07:12PM BLOOD WBC-8.3 RBC-4.16 Hgb-11.3 Hct-35.9 MCV-86 MCH-27.2 MCHC-31.5* RDW-13.8 RDWSD-42.9 Plt [MASKED] [MASKED] 07:12PM BLOOD Neuts-57.8 [MASKED] Monos-6.9 Eos-2.7 Baso-0.4 Im [MASKED] AbsNeut-4.80 AbsLymp-2.66 AbsMono-0.57 AbsEos-0.22 AbsBaso-0.03 [MASKED] 10:50AM BLOOD Glucose-304* UreaN-60* Creat-2.8* Na-134 K-5.3* Cl-96 HCO3-29 AnGap-14 [MASKED] 07:12PM BLOOD ALT-19 AST-13 AlkPhos-126* TotBili-0.2 [MASKED] 07:12PM BLOOD CK-MB-2 cTropnT-0.06* proBNP-338* [MASKED] 05:30AM BLOOD CK-MB-2 cTropnT-0.04* [MASKED] 07:12PM BLOOD Albumin-2.8* Calcium-8.9 Phos-4.0 Mg-1.8 [MASKED] 07:12PM BLOOD TSH-3.0 [MASKED] 07:12PM BLOOD T4-8.1 [MASKED] 07:12PM BLOOD CRP-3.8 [MASKED] 08:33PM URINE Blood-TR Nitrite-NEG Protein-300 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [MASKED] 08:33PM URINE RBC-5* WBC-3 Bacteri-NONE Yeast-NONE Epi-2 [MASKED] 08:33PM URINE Hours-RANDOM UreaN-644 Creat-112 Na-61 TotProt-411 Prot/Cr-3.7* DISCHARGE LABS ==================== [MASKED] 07:25AM BLOOD WBC-6.0 RBC-4.03 Hgb-11.0* Hct-35.0 MCV-87 MCH-27.3 MCHC-31.4* RDW-13.7 RDWSD-42.7 Plt [MASKED] [MASKED] 07:25AM BLOOD Glucose-146* UreaN-45* Creat-2.0* Na-137 K-5.6* Cl-104 HCO3-25 AnGap-14 [MASKED] 07:25AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.0 REPORTS ==================== CXR [MASKED] No acute change. CT Head [MASKED] Right frontal lobe low-attenuation change at the vertex, with associated volume loss, likely sequela of chronic infarct. Small focus of cortical and subcortical low-attenuation left parietal lobe may represent subacute or chronic infarct, consider MRI if clinically indicated.. Chronic bilateral lacunar infarcts basal ganglia. Renal US with Doppler [MASKED] Normal renal ultrasound. Mildly elevated resistive indices of the intrarenal arteries but no sonographically specific evidence of renal artery stenosis. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with a PMH diastolic CHF (likely related to HTN), HTN, HLD, T2DM, and recent [MASKED] admission for CHF exacerbation discharged [MASKED], who presents with presyncope, orthostasis, and [MASKED], likely in the setting of overdiuresis. # Dizziness, Orthostasis: Patient presented with dizziness and presyncope leading to fall, likely secondary to over-diuresis. After receiving 1L IVF, she felt improved and is no longer orthostatic. After holding, Torsemide was resumed at a lower dose, 60mg daily, from prior 80mg BID. Amlodipine and Imdur and Lisinopril were all initially held. Imdur and Amlodipine were resumed prior to discharge. Lisinopril was held on discharge due to mild hyperkalemia, and can be restarted as an outpatient. #Acute Kidney Injury on stage III-IV CKD Improved from Cr 2.8 to Cr 2.0 with IVF and diuretic cessation, c/w discharge Cr from last hospitalization. [MASKED] likely related to overdiuresis. CKD likely due to longstanding diabetes and HTN. Renal u/s was normal with elevated resistive indices of the intrarenal arteries but no renal artery stenosis. Should follow-up outpatient non-urgently with a Nephrologist. #Chronic Diastolic CHF: Most likely diastolic CHF secondary to hypertension, workup for other causes negative last admission. She was admitted at 10 lbs below her prior dry weight. Torsemide reduced from 80mg BID to 60mg once daily. # Prior CVA: CT head was done on admission because of report of a fall with headstrike. This showed findings concerning for sequela of chronic infarct. At this point more history was gathered and the patient endorsed a prior stroke, treated and diagnosed at [MASKED], with no residual deficits. An MRI was ordered to evaluate this further, but the patient declined getting the study due to anxiety and fatigue. She had no active neurologic issues and a normal Neuro exam, so decision was made to defer MRI to outpatient setting. #Type 2 Diabetes, insulin dependent: - Continue home Lantus - Continue home Humalog sliding scale - Continue home Gabapentin for diabetic nephropathy #Iron deficiency: Received IV iron last admission. - EGD and [MASKED] as outpatient - Continue home ferrous sulfate #HLD/CAD Patient with no diagnosed structural ischemic disease, but suffered from demand ischemia at last admission. - Continue home Atorvastatin, ASA #Diabetic foot ulcer: Seen by podiatry last admission, and as an outpatient earlier this week - Continue dressing changes per Podiatry notes TRANSITIONAL ISSUES =================== - Discharge weight: 102.1kg - Discharge diuretic: Torsemide 60mg once daily (prior dose 80mg BID) - Please check electrolytes and renal function at upcoming primary care and cardiology visits this week. If potassium has normalized, can restart Lisinopril (prior dose was 40mg once daily) - Have emailed [MASKED] clinic scheduling department to arrange a clinic visit with a Nurse Practitioner this week. Unable to be arranged over weekend. Long term, she will follow-up with Dr. [MASKED] CHF as well. - Should non-urgently see a Nephrologist for CKD - Recommend outpatient [MASKED] to evaluate iron deficiency anemia - She has never had a mammogram - Outpatient Endocrine follow up for thyroiditis (noted on ultrasound during prior admission) has already been scheduled - Consider MRI Brain as outpatient to better evaluate prior CVA Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Gabapentin 100 mg PO TID 5. Lisinopril 40 mg PO DAILY 6. amLODIPine 10 mg PO DAILY 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Torsemide 80 mg PO BID 9. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine 5 % apply to painful area once daily in the morning Disp #*15 Patch Refills:*0 2. Torsemide 60 mg PO DAILY RX *torsemide 20 mg 3 tablet(s) by mouth once daily Disp #*90 Tablet Refills:*0 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Ferrous Sulfate 325 mg PO DAILY 7. Gabapentin 100 mg PO TID 8. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 10. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until you get labs rechecked at your PCP or [MASKED] visit Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Acute kidney injury on chronic kidney disease Pre-syncope due to overdiuresis Volume depletion Chronic diastolic CHF Type 2 diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [MASKED], You were admitted because of dizziness and lightheadedness. Your blood pressure was low. Based on our test results, this was likely because the dose of your diuretic (water pill - Torsemide) was too high. We gave you intravenous fluids and your blood pressure, kidney function, and symptoms all improved. Your Torsemide (water pill) dose is now 60mg, only ONCE PER DAY. Also, your potassium level was mildly high. Your Lisinopril can make this worse. Thus please DO NOT TAKE YOUR LISINOPRIL until your potassium is rechecked by either your new PCP or your [MASKED]. Please be sure to see all your doctors, including your new PCP, [MASKED]. The Cardiology department will call you on [MASKED] to schedule the next appointment with the heart failure team. It was a pleasure, we wish you all the best. - [MASKED] Cardiology Team Followup Instructions: [MASKED]
[]
[ "N179", "I130", "I5032", "E1122", "E785", "Z794", "Z8673", "Y929", "D509", "I2510" ]
[ "N179: Acute kidney failure, unspecified", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E875: Hyperkalemia", "E11621: Type 2 diabetes mellitus with foot ulcer", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "L97519: Non-pressure chronic ulcer of other part of right foot with unspecified severity", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E785: Hyperlipidemia, unspecified", "I951: Orthostatic hypotension", "Z794: Long term (current) use of insulin", "E869: Volume depletion, unspecified", "N184: Chronic kidney disease, stage 4 (severe)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Y929: Unspecified place or not applicable", "D509: Iron deficiency anemia, unspecified", "E069: Thyroiditis, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "R319: Hematuria, unspecified", "Z9181: History of falling", "E6601: Morbid (severe) obesity due to excess calories", "Z6835: Body mass index [BMI] 35.0-35.9, adult" ]
10,031,575
27,796,946
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, chest pain Major Surgical or Invasive Procedure: None. History of Present Illness: ___ woman with HTN, IDDM, HLD with heart failure (unknown EF) diagnosed ___ at ___ here with worsening dyspnea on exertion, lower extremity edema. She was initially presented to ___ ___ and was diagnosed with heart failure. She was diuresed in the hospital and improved. She had poor adherence on follow up, stopped taking 60mg po Lasix when she was discharged. She did continue to take on metoprolol and lisinopril. She does not weigh herself. Presents with gradually worsening dyspnea on exertion, lower extremity edema, PND, orthopnea for two months, but most noticeably over the last 2 weeks. She cannot walk up a flight of stairs without stopping several times due to dyspnea, she cannot walk >1city block at a time due to dyspnea, which resolves with rest. Her lower extremities have become progressively swollen over the last few months, but now feel "tight" and heavy. She also reported an isolated episode of sharp chest pain awakening her from sleep last night which lasted seconds and resolved without intervention. Location L anterior chest with radiation to her left arm. No association with palpation, position. She denies current chest pain/pressure, or chest pressure that increases with predictable activity or resolves with rest. She was given sublingual nitro x1 in ambulance. Of note, she is a longstanding diabetic, diagnosed ___ years ago. Over the last ___ years has gotten better control. Knows she has retinopathy, severe neuropathy. Has never been told had kidney problems before. She has an opthalomologist but never has seen podiatry. She notes history of foot wound that was "cut" by PCP in ___. She describes being prescribed a 14 day course of augmentin for this wound. She does not remember being told it was related to diabetes. In the ED initial vitals were: 97.6 90 138/83 20 100% Nasal Cannula BP notable for 170-190's/70's-100's Labs/studies notable for: ___: 10773, Trop-T 0.04, CK 426, MB 5 Cr 1.6 (unknown baseline), Chem 10 otherwise unremarkable Hg 10.9, WBC, PLT wnl UA 300 prtn RBC 163, Blood Mod LUE Ultrasound ___: No evidence of deep vein thrombosis in the left upper extremity. CXR ___: No definite focal consolidation is seen. There is no large pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are stable. No pulmonary edema is seen. No acute cardiopulmonary process. BEDSIDE TTE by cards fellow ___: some LVH, mild MR, AI, TR, trivial effusion, unable to clearly assess wall motion. Patient was given: IV Furosemide 80 mg Vitals on transfer: VS: T98 BP194/101, 168/86 HR 73 RR 20 O2 SAT 97% RA On the floor the patient reports fatigue but denies dyspnea, chest pressure, nausea, vomiting. Past Medical History: - Diabetes mellitus, A1C 7.2% on admission (___), complicated by neuropathy - Hypertension - Hyperlipidemia - HF pEF, diagnosed during hospitalization at ___ (___) - R foot ulcer Social History: ___ Family History: Cousin with ICD placement, ___ No family history of early MI, cardiomyopathies, or sudden cardiac death. Physical Exam: == ADMISSION PHYSICAL EXAMINATION == VS: T98 BP194/101, 168/86 HR 73 RR 20 O2 SAT 97% RA I/O: -/540in ED +NR Weight: 126.2kg, unknown dry weight GENERAL: Well developed, well nourished female in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP of 13cm with head of bed at 30 degrees CARDIAC: laterally displaced PMI. Regular rate and rhythm. Normal S1, S2. diastolic murmur. No rubs, or gallops. No thrills or lifts. LUNGS: Respiration is unlabored with no accessory muscle use. Breath sounds limited by habitus. Crackles to bases, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. EXTREMITIES: 4+ pitting edema to thighs B/L, 1+ extending to umbilicus. Warm, well perfused. No clubbing, cyanosis. L>R arm swelling. SKIN: R foot with 1cm punched out, ~3mm deep ulcer with foul smell emanating, but no overt. No rashes. NEURO: decreased sensation to light touch to feet B/L. == DISCHARGE PHYSICAL EXAMINATION == VITALS: T 97.2, BP 135-145/79-88, HR 72-85, RR 18, SpO2 98/RA WEIGHT: 106.1 kg -> 107 kg I/O: 24hr 1100/2175, 8h 100/800 GENERAL: well-appearing obese female, NAD HEENT: moist membranes, PERRL NECK: JVP elevated to 7-8cm at 45 degrees, thyromegaly R>L CARDIAC: RRR, ___ high pitched SEM at RUSB, heard throughout rest of precordium LUNGS: distant breath sounds, CTAB ABDOMEN: Normoactive BS throughout, non tender EXTREMITIES: WWP, 2+ pitting edema to knees b/l. R heel - wrapped in guaze, dressing is clean/dry Pertinent Results: == ADMISSION LABS == ___ 11:45AM BLOOD WBC-6.1 RBC-3.96 Hgb-10.9* Hct-34.2 MCV-86 MCH-27.5 MCHC-31.9* RDW-13.9 RDWSD-43.5 Plt ___ ___ 11:45AM BLOOD Neuts-63.8 ___ Monos-6.4 Eos-1.3 Baso-0.5 Im ___ AbsNeut-3.88 AbsLymp-1.69 AbsMono-0.39 AbsEos-0.08 AbsBaso-0.03 ___ 11:45AM BLOOD ___ PTT-31.8 ___ ___ 11:45AM BLOOD Glucose-83 UreaN-16 Creat-1.6* Na-141 K-3.4 Cl-107 HCO3-28 AnGap-9 ___ 11:45AM BLOOD CK(CPK)-426* ___ 11:45AM BLOOD CK-MB-5 ___ ___ 11:45AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.6 Iron-58 == NOTABLE INTERVAL LABS == ___ 05:55PM BLOOD ALT-12 AST-18 LD(LDH)-303* CK(CPK)-559* AlkPhos-91 TotBili-0.2 ___ 06:29AM BLOOD CK(CPK)-328* ___ 11:45AM BLOOD calTIBC-233* Ferritn-27 TRF-179* ___ 11:45AM BLOOD %HbA1c-7.2* eAG-160* ___ 11:45AM BLOOD TSH-6.1* ___ 03:00PM BLOOD T4-7.4 ___ 11:45AM BLOOD RheuFac-14 ___ CRP-4.9 ___ 03:00PM BLOOD PEP-AWAITING F FreeKap-86.8* FreeLam-52.2* Fr K/L-1.66* IFE-PND == IMAGING == -- ___ CXR No acute cardiopulmonary process. -- ___ UNILAT UPPER EXTR ULTRASOUND No evidence of deep vein thrombosis in the left upper extremity. -- ___ TTE The left atrium is moderately dilated. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 55%). The estimated cardiac index is depressed (<2.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is absent transmitral A wave c/w impaired left atrial mechanical function. Mild to moderate (___) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and low normal global left ventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. Mildly dilated thoracic aorta. Increased PCWP. Absent transmitral A wave. The symmetric left ventricular hypertrophy with increased PCWP and absent transmitral A wave and multivalvular regurgitation are suggestive of an infiltrative process (e.g., amyloid). -- ___ CARDIAC MRI The left atrial AP dimension is mildly increased with moderate left atrial elongation. The right atrium is moderately dilated. There is normal left ventricular wall thickness with normal mass. Normal left ventricular end-diastolic dimension with SEVERELY increased left ventricular end-diastolic volume and moderately increased end-diastolic volume index. There is mild global left ventricular hypokinesis with relative preservation of apical function. The left ventricular cardiac index is normal. There is uniformity in regional T2. Early gadolinium enhancement images showed no enhancement. There is no late gadolinium enhancement (absence of scar/fibrosis). Mildly increased right ventricular end-diastolic volume index with mild global free wall hypokinesis and low normal ejection fraction. Normal origin of the right and left main coronary arteries. Mildly increased ascending aorta diameter (normal BSA indexed ascending aorta diameter) with normal aortic arch diameter and mIldly dilated descending thoracic aorta (normal BSA indexed descending aorta diameter). Mildly increased abdominal aorta diameter (normal BSA indexed abdominal aorta diameter). Moderately increased pulmonary artery diameter with mildly increased BSA indexed PA diameter. The # of aortic valve leaflets could not be determined. There is no aortic valve stenosis. Mild aortic regurgitation is seen. There is moderate mitral regurgitation. There is moderate tricuspid regurgitation. There is a small circumferential pericardial effusion. Pericardial thickness is normal. There is a small right pleural effusion. IMPRESSION: Normal left ventricular wall thickness and global mass. Moderately dilated left ventricular cavity with mild global hypokinesis. No evidence of myocardial edema, inflammation, infiltration or scar/fibrosis. Mildly dilated right ventricular cavity with low normal free wall motion. Moderate mitral regurgitation. Moderate tricuspid regurgitation. These findings are most c/w a non-ischemic dilated cardiomyopathy. ___ Imaging THYROID U.S. Heterogeneous hypervascular thyroid gland compatible with thyroiditis. No discrete nodules identified. == DISCHARGE LABS == ___ 04:25AM BLOOD WBC-6.6 RBC-4.20 Hgb-11.4 Hct-36.1 MCV-86 MCH-27.1 MCHC-31.6* RDW-14.1 RDWSD-43.8 Plt ___ ___ 04:25AM BLOOD Plt ___ ___ 04:25AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0 Brief Hospital Course: This is a ___ year old woman with a PMH notable for hypertension, hyperlipidemia, history of heart failure (NOS) and type II diabetes mellitus (on insulin), who presented with massive ___ edema, concerning for heart failure, found to have signs suggestive of infiltrative cardiac disease on TTE. # Acute on chronic heart failure with preserved ejection fraction: diagnosed ___ at ___ [records obtained, in paper chart -- notable for EF 56%, grade II diastolic dysfunction, dry weight 110 kg]. TTE concerning for restrictive physiology and possible infiltrative process, such as amyloidosis. Cardiac MRI obtained, which demonstrated what is almost certainly dilated cardiomyopathy due to hypertension. No evidence of infiltrative disease on cardiac MRI. Presented massively overloaded on examination. Aggresively diuresed with furosemide gtt, then furosemide boluses, and finally oral torsemide. Initially held lisinopril given elevated Cr, but appears baseline. Slowly restarted & uptitrated, given degree of hypertension & proteinuria. Metoprolol was stopped, given preserved EF and possible constrictive physiology. - Discharge weight: 106.5 kg, 234.8 lbs - Discharge Cr: 2.1 - Discharge diuretic regimen: torsemide 100mg BID # Type II NSTEMI: perhaps demand in setting of volume overload and CHF, as above. Started on aspirin 81 mg daily and atorvastatin 40 mg HS. Once euvolemic, stress test showed no focal ischemia or perfusion defects. # Hypertension: quite elevated on admission (180s+). Lisinopril 40mg used, as above. Started on amlodipine and isosorbide mononitrate, which she tolerated well with satisfactory improvement of BP. # Renal failure: likely chronic, with possible acute component. Significant proteinuria, with Pr/Cr 11.1. Possible etiologies include diabetic nephropathy, cardiorenal syndrome and hypertensive nephropathy. Creatinine 2.1 at discharge; it was stable at this level for ~1 week prior to discharge. # NEUROPATHIC HEEL ULCER: not infected. Likely diabetic. Dressed per wound care recs. Debrided at bedside on ___ by podiatry. Will follow-up with podiatry as outpatient. # TYPE II DIABETES: FSG generally under good control. Glargine decreased to 28U at bedtime with Humalog sliding scale at meals and bedtime. # ELEVATED CK: unclear etiology, resolved. # THYROMEGALY: TSH>6, T4 normal. Thyroid US with vascular congestion. Discussed case with endocrine, who recommends outpatient endocrine follow-up. Follow-up appointment is scheduled. # IRON DEFICIENCY: Given history of CHF and iron studies indicative of deficiency, she was given IV iron while in house, and should have iron studies rechecked as an outpatient. TRANSITIONAL ISSUES: ==================== [ ] f/u with podiatry for neuropathic ulcer [ ] f/u with endocrine for radiographic thyroiditis [ ] Chem ___ at ___ NP appointment next week [ ] f/u with Dr ___ in ___ office after seeing ___ NP [ ] Daily weights, call ___ office if increase >3 pounds in one day [ ] recheck iron studies as an outpatient to ensure proper repletion with IV Iron while in house - Discharge weight: 106.5 kg = 234.8 lbs - Discharge Cr: 2.1 - Discharge diuretic regimen: torsemide 100mg BID Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Glargine 41 Units Bedtime 4. Gabapentin 100 mg PO TID 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 6. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 3. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX *isosorbide mononitrate 30 mg Once tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 5. Torsemide 80 mg PO BID RX *torsemide 20 mg Four tablet(s) by mouth Once in the morning and once in the evening Disp #*240 Tablet Refills:*0 6. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Ferrous Sulfate 325 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. Lisinopril 40 mg PO DAILY 10.straight cane DX: diabetic ulcer and chronic foot pain PX: good ___: 12 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: acute on chronic diastolic heart failure, R foot ulcer, diabetes mellitus (type II, on insulin) Secondary diagnoses: elevated CK 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 too much fluid in your body. You received a medicine called "Lasix" or furosemide, to help remove the extra fluid from your body. You also had extensive testing of your heart to find out why you have "heart failure." This showed that your heart failure is likely related to your high blood pressure. You also were seen by the podiatrists ("foot doctors") because of the wound on the bottom of your right foot. They cleaned it, and recommended that you follow-up with them in their ___ urgent ___ center one week after discharge (___). We noticed that your thyroid gland in your neck is bigger than usual. We did some testing of the thyroid, which showed that it is working normally. Our endocrine doctors ___ for the thyroid gland) will see you in the office in a few weeks to check in on your thyroid. If you notice any difficulty in swallowing, changes in your voice, racing heart or heart fluttering, please call their office to tell them your symptoms. Be sure to take ALL of your medicines as prescribed. Follow up with your doctors, as scheduled below. Be sure to weigh yourself every day! Weigh yourself first thing in the morning, after you have gone to the bathroom. When you were discharged, your weight was 234.8 lbs. If your weight goes up by more than 3 lbs in one day, or 5 lbs in one week, call ___ to speak with our cardiology team about your weight change. It was a pleasure taking care of you! We wish you the very best. Your ___ Cardiology Team Followup Instructions: ___
[ "I130", "I214", "N179", "I5033", "L97419", "Z6841", "E1122", "E785", "Z794", "E11319", "E1140", "N189", "E11621", "E611", "E049", "E6601" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dyspnea, chest pain Major Surgical or Invasive Procedure: None. History of Present Illness: [MASKED] woman with HTN, IDDM, HLD with heart failure (unknown EF) diagnosed [MASKED] at [MASKED] here with worsening dyspnea on exertion, lower extremity edema. She was initially presented to [MASKED] [MASKED] and was diagnosed with heart failure. She was diuresed in the hospital and improved. She had poor adherence on follow up, stopped taking 60mg po Lasix when she was discharged. She did continue to take on metoprolol and lisinopril. She does not weigh herself. Presents with gradually worsening dyspnea on exertion, lower extremity edema, PND, orthopnea for two months, but most noticeably over the last 2 weeks. She cannot walk up a flight of stairs without stopping several times due to dyspnea, she cannot walk >1city block at a time due to dyspnea, which resolves with rest. Her lower extremities have become progressively swollen over the last few months, but now feel "tight" and heavy. She also reported an isolated episode of sharp chest pain awakening her from sleep last night which lasted seconds and resolved without intervention. Location L anterior chest with radiation to her left arm. No association with palpation, position. She denies current chest pain/pressure, or chest pressure that increases with predictable activity or resolves with rest. She was given sublingual nitro x1 in ambulance. Of note, she is a longstanding diabetic, diagnosed [MASKED] years ago. Over the last [MASKED] years has gotten better control. Knows she has retinopathy, severe neuropathy. Has never been told had kidney problems before. She has an opthalomologist but never has seen podiatry. She notes history of foot wound that was "cut" by PCP in [MASKED]. She describes being prescribed a 14 day course of augmentin for this wound. She does not remember being told it was related to diabetes. In the ED initial vitals were: 97.6 90 138/83 20 100% Nasal Cannula BP notable for 170-190's/70's-100's Labs/studies notable for: [MASKED]: 10773, Trop-T 0.04, CK 426, MB 5 Cr 1.6 (unknown baseline), Chem 10 otherwise unremarkable Hg 10.9, WBC, PLT wnl UA 300 prtn RBC 163, Blood Mod LUE Ultrasound [MASKED]: No evidence of deep vein thrombosis in the left upper extremity. CXR [MASKED]: No definite focal consolidation is seen. There is no large pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are stable. No pulmonary edema is seen. No acute cardiopulmonary process. BEDSIDE TTE by cards fellow [MASKED]: some LVH, mild MR, AI, TR, trivial effusion, unable to clearly assess wall motion. Patient was given: IV Furosemide 80 mg Vitals on transfer: VS: T98 BP194/101, 168/86 HR 73 RR 20 O2 SAT 97% RA On the floor the patient reports fatigue but denies dyspnea, chest pressure, nausea, vomiting. Past Medical History: - Diabetes mellitus, A1C 7.2% on admission ([MASKED]), complicated by neuropathy - Hypertension - Hyperlipidemia - HF pEF, diagnosed during hospitalization at [MASKED] ([MASKED]) - R foot ulcer Social History: [MASKED] Family History: Cousin with ICD placement, [MASKED] No family history of early MI, cardiomyopathies, or sudden cardiac death. Physical Exam: == ADMISSION PHYSICAL EXAMINATION == VS: T98 BP194/101, 168/86 HR 73 RR 20 O2 SAT 97% RA I/O: -/540in ED +NR Weight: 126.2kg, unknown dry weight GENERAL: Well developed, well nourished female in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP of 13cm with head of bed at 30 degrees CARDIAC: laterally displaced PMI. Regular rate and rhythm. Normal S1, S2. diastolic murmur. No rubs, or gallops. No thrills or lifts. LUNGS: Respiration is unlabored with no accessory muscle use. Breath sounds limited by habitus. Crackles to bases, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. EXTREMITIES: 4+ pitting edema to thighs B/L, 1+ extending to umbilicus. Warm, well perfused. No clubbing, cyanosis. L>R arm swelling. SKIN: R foot with 1cm punched out, ~3mm deep ulcer with foul smell emanating, but no overt. No rashes. NEURO: decreased sensation to light touch to feet B/L. == DISCHARGE PHYSICAL EXAMINATION == VITALS: T 97.2, BP 135-145/79-88, HR 72-85, RR 18, SpO2 98/RA WEIGHT: 106.1 kg -> 107 kg I/O: 24hr 1100/2175, 8h 100/800 GENERAL: well-appearing obese female, NAD HEENT: moist membranes, PERRL NECK: JVP elevated to 7-8cm at 45 degrees, thyromegaly R>L CARDIAC: RRR, [MASKED] high pitched SEM at RUSB, heard throughout rest of precordium LUNGS: distant breath sounds, CTAB ABDOMEN: Normoactive BS throughout, non tender EXTREMITIES: WWP, 2+ pitting edema to knees b/l. R heel - wrapped in guaze, dressing is clean/dry Pertinent Results: == ADMISSION LABS == [MASKED] 11:45AM BLOOD WBC-6.1 RBC-3.96 Hgb-10.9* Hct-34.2 MCV-86 MCH-27.5 MCHC-31.9* RDW-13.9 RDWSD-43.5 Plt [MASKED] [MASKED] 11:45AM BLOOD Neuts-63.8 [MASKED] Monos-6.4 Eos-1.3 Baso-0.5 Im [MASKED] AbsNeut-3.88 AbsLymp-1.69 AbsMono-0.39 AbsEos-0.08 AbsBaso-0.03 [MASKED] 11:45AM BLOOD [MASKED] PTT-31.8 [MASKED] [MASKED] 11:45AM BLOOD Glucose-83 UreaN-16 Creat-1.6* Na-141 K-3.4 Cl-107 HCO3-28 AnGap-9 [MASKED] 11:45AM BLOOD CK(CPK)-426* [MASKED] 11:45AM BLOOD CK-MB-5 [MASKED] [MASKED] 11:45AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.6 Iron-58 == NOTABLE INTERVAL LABS == [MASKED] 05:55PM BLOOD ALT-12 AST-18 LD(LDH)-303* CK(CPK)-559* AlkPhos-91 TotBili-0.2 [MASKED] 06:29AM BLOOD CK(CPK)-328* [MASKED] 11:45AM BLOOD calTIBC-233* Ferritn-27 TRF-179* [MASKED] 11:45AM BLOOD %HbA1c-7.2* eAG-160* [MASKED] 11:45AM BLOOD TSH-6.1* [MASKED] 03:00PM BLOOD T4-7.4 [MASKED] 11:45AM BLOOD RheuFac-14 [MASKED] CRP-4.9 [MASKED] 03:00PM BLOOD PEP-AWAITING F FreeKap-86.8* FreeLam-52.2* Fr K/L-1.66* IFE-PND == IMAGING == -- [MASKED] CXR No acute cardiopulmonary process. -- [MASKED] UNILAT UPPER EXTR ULTRASOUND No evidence of deep vein thrombosis in the left upper extremity. -- [MASKED] TTE The left atrium is moderately dilated. The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 55%). The estimated cardiac index is depressed (<2.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is absent transmitral A wave c/w impaired left atrial mechanical function. Mild to moderate ([MASKED]) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and low normal global left ventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. Mildly dilated thoracic aorta. Increased PCWP. Absent transmitral A wave. The symmetric left ventricular hypertrophy with increased PCWP and absent transmitral A wave and multivalvular regurgitation are suggestive of an infiltrative process (e.g., amyloid). -- [MASKED] CARDIAC MRI The left atrial AP dimension is mildly increased with moderate left atrial elongation. The right atrium is moderately dilated. There is normal left ventricular wall thickness with normal mass. Normal left ventricular end-diastolic dimension with SEVERELY increased left ventricular end-diastolic volume and moderately increased end-diastolic volume index. There is mild global left ventricular hypokinesis with relative preservation of apical function. The left ventricular cardiac index is normal. There is uniformity in regional T2. Early gadolinium enhancement images showed no enhancement. There is no late gadolinium enhancement (absence of scar/fibrosis). Mildly increased right ventricular end-diastolic volume index with mild global free wall hypokinesis and low normal ejection fraction. Normal origin of the right and left main coronary arteries. Mildly increased ascending aorta diameter (normal BSA indexed ascending aorta diameter) with normal aortic arch diameter and mIldly dilated descending thoracic aorta (normal BSA indexed descending aorta diameter). Mildly increased abdominal aorta diameter (normal BSA indexed abdominal aorta diameter). Moderately increased pulmonary artery diameter with mildly increased BSA indexed PA diameter. The # of aortic valve leaflets could not be determined. There is no aortic valve stenosis. Mild aortic regurgitation is seen. There is moderate mitral regurgitation. There is moderate tricuspid regurgitation. There is a small circumferential pericardial effusion. Pericardial thickness is normal. There is a small right pleural effusion. IMPRESSION: Normal left ventricular wall thickness and global mass. Moderately dilated left ventricular cavity with mild global hypokinesis. No evidence of myocardial edema, inflammation, infiltration or scar/fibrosis. Mildly dilated right ventricular cavity with low normal free wall motion. Moderate mitral regurgitation. Moderate tricuspid regurgitation. These findings are most c/w a non-ischemic dilated cardiomyopathy. [MASKED] Imaging THYROID U.S. Heterogeneous hypervascular thyroid gland compatible with thyroiditis. No discrete nodules identified. == DISCHARGE LABS == [MASKED] 04:25AM BLOOD WBC-6.6 RBC-4.20 Hgb-11.4 Hct-36.1 MCV-86 MCH-27.1 MCHC-31.6* RDW-14.1 RDWSD-43.8 Plt [MASKED] [MASKED] 04:25AM BLOOD Plt [MASKED] [MASKED] 04:25AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0 Brief Hospital Course: This is a [MASKED] year old woman with a PMH notable for hypertension, hyperlipidemia, history of heart failure (NOS) and type II diabetes mellitus (on insulin), who presented with massive [MASKED] edema, concerning for heart failure, found to have signs suggestive of infiltrative cardiac disease on TTE. # Acute on chronic heart failure with preserved ejection fraction: diagnosed [MASKED] at [MASKED] [records obtained, in paper chart -- notable for EF 56%, grade II diastolic dysfunction, dry weight 110 kg]. TTE concerning for restrictive physiology and possible infiltrative process, such as amyloidosis. Cardiac MRI obtained, which demonstrated what is almost certainly dilated cardiomyopathy due to hypertension. No evidence of infiltrative disease on cardiac MRI. Presented massively overloaded on examination. Aggresively diuresed with furosemide gtt, then furosemide boluses, and finally oral torsemide. Initially held lisinopril given elevated Cr, but appears baseline. Slowly restarted & uptitrated, given degree of hypertension & proteinuria. Metoprolol was stopped, given preserved EF and possible constrictive physiology. - Discharge weight: 106.5 kg, 234.8 lbs - Discharge Cr: 2.1 - Discharge diuretic regimen: torsemide 100mg BID # Type II NSTEMI: perhaps demand in setting of volume overload and CHF, as above. Started on aspirin 81 mg daily and atorvastatin 40 mg HS. Once euvolemic, stress test showed no focal ischemia or perfusion defects. # Hypertension: quite elevated on admission (180s+). Lisinopril 40mg used, as above. Started on amlodipine and isosorbide mononitrate, which she tolerated well with satisfactory improvement of BP. # Renal failure: likely chronic, with possible acute component. Significant proteinuria, with Pr/Cr 11.1. Possible etiologies include diabetic nephropathy, cardiorenal syndrome and hypertensive nephropathy. Creatinine 2.1 at discharge; it was stable at this level for ~1 week prior to discharge. # NEUROPATHIC HEEL ULCER: not infected. Likely diabetic. Dressed per wound care recs. Debrided at bedside on [MASKED] by podiatry. Will follow-up with podiatry as outpatient. # TYPE II DIABETES: FSG generally under good control. Glargine decreased to 28U at bedtime with Humalog sliding scale at meals and bedtime. # ELEVATED CK: unclear etiology, resolved. # THYROMEGALY: TSH>6, T4 normal. Thyroid US with vascular congestion. Discussed case with endocrine, who recommends outpatient endocrine follow-up. Follow-up appointment is scheduled. # IRON DEFICIENCY: Given history of CHF and iron studies indicative of deficiency, she was given IV iron while in house, and should have iron studies rechecked as an outpatient. TRANSITIONAL ISSUES: ==================== [ ] f/u with podiatry for neuropathic ulcer [ ] f/u with endocrine for radiographic thyroiditis [ ] Chem [MASKED] at [MASKED] NP appointment next week [ ] f/u with Dr [MASKED] in [MASKED] office after seeing [MASKED] NP [ ] Daily weights, call [MASKED] office if increase >3 pounds in one day [ ] recheck iron studies as an outpatient to ensure proper repletion with IV Iron while in house - Discharge weight: 106.5 kg = 234.8 lbs - Discharge Cr: 2.1 - Discharge diuretic regimen: torsemide 100mg BID Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Glargine 41 Units Bedtime 4. Gabapentin 100 mg PO TID 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 6. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 3. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX *isosorbide mononitrate 30 mg Once tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 5. Torsemide 80 mg PO BID RX *torsemide 20 mg Four tablet(s) by mouth Once in the morning and once in the evening Disp #*240 Tablet Refills:*0 6. Glargine 28 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Ferrous Sulfate 325 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. Lisinopril 40 mg PO DAILY 10.straight cane DX: diabetic ulcer and chronic foot pain PX: good [MASKED]: 12 months Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnoses: acute on chronic diastolic heart failure, R foot ulcer, diabetes mellitus (type II, on insulin) Secondary diagnoses: elevated CK 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 too much fluid in your body. You received a medicine called "Lasix" or furosemide, to help remove the extra fluid from your body. You also had extensive testing of your heart to find out why you have "heart failure." This showed that your heart failure is likely related to your high blood pressure. You also were seen by the podiatrists ("foot doctors") because of the wound on the bottom of your right foot. They cleaned it, and recommended that you follow-up with them in their [MASKED] urgent [MASKED] center one week after discharge ([MASKED]). We noticed that your thyroid gland in your neck is bigger than usual. We did some testing of the thyroid, which showed that it is working normally. Our endocrine doctors [MASKED] for the thyroid gland) will see you in the office in a few weeks to check in on your thyroid. If you notice any difficulty in swallowing, changes in your voice, racing heart or heart fluttering, please call their office to tell them your symptoms. Be sure to take ALL of your medicines as prescribed. Follow up with your doctors, as scheduled below. Be sure to weigh yourself every day! Weigh yourself first thing in the morning, after you have gone to the bathroom. When you were discharged, your weight was 234.8 lbs. If your weight goes up by more than 3 lbs in one day, or 5 lbs in one week, call [MASKED] to speak with our cardiology team about your weight change. It was a pleasure taking care of you! We wish you the very best. Your [MASKED] Cardiology Team Followup Instructions: [MASKED]
[]
[ "I130", "N179", "E1122", "E785", "Z794", "N189" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "N179: Acute kidney failure, unspecified", "I5033: Acute on chronic diastolic (congestive) heart failure", "L97419: Non-pressure chronic ulcer of right heel and midfoot with unspecified severity", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E785: Hyperlipidemia, unspecified", "Z794: Long term (current) use of insulin", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "N189: Chronic kidney disease, unspecified", "E11621: Type 2 diabetes mellitus with foot ulcer", "E611: Iron deficiency", "E049: Nontoxic goiter, unspecified", "E6601: Morbid (severe) obesity due to excess calories" ]
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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Depakote / lisinopril / Topamax / Ultram / hydrochlorothiazide Attending: ___. Chief Complaint: Dyspnea, cough, headache, diarrhea Major Surgical or Invasive Procedure: Colonoscopy and EGD History of Present Illness: ___ year old lady with history of HTN, COPD, IDDM, hypothyroidism, DVT who presented with diarrhea, SOB, and headache x ___ days, found to have severe Hyponatremia. Patient presented for routine PCP check up today, but was complaining of shortness of breath, diarrhea, pounding headache, and ___ edema R>L x 10 days. She reported tan watery diarrhea, ___ episodes/ day, not associated with abdominal pain, nausea or vomiting. She has not had any recent travel or dietary/water source changes. Lives in senior housing so she thinks that maybe half of her apartment complex has diarrhea at baseline. Her appetite had been poor, and additionally reported minimal fluid intake; she has continued to take HCTZ. She endorses lightheadedness for the last several days. In addition, she notes cough ongoing for weeks, non productive, no fevers, no chills. She reports dyspnea with difficulty lying flat due to shortness of breath, also with progressive ___ edema over the last week and half with RLE>LLE. She does have history of DVT many years ago in setting of a "tumor removal" from her leg. Initial vitals at PCP office BP 102/58, Pulse 80, Temp 98.1 °F (36.7 °C), Resp 18, SpO2 97%, and was sent to ___ for further evaluation. At ___, she was noted to have SpO2 90% on RA, no focal neurological deficits on exam, but 2+ ___ edema. Evaluation there remarkable for: Na 115, K 5.4, BUN/Cr ___, LFTS WNL, BNP 522, TSH 4.2 (upper limit of normal), random cortisol 13.9, negative influenza A/B. CTH and CXR WNL (no reports available for review). In the ED, initial vitals were: 97.7 HR 60 BP 182/80 SpO2 99% 2L NC - Exam notable for: "Clinically dry, no crackles on exam, bilateral ___ edema" - Labs notable for: WBC 6.5 Hgb 9.6 Plt 181 114| 80 | 13 ------------- 4.8 | 22 | 0.7 Lactate 1.0 Serum osm 240 Uosm 427 Na 89 Cr 52 Pr/Cr 1.0 U/A >182 WBC, 4 RBC, few bacteria Epi 1 - Imaging was notable for: No new imaging obtained - Patient was given: 250 mL NS bolus Review of systems was negative except as detailed above. Past Medical History: Seizure disorder Hypertension COPD IDDM GERD Hyperlipidemia History of DVT Social History: ___ Family History: Noncontributory Physical Exam: PHYSICAL EXAM ON ADMISSION: GENERAL: Pleasant elderly lady breathing comfortably in no acute distress HEENT: MMM, no JVD at 90 degrees CARDIAC: Normal rate, regular rhythm, no m/r/g appreciated PULMONARY: Diffuse expiratory wheezes throughout all lung fields ABDOMEN: Soft, nontender, distended/obese, no fluid wave apprecaited EXTREMITIES: 2+ tight edema in bilateral ___, RLE>LLE; cap refill >2s SKIN: No rashes appreciated NEURO: AO x 4, moves all 4 extremities symmetrically and with purpose DISCHARGE EXAM: General: Laying down in bed, alert and conversive HEENT: Moist mucous membranes. No pharyngeal exudates or erythema. Lungs: Low lung volumes with minimal air movements. Clear to auscultation bilaterally. CV: Normal rate, regular rhythm, no m/r/g appreciated ABDOMEN: Abdomen soft, nontender, nondistended Ext: No bilateral edema appreciated in lower extremities Neuro: A&Ox3 Pertinent Results: ___ LABS: ============== ___ 08:57PM BLOOD WBC-6.5 RBC-3.73* Hgb-9.6* Hct-27.7* MCV-74* MCH-25.7* MCHC-34.7 RDW-15.9* RDWSD-42.7 Plt ___ ___ 08:57PM BLOOD Neuts-62.2 ___ Monos-8.8 Eos-1.4 Baso-0.2 Im ___ AbsNeut-4.05 AbsLymp-1.73 AbsMono-0.57 AbsEos-0.09 AbsBaso-0.01 ___ 08:57PM BLOOD Plt ___ ___ 08:57PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-114* K-4.8 Cl-80* HCO3-22 AnGap-12 ___ 08:57PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-114* K-4.8 Cl-80* HCO3-22 AnGap-12 ___ 08:57PM BLOOD cTropnT-<0.01 ___ 08:57PM BLOOD proBNP-525* ___ 08:57PM BLOOD TotProt-6.9 Calcium-9.4 Phos-3.7 Mg-1.5* ___ 09:01PM BLOOD Lactate-1.0 Na-114* DISCHARGE LABS: ___ 04:20AM BLOOD WBC-7.5 RBC-3.61* Hgb-9.0* Hct-29.3* MCV-81* MCH-24.9* MCHC-30.7* RDW-18.0* RDWSD-51.2* Plt ___ ___ 04:20AM BLOOD Plt ___ ___ 04:20AM BLOOD Glucose-161* UreaN-14 Creat-0.8 Na-141 K-3.8 Cl-98 HCO3-29 AnGap-14 ___ 04:20AM BLOOD Calcium-9.3 Phos-4.9* Mg-1.9 ___ 04:20AM BLOOD IgA-122 ___ 04:20AM BLOOD tTG-IgA-PND STUDIES: ========= BILAT LOWER EXT VEINS PORT Study Date of ___ No evidence of deep venous thrombosis in the right or left lower extremity veins. Subcutaneous edema is noted in the calves bilaterally. TTE ___ Mild symmetric biventricular hypertrophy with normal left ventricular cavity size and regional/global biventricular systolic function. Echocardiographic evidence for diastolic dysfunction with elevated PCWP. Moderate pulmonary artery systolic hypertension with elevated right atrial pressure. EGD ___ Normal mucosa in the whole esophagus Esophageal hiatal hernia Erosions in the antrum (biopsy) Normal mucosa in the whole examined duodenum Colonoscopy ___ Normal mucosa in the whole colon (random biopsies) Polyp (4mm) in the descending colon (polypectomy) Diverticulosis of the whole colon Recommend repeat colonoscopy in ___ years Brief Hospital Course: Ms. ___ is a ___ with history of HTN, COPD, IDDM, hypothyroidism, DVT who originally presented with diarrhea, SOB, and headache x ___ days, found to have severe hypervolemic hyponatremia that improved with diuresis and discontinuation of her hydrochlorathiazide. She was found to have iron deficiency anemia and dysphagia for which she underwent EGD and colonoscopy without pertinent findings. ACTIVE ISSUES ======================= #Hypotonic, Hypervolemic Hyponatremia Admitted with severe hyponatremia to 111. Etiology was mostly hypervolemia due to diastolic heart failure exacerbation and HCTZ use. We d/c'd HCTZ and placed a fluid restriction and initiated pharmacologic diuresis with loop diuretics until the patient was euvolemic. Patient originally had symptomatic headaches, confusion, and shortness of breath; these all improved with diuresis. Renal was consulted and made recommendations about an outpatient diuretic regimen with torsemide 10 mg PO QD. The patient's Na normalized to 141 by discharge and she was asymptomatic. #Heart failure with preserved ejection fraction Patient originally presented with severe bilateral lower extremity edema, orthopnea, shortness of breath, and severely elevated BNP. LENIs were negative. Responded well to diuresis as above. Was euvolemic at discharge. Discharge weight: 110.4 kg. Discharge Cr: 0.8. #Anemia Hgb remained consistently low with microcytic pattern during admission. Ferritin was low-normal and TIBC was high-normal. Patient also described ongoing weight loss and change in stool patterns (alternating diarrhea/constipation + worm-like stools). Last colonoscopy in ___ included removal of 17 polyps and recommendation for follow-up colonoscopy in ___ year, which patient did not get. She received both a colonoscopy and an EGD as an inpatient. Had one colonic polyp removed and random biopsies sent. EGD was notable for mild gastritis with antral erosions (no stricture). #Change in stool habits Patient reported 10 days of watery diarrhea prior to admission. She also described change in stool formation ("worm/pebble-like"). Diarrhea was likely viral gastroenteritis given time course. C diff was negative. After admission patient was constipated for 1 week. This resolved with a bowel prep that was done in preparation of an inpatient colonoscopy to evaluate for iron deficiency anemia (see above). IgA levels and transglutaminase antibodies were sent, both negative. #Dysphagia Patient complained of discomfort while swallowing during admission. Was evaluated by speech and swallow who found no oropharyngeal pathology. EGD showed mild gastritis, no evidence of esophageal stricture. #Klebsiella UTI Patient had UA concerning for infection upon admission, speciated to Klebsiella. Was treated with ceftriaxone x 3 days with good result. Subsequently denied urinary discomfort. #Vulvovaginal candidiasis #Urinary retention Patient had vaginal discharge and inner groin rash consistent with candidiasis. Responded very well to PO fluconazole and miconazole powder. Pt originally had Foley upon admission which was discontinued. Pt had one day of urinary retention which later resolved. Likely was due to UTI / prolonged Foley placement. # Hypoxia/dyspnea Patient had acute on chronic dyspnea during hospitalization. Has 40 pack year smoking history and COPD. Generally felt with activity. CXR without evidence of pulmonary edema, pneumonia, or pleural effusion. LENIs negative as above. Patient's oxygenation improved with 2L NC, later weaned to RA. She was also given standing Duonebs. #Hyperglycemia Patient was managed on an insulin sliding scale. PO anti-hyperglycemics were held. #Sore throat Patient complained of sore throat that was managed with throat lozenges and chloraseptic spray with good response. Likely a viral pharyngitis. No erythema or exudates on exam. #Hypomagensia Patient had hypomagnesmia upon admission that normalized with administration of MgSO4. CHRONIC ISSUES ======================== # History of seizures: Continued home keppra # Hypertension: Home losartan was increased from 25 to 50 mg PO QD. Eventually may benefit from increasing home losartan to 100 mg but holding off currently i/s/o ongoing diuresis; continue metoprolol # Hyperlipidemia: Continued home pravastatin. # Diabetes: Received insulin SSI while in house. # Hypothyroidism: Continued home levothyroxine 175 mcg. Transitional issues [ ] HFpEF: patient to be discharged on PO torsemide 10 mg QD as maintenance diuretic. Please adjust PRN to maintain weight and euvolemic status. Discharge dry weight 110.4 kg. Discharge Cr 0.8. [ ] GI biopsies: F/u on pathology from colonoscopy random biopsies and polypectomy. F/u on EGD biopsy pathology of antral erosions. [ ] Mild gastritis: counsel patient to avoid NSAIDS given hx of microcytic anemia and gastritis on EGD [ ] Weight loss, poor appetite: patient should receive age-appropriate cancer screening and PHQ-9 screening as outpatient for follow-up for poor appetite and weight loss. Patient endorsed weakness, confusion, poor appetite for several weeks prior to admission. ? if this was due to low sodium that had been present for some time. She denied symptoms of depression. [ ] Patient noted to have iron deficiency anemia throughout hospitalization. Colonoscopy and EGD revealed one polyp and mild gastritis. Pt should have follow up for ongoing anemia with monitoring of symptoms. Greater than ___ hour spent on care on day of discharge. #CODE STATUS: Full, limited trial #CONTACT: Son ___ ___ Pt's son ___, is alternate: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Ibuprofen 800 mg PO Q12H:PRN Pain - Mild 3. Levothyroxine Sodium 175 mcg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Losartan Potassium 25 mg PO DAILY 6. LevETIRAcetam 1000 mg PO BID 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 9. Pravastatin 40 mg PO QPM 10. Gabapentin 600 mg PO TID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Omeprazole 40 mg PO DAILY 13. glimepiride 2 mg oral BID 14. Aspirin 81 mg PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Heparin 5000 UNIT SC BID 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H sob 4. Miconazole Powder 2% 1 Appl TP TID:PRN Rash 5. Multivitamins 1 TAB PO DAILY 6. Nicotine Patch 14 mg/day TD DAILY 7. Losartan Potassium 50 mg PO DAILY 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 9. Aspirin 81 mg PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU BID 11. Gabapentin 600 mg PO TID 12. glimepiride 2 mg oral BID 13. LevETIRAcetam 1000 mg PO BID 14. Levothyroxine Sodium 175 mcg PO DAILY 15. MetFORMIN (Glucophage) 1000 mg PO BID 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Omeprazole 40 mg PO DAILY 18. Pravastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary diagnosis Hypervolemic Hyponatremia Secondary diagnosis Iron deficiency anemia Constipation Vaginal candidiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because you had a headache, shortness of breath, and diarrhea. We found that you had very low sodium levels in your blood. This is called hyponatremia. - You also had anemia (low blood levels) with low iron levels. WHAT HAPPENED TO ME IN THE HOSPITAL? - We gave you diuretics to lower the amount of fluid in your body. - You got a upper endoscopy and colonoscopy that found some irritation in the esophagus. There was one polyp in the colon. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "I110", "I5031", "E871", "N390", "A09", "Z6842", "F05", "D509", "R1310", "B961", "B373", "R339", "T502X5A", "Y92099", "J449", "J029", "E8342", "G40909", "E785", "E039", "K635", "K5730", "Z86718", "E1165", "F17210", "E1140", "E669" ]
Allergies: Depakote / lisinopril / Topamax / Ultram / hydrochlorothiazide Chief Complaint: Dyspnea, cough, headache, diarrhea Major Surgical or Invasive Procedure: Colonoscopy and EGD History of Present Illness: [MASKED] year old lady with history of HTN, COPD, IDDM, hypothyroidism, DVT who presented with diarrhea, SOB, and headache x [MASKED] days, found to have severe Hyponatremia. Patient presented for routine PCP check up today, but was complaining of shortness of breath, diarrhea, pounding headache, and [MASKED] edema R>L x 10 days. She reported tan watery diarrhea, [MASKED] episodes/ day, not associated with abdominal pain, nausea or vomiting. She has not had any recent travel or dietary/water source changes. Lives in senior housing so she thinks that maybe half of her apartment complex has diarrhea at baseline. Her appetite had been poor, and additionally reported minimal fluid intake; she has continued to take HCTZ. She endorses lightheadedness for the last several days. In addition, she notes cough ongoing for weeks, non productive, no fevers, no chills. She reports dyspnea with difficulty lying flat due to shortness of breath, also with progressive [MASKED] edema over the last week and half with RLE>LLE. She does have history of DVT many years ago in setting of a "tumor removal" from her leg. Initial vitals at PCP office BP 102/58, Pulse 80, Temp 98.1 °F (36.7 °C), Resp 18, SpO2 97%, and was sent to [MASKED] for further evaluation. At [MASKED], she was noted to have SpO2 90% on RA, no focal neurological deficits on exam, but 2+ [MASKED] edema. Evaluation there remarkable for: Na 115, K 5.4, BUN/Cr [MASKED], LFTS WNL, BNP 522, TSH 4.2 (upper limit of normal), random cortisol 13.9, negative influenza A/B. CTH and CXR WNL (no reports available for review). In the ED, initial vitals were: 97.7 HR 60 BP 182/80 SpO2 99% 2L NC - Exam notable for: "Clinically dry, no crackles on exam, bilateral [MASKED] edema" - Labs notable for: WBC 6.5 Hgb 9.6 Plt 181 114| 80 | 13 ------------- 4.8 | 22 | 0.7 Lactate 1.0 Serum osm 240 Uosm 427 Na 89 Cr 52 Pr/Cr 1.0 U/A >182 WBC, 4 RBC, few bacteria Epi 1 - Imaging was notable for: No new imaging obtained - Patient was given: 250 mL NS bolus Review of systems was negative except as detailed above. Past Medical History: Seizure disorder Hypertension COPD IDDM GERD Hyperlipidemia History of DVT Social History: [MASKED] Family History: Noncontributory Physical Exam: PHYSICAL EXAM ON ADMISSION: GENERAL: Pleasant elderly lady breathing comfortably in no acute distress HEENT: MMM, no JVD at 90 degrees CARDIAC: Normal rate, regular rhythm, no m/r/g appreciated PULMONARY: Diffuse expiratory wheezes throughout all lung fields ABDOMEN: Soft, nontender, distended/obese, no fluid wave apprecaited EXTREMITIES: 2+ tight edema in bilateral [MASKED], RLE>LLE; cap refill >2s SKIN: No rashes appreciated NEURO: AO x 4, moves all 4 extremities symmetrically and with purpose DISCHARGE EXAM: General: Laying down in bed, alert and conversive HEENT: Moist mucous membranes. No pharyngeal exudates or erythema. Lungs: Low lung volumes with minimal air movements. Clear to auscultation bilaterally. CV: Normal rate, regular rhythm, no m/r/g appreciated ABDOMEN: Abdomen soft, nontender, nondistended Ext: No bilateral edema appreciated in lower extremities Neuro: A&Ox3 Pertinent Results: [MASKED] LABS: ============== [MASKED] 08:57PM BLOOD WBC-6.5 RBC-3.73* Hgb-9.6* Hct-27.7* MCV-74* MCH-25.7* MCHC-34.7 RDW-15.9* RDWSD-42.7 Plt [MASKED] [MASKED] 08:57PM BLOOD Neuts-62.2 [MASKED] Monos-8.8 Eos-1.4 Baso-0.2 Im [MASKED] AbsNeut-4.05 AbsLymp-1.73 AbsMono-0.57 AbsEos-0.09 AbsBaso-0.01 [MASKED] 08:57PM BLOOD Plt [MASKED] [MASKED] 08:57PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-114* K-4.8 Cl-80* HCO3-22 AnGap-12 [MASKED] 08:57PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-114* K-4.8 Cl-80* HCO3-22 AnGap-12 [MASKED] 08:57PM BLOOD cTropnT-<0.01 [MASKED] 08:57PM BLOOD proBNP-525* [MASKED] 08:57PM BLOOD TotProt-6.9 Calcium-9.4 Phos-3.7 Mg-1.5* [MASKED] 09:01PM BLOOD Lactate-1.0 Na-114* DISCHARGE LABS: [MASKED] 04:20AM BLOOD WBC-7.5 RBC-3.61* Hgb-9.0* Hct-29.3* MCV-81* MCH-24.9* MCHC-30.7* RDW-18.0* RDWSD-51.2* Plt [MASKED] [MASKED] 04:20AM BLOOD Plt [MASKED] [MASKED] 04:20AM BLOOD Glucose-161* UreaN-14 Creat-0.8 Na-141 K-3.8 Cl-98 HCO3-29 AnGap-14 [MASKED] 04:20AM BLOOD Calcium-9.3 Phos-4.9* Mg-1.9 [MASKED] 04:20AM BLOOD IgA-122 [MASKED] 04:20AM BLOOD tTG-IgA-PND STUDIES: ========= BILAT LOWER EXT VEINS PORT Study Date of [MASKED] No evidence of deep venous thrombosis in the right or left lower extremity veins. Subcutaneous edema is noted in the calves bilaterally. TTE [MASKED] Mild symmetric biventricular hypertrophy with normal left ventricular cavity size and regional/global biventricular systolic function. Echocardiographic evidence for diastolic dysfunction with elevated PCWP. Moderate pulmonary artery systolic hypertension with elevated right atrial pressure. EGD [MASKED] Normal mucosa in the whole esophagus Esophageal hiatal hernia Erosions in the antrum (biopsy) Normal mucosa in the whole examined duodenum Colonoscopy [MASKED] Normal mucosa in the whole colon (random biopsies) Polyp (4mm) in the descending colon (polypectomy) Diverticulosis of the whole colon Recommend repeat colonoscopy in [MASKED] years Brief Hospital Course: Ms. [MASKED] is a [MASKED] with history of HTN, COPD, IDDM, hypothyroidism, DVT who originally presented with diarrhea, SOB, and headache x [MASKED] days, found to have severe hypervolemic hyponatremia that improved with diuresis and discontinuation of her hydrochlorathiazide. She was found to have iron deficiency anemia and dysphagia for which she underwent EGD and colonoscopy without pertinent findings. ACTIVE ISSUES ======================= #Hypotonic, Hypervolemic Hyponatremia Admitted with severe hyponatremia to 111. Etiology was mostly hypervolemia due to diastolic heart failure exacerbation and HCTZ use. We d/c'd HCTZ and placed a fluid restriction and initiated pharmacologic diuresis with loop diuretics until the patient was euvolemic. Patient originally had symptomatic headaches, confusion, and shortness of breath; these all improved with diuresis. Renal was consulted and made recommendations about an outpatient diuretic regimen with torsemide 10 mg PO QD. The patient's Na normalized to 141 by discharge and she was asymptomatic. #Heart failure with preserved ejection fraction Patient originally presented with severe bilateral lower extremity edema, orthopnea, shortness of breath, and severely elevated BNP. LENIs were negative. Responded well to diuresis as above. Was euvolemic at discharge. Discharge weight: 110.4 kg. Discharge Cr: 0.8. #Anemia Hgb remained consistently low with microcytic pattern during admission. Ferritin was low-normal and TIBC was high-normal. Patient also described ongoing weight loss and change in stool patterns (alternating diarrhea/constipation + worm-like stools). Last colonoscopy in [MASKED] included removal of 17 polyps and recommendation for follow-up colonoscopy in [MASKED] year, which patient did not get. She received both a colonoscopy and an EGD as an inpatient. Had one colonic polyp removed and random biopsies sent. EGD was notable for mild gastritis with antral erosions (no stricture). #Change in stool habits Patient reported 10 days of watery diarrhea prior to admission. She also described change in stool formation ("worm/pebble-like"). Diarrhea was likely viral gastroenteritis given time course. C diff was negative. After admission patient was constipated for 1 week. This resolved with a bowel prep that was done in preparation of an inpatient colonoscopy to evaluate for iron deficiency anemia (see above). IgA levels and transglutaminase antibodies were sent, both negative. #Dysphagia Patient complained of discomfort while swallowing during admission. Was evaluated by speech and swallow who found no oropharyngeal pathology. EGD showed mild gastritis, no evidence of esophageal stricture. #Klebsiella UTI Patient had UA concerning for infection upon admission, speciated to Klebsiella. Was treated with ceftriaxone x 3 days with good result. Subsequently denied urinary discomfort. #Vulvovaginal candidiasis #Urinary retention Patient had vaginal discharge and inner groin rash consistent with candidiasis. Responded very well to PO fluconazole and miconazole powder. Pt originally had Foley upon admission which was discontinued. Pt had one day of urinary retention which later resolved. Likely was due to UTI / prolonged Foley placement. # Hypoxia/dyspnea Patient had acute on chronic dyspnea during hospitalization. Has 40 pack year smoking history and COPD. Generally felt with activity. CXR without evidence of pulmonary edema, pneumonia, or pleural effusion. LENIs negative as above. Patient's oxygenation improved with 2L NC, later weaned to RA. She was also given standing Duonebs. #Hyperglycemia Patient was managed on an insulin sliding scale. PO anti-hyperglycemics were held. #Sore throat Patient complained of sore throat that was managed with throat lozenges and chloraseptic spray with good response. Likely a viral pharyngitis. No erythema or exudates on exam. #Hypomagensia Patient had hypomagnesmia upon admission that normalized with administration of MgSO4. CHRONIC ISSUES ======================== # History of seizures: Continued home keppra # Hypertension: Home losartan was increased from 25 to 50 mg PO QD. Eventually may benefit from increasing home losartan to 100 mg but holding off currently i/s/o ongoing diuresis; continue metoprolol # Hyperlipidemia: Continued home pravastatin. # Diabetes: Received insulin SSI while in house. # Hypothyroidism: Continued home levothyroxine 175 mcg. Transitional issues [ ] HFpEF: patient to be discharged on PO torsemide 10 mg QD as maintenance diuretic. Please adjust PRN to maintain weight and euvolemic status. Discharge dry weight 110.4 kg. Discharge Cr 0.8. [ ] GI biopsies: F/u on pathology from colonoscopy random biopsies and polypectomy. F/u on EGD biopsy pathology of antral erosions. [ ] Mild gastritis: counsel patient to avoid NSAIDS given hx of microcytic anemia and gastritis on EGD [ ] Weight loss, poor appetite: patient should receive age-appropriate cancer screening and PHQ-9 screening as outpatient for follow-up for poor appetite and weight loss. Patient endorsed weakness, confusion, poor appetite for several weeks prior to admission. ? if this was due to low sodium that had been present for some time. She denied symptoms of depression. [ ] Patient noted to have iron deficiency anemia throughout hospitalization. Colonoscopy and EGD revealed one polyp and mild gastritis. Pt should have follow up for ongoing anemia with monitoring of symptoms. Greater than [MASKED] hour spent on care on day of discharge. #CODE STATUS: Full, limited trial #CONTACT: Son [MASKED] [MASKED] Pt's son [MASKED], is alternate: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Ibuprofen 800 mg PO Q12H:PRN Pain - Mild 3. Levothyroxine Sodium 175 mcg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Losartan Potassium 25 mg PO DAILY 6. LevETIRAcetam 1000 mg PO BID 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 9. Pravastatin 40 mg PO QPM 10. Gabapentin 600 mg PO TID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Omeprazole 40 mg PO DAILY 13. glimepiride 2 mg oral BID 14. Aspirin 81 mg PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Heparin 5000 UNIT SC BID 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H sob 4. Miconazole Powder 2% 1 Appl TP TID:PRN Rash 5. Multivitamins 1 TAB PO DAILY 6. Nicotine Patch 14 mg/day TD DAILY 7. Losartan Potassium 50 mg PO DAILY 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 9. Aspirin 81 mg PO DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU BID 11. Gabapentin 600 mg PO TID 12. glimepiride 2 mg oral BID 13. LevETIRAcetam 1000 mg PO BID 14. Levothyroxine Sodium 175 mcg PO DAILY 15. MetFORMIN (Glucophage) 1000 mg PO BID 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Omeprazole 40 mg PO DAILY 18. Pravastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Primary diagnosis Hypervolemic Hyponatremia Secondary diagnosis Iron deficiency anemia Constipation Vaginal candidiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You came to the hospital because you had a headache, shortness of breath, and diarrhea. We found that you had very low sodium levels in your blood. This is called hyponatremia. - You also had anemia (low blood levels) with low iron levels. WHAT HAPPENED TO ME IN THE HOSPITAL? - We gave you diuretics to lower the amount of fluid in your body. - You got a upper endoscopy and colonoscopy that found some irritation in the esophagus. There was one polyp in the colon. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I110", "E871", "N390", "D509", "J449", "E785", "E039", "Z86718", "E1165", "F17210", "E669" ]
[ "I110: Hypertensive heart disease with heart failure", "I5031: Acute diastolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "N390: Urinary tract infection, site not specified", "A09: Infectious gastroenteritis and colitis, unspecified", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "F05: Delirium due to known physiological condition", "D509: Iron deficiency anemia, unspecified", "R1310: Dysphagia, unspecified", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "B373: Candidiasis of vulva and vagina", "R339: Retention of urine, unspecified", "T502X5A: Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter", "Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause", "J449: Chronic obstructive pulmonary disease, unspecified", "J029: Acute pharyngitis, unspecified", "E8342: Hypomagnesemia", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "K635: Polyp of colon", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding", "Z86718: Personal history of other venous thrombosis and embolism", "E1165: Type 2 diabetes mellitus with hyperglycemia", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E669: Obesity, unspecified" ]
10,032,409
28,020,206
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine / Advair HFA / Losartan / Levofloxacin / hydrochlorothiazide Attending: ___. Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: Intubation - ___ History of Present Illness: ___ with PMH COPD on 3L home O2, dCHF, CAD, EtOH abuse, and schizoaffective disorder who presented with respiratory failure. Per patient's daughter she was recently discharged from ___ ___ 2 weeks ago after a prolonged 3 week stay. During that time she was treated for a COPD exacerbation and discharged on a prednisone taper, which she finished one week ago. Her family was also told that she may have had a pneumonia, although there was reportedly some disagreement over this diagnosis. ___ reportedly recommended rehab but her family decided to take her home. Since returning home her family has noticed progressive failure to thrive. She was able to walk on her own prior to hospitalization, but since returning has stayed mostly in bed. Her activity has been limited by both dyspnea and weakness. Her family was also concerned that she may have been depressed and was also occasionally confused. At ___ there was a concern for aspiration and she was discharged on thickened liquids. She ran out of these several days ago. Per her family she did not have any witnessed aspiration events. For the past few days her family noticed that her breathing was getting progressively faster and she looked like she was hyperventilating. She appeared diaphoretic but had no known fevers. She has a chronic productive cough but is unable to produce sputum on her own. This has not recently changed. She sleeps on an angled pillow at home which has also not recently changed. Her nebulizers were helping her breathing but relief was not as long as before. Today she was working with physical therapy at home and she was noted to be hypoxic to < 90% on her home 3L. The physical therapist increased her O2 to 4L but she remained hypoxic. At that point her daughters called EMS. EMS found her to be in significant respiratory distress and placed her on CPAP. In the ED she was intubated on arrival for tachypnea in the ___. In the ED, initial vitals: 100.2 50 133/62 18 100% on 100% FiO2 - Exam notable for severe tachypnea in the ___ - Labs were notable for: lactate 2.9, UA with > 1000 glucose but negative ketones, leukocytosis of 20.6, troponin < 0.01, BNP 386. ABG post intubation 7.38 pCO2 52 pO2 180 HCO3 32 (TV 450 RR 18 PEEP 5 FiO2 100%) - Imaging: CXR with asymmetric pulmonary edema, R > L - Patient was given: etomidate/rocuronium induction, fentanyl/midaz sedation, 2g IV cefepime, 1g IV vancomycin, 125mg IV methylprednisolone - Consults: none On arrival to the MICU, she was sedated and noted to be bradycardic in the ___. She was normotensive. Past Medical History: - COPD (3L home O2) - Diabetic type 2 - ETOH abuse - tobacco addication - diabetic retinopathy - CAD - HTN - Elevated cholesteral - schizoaffective d/o - tardive dyskinesia - vertebral compression fx - Left radial fx - hyponatremia - thyroid nodule Social History: ___ Family History: - Family History:Mother: ___, heart disease, hypertension, diabetes, anemia - Sister: ___ cancer - Father: ___, TB, passed away in ___ - Daughter: ___ Physical ___: Admission Exam ================ Vitals: 98.4 48 132/68 23 99% 50% FiO2 PEEP 5 GENERAL: Sedated but arousable, following commands HEENT: NC/AT, sclera anicteric NECK: supple, JVP difficult to assess given body habitus LUNGS: decreased and coarse breath sounds anteriorly CV: Bradycardic, regular rhythm, no murmur/rubs/gallops ABD: soft, non-tender, non-distended, no rebound tenderness or guarding EXT: Warm, well perfused, trace peripheral edema SKIN: no rashes on limited exam NEURO: moving all extremities ACCESS: subclavian Pertinent Results: Admission Labs =============== ___ 05:11PM BLOOD WBC-20.6*# RBC-4.94 Hgb-13.2 Hct-42.6 MCV-86 MCH-26.7 MCHC-31.0* RDW-15.6* RDWSD-48.4* Plt ___ ___ 05:11PM BLOOD Neuts-76.8* Lymphs-12.1* Monos-7.3 Eos-2.3 Baso-0.2 Im ___ AbsNeut-15.81*# AbsLymp-2.50 AbsMono-1.50* AbsEos-0.48 AbsBaso-0.04 ___ 05:11PM BLOOD Plt ___ ___ 01:43AM BLOOD ___ PTT-24.1* ___ ___ 05:11PM BLOOD Glucose-228* UreaN-16 Creat-1.0 Na-139 K-4.4 Cl-97 HCO3-25 AnGap-21* ___ 05:11PM BLOOD ALT-63* AST-69* AlkPhos-133* TotBili-0.2 ___ 05:11PM BLOOD proBNP-386 ___ 05:11PM BLOOD Albumin-3.9 Calcium-10.3 Phos-3.7 Mg-2.2 ___ 05:11PM BLOOD TSH-0.38 ___ 05:45PM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5 FiO2-100 pO2-180* pCO2-52* pH-7.38 calTCO2-32* Base XS-4 AADO2-___ REQ O2-81 Intubat-INTUBATED Vent-CONTROLLED ___ 05:24PM BLOOD Lactate-2.9* Imaging ======== CXR ___ IMPRESSION: 1. Monitoring and support devices are in appropriate position. 2. Pulmonary vascular congestion is asymmetrically worse on the right. CXR ___ Post PICC FINDINGS: Single AP portable upright view the chest provided. There has been placement of a right subclavian central venous catheter with its tip in the mid SVC region. The endotracheal tube is again seen with its tip located 5.3 cm above the carina. The NG tube courses below the left hemidiaphragm, tip excluded from view. Right-sided interstitial opacity again noted which could reflect asymmetric pulmonary edema. The heart is mildly enlarged. No pneumothorax. ___ LENIs FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ CXR IMPRESSION: Compared to chest radiographs since ___, most recently ___ and ___. Moderate cardiomegaly is chronic. Marked disparity in radiodensity lungs could be due to asymmetric distribution of edema in the setting of emphysema, but other explanation should be considered. These include acute airway obstruction in the left lung, or large unilateral pulmonary embolism interrupting circulation to the left lung and prompting mild edema on the right. ET tube and right subclavian line are in standard placements. Esophageal drainage tube passes into the stomach and out of view. ___ CT Chest w/o contrast IMPRESSION: 1. Asymmetric hyperlucency of the left lung compared to the right appears chronic and likely related to a combination of asymmetric pulmonary edema in the right lung and asymmetric emphysema in the left upper lobe. 2. Superimposed bibasilar consolidations concerning for aspiration or aspiration pneumonia. 3. Lipomatous hypertrophy of the intra-atrial septum measuring 2.1 cm is usually asymptomatic but can be associated with arrhythmias. ___ TTE The left atrium is elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, left ventricular function is hyperdynamic and the heart rate is faster. There is less mitral regurgitation. Pulmonary artery pressure is unable to be determined. ___ RUQ u/s w duplex IMPRESSION: 1. Patent hepatic vasculature. 2. Mild pulsatility of the main portal vein waveform suggests underlying heart failure. 3. Otherwise normal abdominal ultrasound. ___ CXR IMPRESSION: There has been interval removal of a right subclavian central venous catheter. A right PICC terminates at the lower SVC. A Dobbhoff tube terminates within the stomach. The heart size remains normal. The hilar and mediastinal contours are unchanged since the prior radiograph obtained at 20:08. There is no pneumothorax or focal consolidation. A small left pleural effusion is unchanged. Brief Hospital Course: ___ with PMH COPD on 3L home O2, dCHF, CAD, EtOH abuse, and schizoaffective disorder who presented with respiratory failure after recent admission at ___ for COPD exacerbation and pneumonia. # Mixed hypoxic/hypercarbic respiratory failure Intubated in the ED for tachypnea in the ___ and mixed hypoxic and hypercarbic respiratory failure. This was felt secondary to COPD exacerbation in the setting of discontinuing prednisone 1 week ago for prior exacerbation. This may have been exacerbated by aspiration pneumonia. CT chest showed asymmetric R pulmonary edema and bibasilar infiltrates. She was treated with a steroid course and initial vanc/cefepime/azithromycin, which was narrowed to ceftriaxone/azithromycin. She also received Lasix IV boluses to assist weaning off ventilator. She was extubated on ___. Transferred to floor on ___. On the floor, she again developed respiratory distress following a likely aspiration event (she was NPO at the time). She continued to have respiratory distress, prompting a goals of care discussion, during which it was felt based, after discussion with her family and HCP, to focus on comfort. She was transitioned to comfort care on ___ and started on a morphine drip with improvement in her respiratory distress and agitation. A scopolamine patch was applied. Time of death was declared at 1230 ___ on ___. # Delirium: Patient had episodes of agitation in ICU worse in evenings. She has schizoaffective disorder at baseline. She improved with Seroquel qhs. She was continued on home tetrabenazine and perphenazine. # SVT: She had episodes of SVT in ICU in setting of holding home metop and diltiazem. This improved once home beta blockade was resumed. # HTN: home amlodipine, metop, and diltiazem held initially in setting of infection. These were gradually re-started. # HLD: continued ASA, pravastatin _____________ She was transitioned to comfort care on ___ and started on a morphine drip with improvement in her respiratory distress and agitation. A scopolamine patch was applied. Time of death was declared at 1230 ___ on ___. Family was notified. Autopsy was declined. Discharge Disposition: Expired Discharge Diagnosis: COPD Aspiration pneumonia Respiratory Arrest Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: ___
[ "J9621", "J690", "N179", "E870", "I471", "E1165", "F0390", "F05", "I5030", "J441", "J9622", "E11319", "Z9981", "I10", "I2510", "F259", "E785", "Z66", "G2401", "T43595A", "Y92230", "R740" ]
Allergies: Penicillins / Enalapril / Ace Inhibitors / Iodine / Codeine / Advair HFA / Losartan / Levofloxacin / hydrochlorothiazide Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: Intubation - [MASKED] History of Present Illness: [MASKED] with PMH COPD on 3L home O2, dCHF, CAD, EtOH abuse, and schizoaffective disorder who presented with respiratory failure. Per patient's daughter she was recently discharged from [MASKED] [MASKED] 2 weeks ago after a prolonged 3 week stay. During that time she was treated for a COPD exacerbation and discharged on a prednisone taper, which she finished one week ago. Her family was also told that she may have had a pneumonia, although there was reportedly some disagreement over this diagnosis. [MASKED] reportedly recommended rehab but her family decided to take her home. Since returning home her family has noticed progressive failure to thrive. She was able to walk on her own prior to hospitalization, but since returning has stayed mostly in bed. Her activity has been limited by both dyspnea and weakness. Her family was also concerned that she may have been depressed and was also occasionally confused. At [MASKED] there was a concern for aspiration and she was discharged on thickened liquids. She ran out of these several days ago. Per her family she did not have any witnessed aspiration events. For the past few days her family noticed that her breathing was getting progressively faster and she looked like she was hyperventilating. She appeared diaphoretic but had no known fevers. She has a chronic productive cough but is unable to produce sputum on her own. This has not recently changed. She sleeps on an angled pillow at home which has also not recently changed. Her nebulizers were helping her breathing but relief was not as long as before. Today she was working with physical therapy at home and she was noted to be hypoxic to < 90% on her home 3L. The physical therapist increased her O2 to 4L but she remained hypoxic. At that point her daughters called EMS. EMS found her to be in significant respiratory distress and placed her on CPAP. In the ED she was intubated on arrival for tachypnea in the [MASKED]. In the ED, initial vitals: 100.2 50 133/62 18 100% on 100% FiO2 - Exam notable for severe tachypnea in the [MASKED] - Labs were notable for: lactate 2.9, UA with > 1000 glucose but negative ketones, leukocytosis of 20.6, troponin < 0.01, BNP 386. ABG post intubation 7.38 pCO2 52 pO2 180 HCO3 32 (TV 450 RR 18 PEEP 5 FiO2 100%) - Imaging: CXR with asymmetric pulmonary edema, R > L - Patient was given: etomidate/rocuronium induction, fentanyl/midaz sedation, 2g IV cefepime, 1g IV vancomycin, 125mg IV methylprednisolone - Consults: none On arrival to the MICU, she was sedated and noted to be bradycardic in the [MASKED]. She was normotensive. Past Medical History: - COPD (3L home O2) - Diabetic type 2 - ETOH abuse - tobacco addication - diabetic retinopathy - CAD - HTN - Elevated cholesteral - schizoaffective d/o - tardive dyskinesia - vertebral compression fx - Left radial fx - hyponatremia - thyroid nodule Social History: [MASKED] Family History: - Family History:Mother: [MASKED], heart disease, hypertension, diabetes, anemia - Sister: [MASKED] cancer - Father: [MASKED], TB, passed away in [MASKED] - Daughter: [MASKED] Physical [MASKED]: Admission Exam ================ Vitals: 98.4 48 132/68 23 99% 50% FiO2 PEEP 5 GENERAL: Sedated but arousable, following commands HEENT: NC/AT, sclera anicteric NECK: supple, JVP difficult to assess given body habitus LUNGS: decreased and coarse breath sounds anteriorly CV: Bradycardic, regular rhythm, no murmur/rubs/gallops ABD: soft, non-tender, non-distended, no rebound tenderness or guarding EXT: Warm, well perfused, trace peripheral edema SKIN: no rashes on limited exam NEURO: moving all extremities ACCESS: subclavian Pertinent Results: Admission Labs =============== [MASKED] 05:11PM BLOOD WBC-20.6*# RBC-4.94 Hgb-13.2 Hct-42.6 MCV-86 MCH-26.7 MCHC-31.0* RDW-15.6* RDWSD-48.4* Plt [MASKED] [MASKED] 05:11PM BLOOD Neuts-76.8* Lymphs-12.1* Monos-7.3 Eos-2.3 Baso-0.2 Im [MASKED] AbsNeut-15.81*# AbsLymp-2.50 AbsMono-1.50* AbsEos-0.48 AbsBaso-0.04 [MASKED] 05:11PM BLOOD Plt [MASKED] [MASKED] 01:43AM BLOOD [MASKED] PTT-24.1* [MASKED] [MASKED] 05:11PM BLOOD Glucose-228* UreaN-16 Creat-1.0 Na-139 K-4.4 Cl-97 HCO3-25 AnGap-21* [MASKED] 05:11PM BLOOD ALT-63* AST-69* AlkPhos-133* TotBili-0.2 [MASKED] 05:11PM BLOOD proBNP-386 [MASKED] 05:11PM BLOOD Albumin-3.9 Calcium-10.3 Phos-3.7 Mg-2.2 [MASKED] 05:11PM BLOOD TSH-0.38 [MASKED] 05:45PM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5 FiO2-100 pO2-180* pCO2-52* pH-7.38 calTCO2-32* Base XS-4 AADO2-[MASKED] REQ O2-81 Intubat-INTUBATED Vent-CONTROLLED [MASKED] 05:24PM BLOOD Lactate-2.9* Imaging ======== CXR [MASKED] IMPRESSION: 1. Monitoring and support devices are in appropriate position. 2. Pulmonary vascular congestion is asymmetrically worse on the right. CXR [MASKED] Post PICC FINDINGS: Single AP portable upright view the chest provided. There has been placement of a right subclavian central venous catheter with its tip in the mid SVC region. The endotracheal tube is again seen with its tip located 5.3 cm above the carina. The NG tube courses below the left hemidiaphragm, tip excluded from view. Right-sided interstitial opacity again noted which could reflect asymmetric pulmonary edema. The heart is mildly enlarged. No pneumothorax. [MASKED] LENIs FINDINGS: There is normal compressibility, flow, and augmentation of the bilateral common femoral, femoral, and popliteal veins. Normal color flow is 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. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. [MASKED] CXR IMPRESSION: Compared to chest radiographs since [MASKED], most recently [MASKED] and [MASKED]. Moderate cardiomegaly is chronic. Marked disparity in radiodensity lungs could be due to asymmetric distribution of edema in the setting of emphysema, but other explanation should be considered. These include acute airway obstruction in the left lung, or large unilateral pulmonary embolism interrupting circulation to the left lung and prompting mild edema on the right. ET tube and right subclavian line are in standard placements. Esophageal drainage tube passes into the stomach and out of view. [MASKED] CT Chest w/o contrast IMPRESSION: 1. Asymmetric hyperlucency of the left lung compared to the right appears chronic and likely related to a combination of asymmetric pulmonary edema in the right lung and asymmetric emphysema in the left upper lobe. 2. Superimposed bibasilar consolidations concerning for aspiration or aspiration pneumonia. 3. Lipomatous hypertrophy of the intra-atrial septum measuring 2.1 cm is usually asymptomatic but can be associated with arrhythmias. [MASKED] TTE The left atrium is elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [MASKED], left ventricular function is hyperdynamic and the heart rate is faster. There is less mitral regurgitation. Pulmonary artery pressure is unable to be determined. [MASKED] RUQ u/s w duplex IMPRESSION: 1. Patent hepatic vasculature. 2. Mild pulsatility of the main portal vein waveform suggests underlying heart failure. 3. Otherwise normal abdominal ultrasound. [MASKED] CXR IMPRESSION: There has been interval removal of a right subclavian central venous catheter. A right PICC terminates at the lower SVC. A Dobbhoff tube terminates within the stomach. The heart size remains normal. The hilar and mediastinal contours are unchanged since the prior radiograph obtained at 20:08. There is no pneumothorax or focal consolidation. A small left pleural effusion is unchanged. Brief Hospital Course: [MASKED] with PMH COPD on 3L home O2, dCHF, CAD, EtOH abuse, and schizoaffective disorder who presented with respiratory failure after recent admission at [MASKED] for COPD exacerbation and pneumonia. # Mixed hypoxic/hypercarbic respiratory failure Intubated in the ED for tachypnea in the [MASKED] and mixed hypoxic and hypercarbic respiratory failure. This was felt secondary to COPD exacerbation in the setting of discontinuing prednisone 1 week ago for prior exacerbation. This may have been exacerbated by aspiration pneumonia. CT chest showed asymmetric R pulmonary edema and bibasilar infiltrates. She was treated with a steroid course and initial vanc/cefepime/azithromycin, which was narrowed to ceftriaxone/azithromycin. She also received Lasix IV boluses to assist weaning off ventilator. She was extubated on [MASKED]. Transferred to floor on [MASKED]. On the floor, she again developed respiratory distress following a likely aspiration event (she was NPO at the time). She continued to have respiratory distress, prompting a goals of care discussion, during which it was felt based, after discussion with her family and HCP, to focus on comfort. She was transitioned to comfort care on [MASKED] and started on a morphine drip with improvement in her respiratory distress and agitation. A scopolamine patch was applied. Time of death was declared at 1230 [MASKED] on [MASKED]. # Delirium: Patient had episodes of agitation in ICU worse in evenings. She has schizoaffective disorder at baseline. She improved with Seroquel qhs. She was continued on home tetrabenazine and perphenazine. # SVT: She had episodes of SVT in ICU in setting of holding home metop and diltiazem. This improved once home beta blockade was resumed. # HTN: home amlodipine, metop, and diltiazem held initially in setting of infection. These were gradually re-started. # HLD: continued ASA, pravastatin [MASKED] She was transitioned to comfort care on [MASKED] and started on a morphine drip with improvement in her respiratory distress and agitation. A scopolamine patch was applied. Time of death was declared at 1230 [MASKED] on [MASKED]. Family was notified. Autopsy was declined. Discharge Disposition: Expired Discharge Diagnosis: COPD Aspiration pneumonia Respiratory Arrest Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: [MASKED]
[]
[ "N179", "E1165", "I10", "I2510", "E785", "Z66", "Y92230" ]
[ "J9621: Acute and chronic respiratory failure with hypoxia", "J690: Pneumonitis due to inhalation of food and vomit", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "I471: Supraventricular tachycardia", "E1165: Type 2 diabetes mellitus with hyperglycemia", "F0390: Unspecified dementia without behavioral disturbance", "F05: Delirium due to known physiological condition", "I5030: Unspecified diastolic (congestive) heart failure", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "J9622: Acute and chronic respiratory failure with hypercapnia", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "Z9981: Dependence on supplemental oxygen", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F259: Schizoaffective disorder, unspecified", "E785: Hyperlipidemia, unspecified", "Z66: Do not resuscitate", "G2401: Drug induced subacute dyskinesia", "T43595A: Adverse effect of other antipsychotics and neuroleptics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]" ]
10,033,085
23,404,293
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R foot Osteomyelitis Major Surgical or Invasive Procedure: ___: R ___ MPJ debridement; abx spacer History of Present Illness: ___ male patient presenting to the ED with concern for a right toe infection. Patient with PMH of DM with history of prior foot infections. He gets his care in ___. He states that he has a 5 week history of a R foot/hallux infection. He had been on IV abx converted to orals and then started on daptomycin/ertapenem by Infectious Disease in ___. He relates that his foot has continued to be erythematous and swollen for the past few weeks despite abx course. He was seen today by his podiatrist and had xrays take which revealed bony destruction. He was then told to present to ___ for further workup and treatment. Denies any recent fevers or chills. No recent nausea, vomiting, chest pain, or SOB. The foot is not painful but he has neuropathy. Past Medical History: DM - does not recall last HgbA1C HTN cataracts - surgery in the past Social History: ___ Family History: n/c Physical Exam: Admission Phyisical Exam: PE: Vitals: 98.1 98 189/108 17 99% RA GEN: NAD, Aox3 RESP: CTA, breathing comfortably on room air CV: RRR ABD: soft, nontender, ___ FOCUSED EXAM: Dp/Pt pulses palpable b/l. crt<3sec to the digits. normal proximal to distal cooling. Edema to the R forefoot and ___ MPJ area. Small ulceration to the plantar aspect of the R hallux which probes deep. Mild erythema surrounding the R ___ MPJ. No pain with palpation. NEURO: CNII-XII intact. light touch sensation diminished to the ___ b/l. Discharge Physical Exam: PE: Vitals: GEN: NAD, Aox3 RESP: CTA, breathing comfortably on room air CV: RRR ABD: soft, nontender, ___ FOCUSED EXAM: crt<3sec to the digits. Dry surgical dressing intact Pertinent Results: ___ 10:10PM BLOOD WBC-7.6 RBC-4.18* Hgb-11.7* Hct-37.5* MCV-90 MCH-28.0 MCHC-31.2* RDW-15.0 RDWSD-48.4* Plt ___ ___ 10:10PM BLOOD Neuts-83* Bands-2 Lymphs-7* Monos-4* Eos-2 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-6.46* AbsLymp-0.53* AbsMono-0.30 AbsEos-0.15 AbsBaso-0.00* ___ 10:10PM BLOOD ___ PTT-34.8 ___ ___ 10:10PM BLOOD Glucose-69* UreaN-19 Creat-1.0 Na-141 K-4.7 Cl-102 HCO3-23 AnGap-16 ___ 07:28AM BLOOD %HbA1c-9.5* eAG-226* ___ 06:34AM BLOOD CRP-11.2* ___ 10:27PM BLOOD Lactate-1.8 ___ 1:45 pm TISSUE PROXIMAL PHALYNIX 5. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 1:38 pm TISSUE IST METATARSAL. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Preliminary): GRAM POSITIVE COCCUS(COCCI). RARE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Brief Hospital Course: The patient was admitted to the podiatric surgery service from the ED on ___ for a R foot infection. On admission, he was started on broad spectrum antibiotics. He was taking to the OR for Right foot debridement on ___. Pt was evaluated by anesthesia and taken to the operating room. There were no adverse events in the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU in stable condition, then transferred to the ward for observation. Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. He was placed on vancomycin, ciprofloxacin, and flagyl while hospitalized and discharged with oral antibiotics. His intake and output were closely monitored and noted to be adequate. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. The patient was subsequently discharged to home on POD3 with IV antibiotics. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 25 mg PO BID 2. MetFORMIN XR (Glucophage XR) 500 mg PO Q8H 3. amLODIPine 10 mg PO DAILY 4. SITagliptin 100 mg oral DAILY 5. Other 34 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Daptomycin 600 mg IV Q24H Duration: 6 Weeks RX *daptomycin 500 mg 600 mg IV q24h Disp #*51 Vial Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Ertapenem Sodium 1 g IV Q24H Duration: 6 Weeks RX *ertapenem [Invanz] 1 gram 1 gram IV q24h Disp #*42 Vial Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet(s) by mouth q4-6h Disp #*20 Tablet Refills:*0 6. Other 34 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Carvedilol 25 mg PO BID 10. MetFORMIN XR (Glucophage XR) 500 mg PO Q8H 11. SITagliptin 100 mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R foot Osteomyelitis 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 at ___. You were admitted to the Podiatric Surgery service after your right foot surgery. You were given IV antibiotics while here. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain non weight bearing to your R foot until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___
[ "E1169", "M86171", "M86671", "Z794", "I10", "Z006" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: R foot Osteomyelitis Major Surgical or Invasive Procedure: [MASKED]: R [MASKED] MPJ debridement; abx spacer History of Present Illness: [MASKED] male patient presenting to the ED with concern for a right toe infection. Patient with PMH of DM with history of prior foot infections. He gets his care in [MASKED]. He states that he has a 5 week history of a R foot/hallux infection. He had been on IV abx converted to orals and then started on daptomycin/ertapenem by Infectious Disease in [MASKED]. He relates that his foot has continued to be erythematous and swollen for the past few weeks despite abx course. He was seen today by his podiatrist and had xrays take which revealed bony destruction. He was then told to present to [MASKED] for further workup and treatment. Denies any recent fevers or chills. No recent nausea, vomiting, chest pain, or SOB. The foot is not painful but he has neuropathy. Past Medical History: DM - does not recall last HgbA1C HTN cataracts - surgery in the past Social History: [MASKED] Family History: n/c Physical Exam: Admission Phyisical Exam: PE: Vitals: 98.1 98 189/108 17 99% RA GEN: NAD, Aox3 RESP: CTA, breathing comfortably on room air CV: RRR ABD: soft, nontender, [MASKED] FOCUSED EXAM: Dp/Pt pulses palpable b/l. crt<3sec to the digits. normal proximal to distal cooling. Edema to the R forefoot and [MASKED] MPJ area. Small ulceration to the plantar aspect of the R hallux which probes deep. Mild erythema surrounding the R [MASKED] MPJ. No pain with palpation. NEURO: CNII-XII intact. light touch sensation diminished to the [MASKED] b/l. Discharge Physical Exam: PE: Vitals: GEN: NAD, Aox3 RESP: CTA, breathing comfortably on room air CV: RRR ABD: soft, nontender, [MASKED] FOCUSED EXAM: crt<3sec to the digits. Dry surgical dressing intact Pertinent Results: [MASKED] 10:10PM BLOOD WBC-7.6 RBC-4.18* Hgb-11.7* Hct-37.5* MCV-90 MCH-28.0 MCHC-31.2* RDW-15.0 RDWSD-48.4* Plt [MASKED] [MASKED] 10:10PM BLOOD Neuts-83* Bands-2 Lymphs-7* Monos-4* Eos-2 Baso-0 [MASKED] Metas-2* Myelos-0 AbsNeut-6.46* AbsLymp-0.53* AbsMono-0.30 AbsEos-0.15 AbsBaso-0.00* [MASKED] 10:10PM BLOOD [MASKED] PTT-34.8 [MASKED] [MASKED] 10:10PM BLOOD Glucose-69* UreaN-19 Creat-1.0 Na-141 K-4.7 Cl-102 HCO3-23 AnGap-16 [MASKED] 07:28AM BLOOD %HbA1c-9.5* eAG-226* [MASKED] 06:34AM BLOOD CRP-11.2* [MASKED] 10:27PM BLOOD Lactate-1.8 [MASKED] 1:45 pm TISSUE PROXIMAL PHALYNIX 5. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [MASKED] 1:38 pm TISSUE IST METATARSAL. GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Preliminary): GRAM POSITIVE COCCUS(COCCI). RARE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Brief Hospital Course: The patient was admitted to the podiatric surgery service from the ED on [MASKED] for a R foot infection. On admission, he was started on broad spectrum antibiotics. He was taking to the OR for Right foot debridement on [MASKED]. Pt was evaluated by anesthesia and taken to the operating room. There were no adverse events in the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU in stable condition, then transferred to the ward for observation. Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. He was placed on vancomycin, ciprofloxacin, and flagyl while hospitalized and discharged with oral antibiotics. His intake and output were closely monitored and noted to be adequate. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. The patient was subsequently discharged to home on POD3 with IV antibiotics. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 25 mg PO BID 2. MetFORMIN XR (Glucophage XR) 500 mg PO Q8H 3. amLODIPine 10 mg PO DAILY 4. SITagliptin 100 mg oral DAILY 5. Other 34 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Daptomycin 600 mg IV Q24H Duration: 6 Weeks RX *daptomycin 500 mg 600 mg IV q24h Disp #*51 Vial Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Ertapenem Sodium 1 g IV Q24H Duration: 6 Weeks RX *ertapenem [Invanz] 1 gram 1 gram IV q24h Disp #*42 Vial Refills:*0 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet(s) by mouth q4-6h Disp #*20 Tablet Refills:*0 6. Other 34 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Carvedilol 25 mg PO BID 10. MetFORMIN XR (Glucophage XR) 500 mg PO Q8H 11. SITagliptin 100 mg oral DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: R foot Osteomyelitis 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 at [MASKED]. You were admitted to the Podiatric Surgery service after your right foot surgery. You were given IV antibiotics while here. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain non weight bearing to your R foot until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next [MASKED] days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are [MASKED] through [MASKED]. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: [MASKED]
[]
[ "Z794", "I10" ]
[ "E1169: Type 2 diabetes mellitus with other specified complication", "M86171: Other acute osteomyelitis, right ankle and foot", "M86671: Other chronic osteomyelitis, right ankle and foot", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]
10,033,290
22,588,582
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: RUE pain/weakness Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ man with afib on apixaban, CHF, and LBBB who presents from clinic for evaluation of left hand pain and right arm pain. History was obtained with help from a ___ in Yesterday, he developed acute onset numbness and pain in his right hand. Started at 2pm when he was on the bus going home after working for a day. Did not do anything out of the ordinary at work, did not lift heavy boxes. Pain (numbness, some tingling with needle-like sensation) was most severe in his right thumb, and it went up his right arm gradually. Felt like his arm was not there, and he would have to use his left hand to move his right arm around. At ___, sensation was returning, and he started being able to move his arm again. He took eliquis at 8pm, then another at 10pm, and another at midnight. He felt like this helped his weakness. He went to work today and noticed that he was unable to do things as quickly with his right hand. He was also having some trouble with fine motor movements such as buttoning his pants. Still has pain in her right thumb and thenar eminence, sometimes his fingertips as well. Pain is worse with certain positions. Of note, he has been taking 2 tablets of eliquis at midnight since ___ started rather than BID. Past Medical History: afib, CHF, LBBB, varicose veins Social History: ___ Family History: mother with CAD, father with liver cancer, brother died of cancer Physical Exam: ADMISSION PHYSICAL EXAMINATION Vitals: T: 96.8F HR: 60 BP: 141/85 RR: 16 SaO2: 98% RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: irregularly irregular Pulmonary: breathing comfortably on RA Abdomen: Soft, NT, ND Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. No dysarthria. Normal prosody. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [Delt] [Bic] [Tri] [ECR] [FEx][IO] [IP] [Quad] [Ham] [TA] [Gas] L 5 5 5 5 5 4+ 5 5 5 5 5 R 5 5 5 5 5 4+ 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 1+ 1+ 1+ 1+ 0 R 1+ 1+ 1+ 1+ 0 Plantar response flexor bilaterally - Sensory: decreased sensation to pin over right thenar eminence, thumb/index/middle/ring fingers, and just below the pinky finger. Dorsum of hand is normal as is the pinky finger. Decreased sensation to LT over similar areas. Intact elsewhere. Increased pain with wrist flexion and extension on the right. - Coordination: No dysmetria with finger to nose testing bilaterally. Able to tap each finger to thumb easily on L hand, more difficult on R hand though pt says this is pain limited. Also slower with rapid alternating movements in R hand. - Gait: deferred DISCHARGE EXAM MS ___, attentive, fluent CN PERRLA, no droop, Motor: ___ throughout, sensory intact to light tough. Able to ambulate with good balance. Reports pain with manipulation of the first carpo-metacarpal joint Pertinent Results: ___ 01:50PM BLOOD WBC-6.8 RBC-4.66 Hgb-14.4 Hct-41.0 MCV-88 MCH-30.9 MCHC-35.1 RDW-12.2 RDWSD-39.2 Plt ___ ___ 07:35PM BLOOD WBC-7.1 RBC-4.67 Hgb-14.4 Hct-41.5 MCV-89 MCH-30.8 MCHC-34.7 RDW-12.2 RDWSD-39.5 Plt ___ ___ 07:35PM BLOOD Neuts-51.1 ___ Monos-8.1 Eos-4.5 Baso-0.3 Im ___ AbsNeut-3.64 AbsLymp-2.54 AbsMono-0.58 AbsEos-0.32 AbsBaso-0.02 ___ 01:50PM BLOOD ___ PTT-33.2 ___ ___ 07:35PM BLOOD ___ PTT-32.9 ___ ___ 01:50PM BLOOD Glucose-126* UreaN-17 Creat-0.8 Na-137 K-4.5 Cl-100 HCO3-26 AnGap-16 ___ 07:35PM BLOOD Glucose-92 UreaN-15 Creat-0.7 Na-139 K-3.9 Cl-102 HCO3-29 AnGap-12 ___ 07:35PM BLOOD ALT-15 AST-16 AlkPhos-51 TotBili-0.7 ___ 01:50PM BLOOD CK-MB-5 cTropnT-<0.01 ___ 07:35PM BLOOD Albumin-4.4 Calcium-9.4 Phos-4.0 Mg-1.9 Cholest-158 ___ 07:35PM BLOOD %HbA1c-6.3* eAG-134* ___ 07:35PM BLOOD Triglyc-95 HDL-39 CHOL/HD-4.1 LDLcalc-100 ___ 07:35PM BLOOD TSH-1.4 HAND (PA,LAT AND OBLIQUE) RIGHT Severe osteoarthritis of the first CMC and triscaphe joint and probable mild degenerative changes of the radio scaphoid joint. Minimal degenerative change involving the DIP joints. No fracture, dislocation, bone erosion, suspicious lytic or sclerotic lesion, soft tissue calcification or radiopaque foreign body identified. IMPRESSION: Osteoarthritis including severe osteoarthritis of the first CMC and triscaphe joints. No fracture or bone erosion. Brief Hospital Course: ___ man with afib on AC (but not taking it correctly at the moment) presents with R hand pain with a report of weakness after sleeping on the arm. He has had weakness of the arm in the past after sleeping on it in a peculiar way. He main complaint that brought him into the hospital is pain in the joints of the hand. Xray confirmed severe arthritis in the first CMC and triscaphe joint. He was prescribed ibuprofen for pain and given a prescription for a wrist splint to stabilize his hand while sleeping. He was also instructed to take his Eliquis BID in order to best prevent future strokes. He should follow up with his PCP in one week. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Furosemide 20 mg PO DAILY:PRN edema 3. Lisinopril 5 mg PO DAILY 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Simvastatin 40 mg PO QPM Discharge Medications: 1. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. Furosemide 20 mg PO DAILY:PRN edema 4. Lisinopril 5 mg PO DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Simvastatin 40 mg PO QPM 7.Hand Splint Please provide splint to the right hand for stabilization during sleep Discharge Disposition: Home Discharge Diagnosis: Hand Arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, You were admitted with symptoms of hand pain. We performed an xray of your hand which showed a fair amount of arthritis but no evidence of fracture or dislocation. We are providing you with a prescription for ibuprofen to help with the pain as well as a hand splint to stabilize the area while you sleep. It was a pleasure taking care of you. ___ Neurology Followup Instructions: ___
[ "M19041", "I110", "I509", "I482", "Z7902", "I447" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: RUE pain/weakness Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] man with afib on apixaban, CHF, and LBBB who presents from clinic for evaluation of left hand pain and right arm pain. History was obtained with help from a [MASKED] in Yesterday, he developed acute onset numbness and pain in his right hand. Started at 2pm when he was on the bus going home after working for a day. Did not do anything out of the ordinary at work, did not lift heavy boxes. Pain (numbness, some tingling with needle-like sensation) was most severe in his right thumb, and it went up his right arm gradually. Felt like his arm was not there, and he would have to use his left hand to move his right arm around. At [MASKED], sensation was returning, and he started being able to move his arm again. He took eliquis at 8pm, then another at 10pm, and another at midnight. He felt like this helped his weakness. He went to work today and noticed that he was unable to do things as quickly with his right hand. He was also having some trouble with fine motor movements such as buttoning his pants. Still has pain in her right thumb and thenar eminence, sometimes his fingertips as well. Pain is worse with certain positions. Of note, he has been taking 2 tablets of eliquis at midnight since [MASKED] started rather than BID. Past Medical History: afib, CHF, LBBB, varicose veins Social History: [MASKED] Family History: mother with CAD, father with liver cancer, brother died of cancer Physical Exam: ADMISSION PHYSICAL EXAMINATION Vitals: T: 96.8F HR: 60 BP: 141/85 RR: 16 SaO2: 98% RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple [MASKED]: irregularly irregular Pulmonary: breathing comfortably on RA Abdomen: Soft, NT, ND Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. No dysarthria. Normal prosody. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength [MASKED] bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [Delt] [Bic] [Tri] [ECR] [FEx][IO] [IP] [Quad] [Ham] [TA] [Gas] L 5 5 5 5 5 4+ 5 5 5 5 5 R 5 5 5 5 5 4+ 5 5 5 5 5 - Reflexes: [Bic] [Tri] [[MASKED]] [Quad] [Gastroc] L 1+ 1+ 1+ 1+ 0 R 1+ 1+ 1+ 1+ 0 Plantar response flexor bilaterally - Sensory: decreased sensation to pin over right thenar eminence, thumb/index/middle/ring fingers, and just below the pinky finger. Dorsum of hand is normal as is the pinky finger. Decreased sensation to LT over similar areas. Intact elsewhere. Increased pain with wrist flexion and extension on the right. - Coordination: No dysmetria with finger to nose testing bilaterally. Able to tap each finger to thumb easily on L hand, more difficult on R hand though pt says this is pain limited. Also slower with rapid alternating movements in R hand. - Gait: deferred DISCHARGE EXAM MS [MASKED], attentive, fluent CN PERRLA, no droop, Motor: [MASKED] throughout, sensory intact to light tough. Able to ambulate with good balance. Reports pain with manipulation of the first carpo-metacarpal joint Pertinent Results: [MASKED] 01:50PM BLOOD WBC-6.8 RBC-4.66 Hgb-14.4 Hct-41.0 MCV-88 MCH-30.9 MCHC-35.1 RDW-12.2 RDWSD-39.2 Plt [MASKED] [MASKED] 07:35PM BLOOD WBC-7.1 RBC-4.67 Hgb-14.4 Hct-41.5 MCV-89 MCH-30.8 MCHC-34.7 RDW-12.2 RDWSD-39.5 Plt [MASKED] [MASKED] 07:35PM BLOOD Neuts-51.1 [MASKED] Monos-8.1 Eos-4.5 Baso-0.3 Im [MASKED] AbsNeut-3.64 AbsLymp-2.54 AbsMono-0.58 AbsEos-0.32 AbsBaso-0.02 [MASKED] 01:50PM BLOOD [MASKED] PTT-33.2 [MASKED] [MASKED] 07:35PM BLOOD [MASKED] PTT-32.9 [MASKED] [MASKED] 01:50PM BLOOD Glucose-126* UreaN-17 Creat-0.8 Na-137 K-4.5 Cl-100 HCO3-26 AnGap-16 [MASKED] 07:35PM BLOOD Glucose-92 UreaN-15 Creat-0.7 Na-139 K-3.9 Cl-102 HCO3-29 AnGap-12 [MASKED] 07:35PM BLOOD ALT-15 AST-16 AlkPhos-51 TotBili-0.7 [MASKED] 01:50PM BLOOD CK-MB-5 cTropnT-<0.01 [MASKED] 07:35PM BLOOD Albumin-4.4 Calcium-9.4 Phos-4.0 Mg-1.9 Cholest-158 [MASKED] 07:35PM BLOOD %HbA1c-6.3* eAG-134* [MASKED] 07:35PM BLOOD Triglyc-95 HDL-39 CHOL/HD-4.1 LDLcalc-100 [MASKED] 07:35PM BLOOD TSH-1.4 HAND (PA,LAT AND OBLIQUE) RIGHT Severe osteoarthritis of the first CMC and triscaphe joint and probable mild degenerative changes of the radio scaphoid joint. Minimal degenerative change involving the DIP joints. No fracture, dislocation, bone erosion, suspicious lytic or sclerotic lesion, soft tissue calcification or radiopaque foreign body identified. IMPRESSION: Osteoarthritis including severe osteoarthritis of the first CMC and triscaphe joints. No fracture or bone erosion. Brief Hospital Course: [MASKED] man with afib on AC (but not taking it correctly at the moment) presents with R hand pain with a report of weakness after sleeping on the arm. He has had weakness of the arm in the past after sleeping on it in a peculiar way. He main complaint that brought him into the hospital is pain in the joints of the hand. Xray confirmed severe arthritis in the first CMC and triscaphe joint. He was prescribed ibuprofen for pain and given a prescription for a wrist splint to stabilize his hand while sleeping. He was also instructed to take his Eliquis BID in order to best prevent future strokes. He should follow up with his PCP in one week. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Furosemide 20 mg PO DAILY:PRN edema 3. Lisinopril 5 mg PO DAILY 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Simvastatin 40 mg PO QPM Discharge Medications: 1. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. Furosemide 20 mg PO DAILY:PRN edema 4. Lisinopril 5 mg PO DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Simvastatin 40 mg PO QPM 7.Hand Splint Please provide splint to the right hand for stabilization during sleep Discharge Disposition: Home Discharge Diagnosis: Hand Arthritis 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 with symptoms of hand pain. We performed an xray of your hand which showed a fair amount of arthritis but no evidence of fracture or dislocation. We are providing you with a prescription for ibuprofen to help with the pain as well as a hand splint to stabilize the area while you sleep. It was a pleasure taking care of you. [MASKED] Neurology Followup Instructions: [MASKED]
[]
[ "I110", "Z7902" ]
[ "M19041: Primary osteoarthritis, right hand", "I110: Hypertensive heart disease with heart failure", "I509: Heart failure, unspecified", "I482: Chronic atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I447: Left bundle-branch block, unspecified" ]
10,033,290
27,373,164
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: Cardiac Catheterization, ___: No angiographically apparent CAD. Elevated filling pressures CRT-D placement, ___ attach Pertinent Results: ADMISSION LABS: =============== ___ 10:10AM BLOOD WBC-5.9 RBC-4.96 Hgb-15.0 Hct-44.9 MCV-91 MCH-30.2 MCHC-33.4 RDW-12.5 RDWSD-40.5 Plt ___ ___ 10:10AM BLOOD Neuts-61.4 ___ Monos-7.6 Eos-2.2 Baso-0.2 Im ___ AbsNeut-3.62 AbsLymp-1.67 AbsMono-0.45 AbsEos-0.13 AbsBaso-0.01 ___ 06:22AM BLOOD ___ PTT-45.0* ___ ___ 10:10AM BLOOD Glucose-138* UreaN-14 Creat-0.6 Na-140 K-4.8 Cl-102 HCO3-27 AnGap-11 ___ 10:10AM BLOOD proBNP-618* ___ 10:10AM BLOOD cTropnT-0.02* ___ 03:00PM BLOOD cTropnT-0.01 ___ 06:22AM BLOOD Calcium-9.3 Phos-4.6* Mg-1.9 PERTINENT LABS: =============== ___ 07:20AM BLOOD calTIBC-355 Ferritn-317 TRF-273 ___ 07:20AM BLOOD TSH-1.6 ___ 05:00PM BLOOD ANGIOTENSIN 1 - CONVERTING ___ MICROBIOLOGY: ============= ___ 05:00PM BLOOD HIV Ab-NEG IMAGING: ======== CXR, ___: Limited study due to low lung volumes. Moderate cardiac enlargement. Otherwise unremarkable. Prominent hilar contours are unchanged. TTE, ___: LVEF 30%. Dilated, dyssynchronous left ventricle Coronary angiography, ___: The left main, left anterior descending, circumflex and right coronary artery have no angiographically significant coronary abnormalities.The coronary circulation is left dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel.The Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The Atrioventricular Circumflex, arising from the mid segment, is a medium caliber vessel. The Left Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a small caliber vessel. CXR, ___: There is stable elevation of the right hemidiaphragm with subsegmental atelectasis in the right lung base. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. No evidence of pneumonia. There is stable elevation of the right hemidiaphragm with interposition of colon between the anterior abdominal wall and the liver. Left-sided pacemaker is unchanged. There is stable subsegmental atelectasis in the right lung base. DISCHARGE LABS: =============== ___ 06:42AM BLOOD WBC-9.3 RBC-4.88 Hgb-14.8 Hct-43.1 MCV-88 MCH-30.3 MCHC-34.3 RDW-12.1 RDWSD-39.1 Plt ___ ___ 06:42AM BLOOD Glucose-126* UreaN-23* Creat-0.9 Na-137 K-4.3 Cl-94* HCO3-28 AnGap-15 ___ 06:42AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1 Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [] Follow up with device clinic ___ [] Obtain repeat Chem7 on ___ to assess electrolytes on new diuretic regimen. ___ require adjustments in torsemide dose (discharged on 40mg daily). [] Follow up serum ACE for non-ischemic dilated cardiomyopathy work up DISCHARGE WEIGHT: 264lbs DISCHARGE Cr: 0.9 # CODE STATUS: Full, confirmed # CONTACT ___ (Wife) ___ BRIEF HOSPITAL SUMMARY: ======================= ___ year old male with a past medical history significant for HFpEF, atrial fibrillation(on apixaban), and HTN who presented with exertional chest pain and SOB only partially relieved with rest concerning for unstable angina. On admission, troponins peaked at a mild elevation of 0.02. EKG was without any ischemic changes. Patient was initially on a nitro gtt which was discontinued upon resolution of CP. Patient underwent coronary angiography on ___ which revealed no apparent CAD but did reveal elevated filling pressures. TTE on this admission revealed newly reduced EF of 30% with a dilated and dyssynchronous LV. Patient underwent inpatient CRT-D placement ___. He was further diuresed with IV Lasix boluses before transitioning to torsemide 40mg daily. Course complicated by short <6sec episodes of NSVT for which he was uptitrated on his nodal blocker, but continues to have intermittent palpitations upon discharge. CORONARIES: No obstructive CAD (___) PUMP: LVEF 30% (___) RHYTHM: AF =============== ACTIVE ISSUES: =============== # UA/NSTEMI Patient initially presented after experiencing L anterior chest pressure/discomfort that was provoked by exertion and only partially relieved with rest. Patient states that over the past several months he has had similar pains, although less severe. He notes they only occur with physical exertion or with emotion duress. Associated with this pain he found himself SOB and diaphoretic. On admission, he was noted to have a mild troponin elevation which peaked at 0.02. EKG was without ischemic changes. Patient was managed on a heparin gtt as well as daily aspirin and statin for concern for ACS. Patient was initially on a beta blocker; however, on ___ this was held as patient was notably bradycardic overnight to ___, albeit while asleep and otherwise asymptomatic. Patient underwent coronary angiography on ___ which revealed no apparent CAD, but elevated filling pressures. # HFpEF --> HFrEF Patient with a history of non-ischemic cardiomyopathy and associated HFpEF of unclear etiology (suspected HTN heart disease). Throughout admission, patient appeared euvolemic and not otherwise decompensated. He exhibited some mild trace ___ edema over the RLE, but he notes this is chronic and related to venous insufficiency. Patient did not have an elevated BNP on admission. On ___, patient underwent repeat TTE as he had none prior since ___. Repeat TTE revealed newly reduced LVEF of 30% as well as dilated LV and underlying dssynchrony. EP was consulted, and patient underwent CRT-D placement. Workup for non-ischemic cardiomyopathy including TSH, HIV, and Iron panel. ACE level pending as above. Patient was subsequently actively diuresed with IV boluses of Lasix before transitioning to torsemide 40mg daily. ___ CRT-D placement on ___, patient was started back on metoprolol, titrated to 150mg daily. He is unable to life heavy objects for 6 weeks in setting of CRT-D (through ___. Will write work note to excuse from heavy duties at discharge. # Atrial Fibrillation Patient on metoprolol and apixaban at home. Apixaban was held initially during his hospitalization while on heparin gtt as above. His apixaban was restarted following cath. His metoprolol was initially held secondary to significant, albeit asymptomatic, bradycardia to ___ while asleep. ___ CRT-D placement, metoprolol was restarted and increased as above to attempt to address intermittent NSVT. CHRONIC ISSUES: ================ # OSA: Continued home CPAP. # HTN: Continued his home lisinopril. Metoprolol was held for reasons stated above and was continued upon discharge. >30 minutes spent at patient's bedside/coordination of care/discharge planning. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Lisinopril 10 mg PO DAILY 3. Metoprolol Succinate XL 12.5 mg PO DAILY 4. Simvastatin 40 mg PO QPM Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Metoprolol Succinate XL 150 mg PO DAILY 3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain 4. Torsemide 40 mg PO DAILY 5. Apixaban 5 mg PO BID 6. Lisinopril 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================== Atypical chest pain HFrEF, non-ischemic dilated cardiomyopathy ___ CRT-D SECONDARY DIAGNOSES: ==================== Atrial fibrillation OSA HTN Non-sustained ventricular tachycardia 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 ___ at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - ___ were admitted because ___ had chest pain and shortness of breath WHAT HAPPENED IN THE HOSPITAL? ============================== - ___ received medications which helped your chest pain - ___ underwent cardiac catheterization, a procedure that allowed us to visualize the arteries of your heart. This procedure revealed no blockages in your heart, but did show the pressures in your heart were high. - ___ were treated with diuretic medications to lower the pressure in your heart - ___ received ___ CRT-D, a pace making device that may help your heart function better WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. - Your weight at discharge is 264lbs. Please weigh yourself today at home and use this as your new baseline - Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs. Thank ___ for allowing us to be involved in your care, we wish ___ all the best! Your ___ Healthcare Team Followup Instructions: ___
[ "I110", "I4821", "I472", "Z7902", "I420", "I5042", "G4733", "I872", "Z8249", "I2720", "E669", "Z6834", "I447" ]
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: Cardiac Catheterization, [MASKED]: No angiographically apparent CAD. Elevated filling pressures CRT-D placement, [MASKED] attach Pertinent Results: ADMISSION LABS: =============== [MASKED] 10:10AM BLOOD WBC-5.9 RBC-4.96 Hgb-15.0 Hct-44.9 MCV-91 MCH-30.2 MCHC-33.4 RDW-12.5 RDWSD-40.5 Plt [MASKED] [MASKED] 10:10AM BLOOD Neuts-61.4 [MASKED] Monos-7.6 Eos-2.2 Baso-0.2 Im [MASKED] AbsNeut-3.62 AbsLymp-1.67 AbsMono-0.45 AbsEos-0.13 AbsBaso-0.01 [MASKED] 06:22AM BLOOD [MASKED] PTT-45.0* [MASKED] [MASKED] 10:10AM BLOOD Glucose-138* UreaN-14 Creat-0.6 Na-140 K-4.8 Cl-102 HCO3-27 AnGap-11 [MASKED] 10:10AM BLOOD proBNP-618* [MASKED] 10:10AM BLOOD cTropnT-0.02* [MASKED] 03:00PM BLOOD cTropnT-0.01 [MASKED] 06:22AM BLOOD Calcium-9.3 Phos-4.6* Mg-1.9 PERTINENT LABS: =============== [MASKED] 07:20AM BLOOD calTIBC-355 Ferritn-317 TRF-273 [MASKED] 07:20AM BLOOD TSH-1.6 [MASKED] 05:00PM BLOOD ANGIOTENSIN 1 - CONVERTING [MASKED] MICROBIOLOGY: ============= [MASKED] 05:00PM BLOOD HIV Ab-NEG IMAGING: ======== CXR, [MASKED]: Limited study due to low lung volumes. Moderate cardiac enlargement. Otherwise unremarkable. Prominent hilar contours are unchanged. TTE, [MASKED]: LVEF 30%. Dilated, dyssynchronous left ventricle Coronary angiography, [MASKED]: The left main, left anterior descending, circumflex and right coronary artery have no angiographically significant coronary abnormalities.The coronary circulation is left dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel.The Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The Atrioventricular Circumflex, arising from the mid segment, is a medium caliber vessel. The Left Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a small caliber vessel. CXR, [MASKED]: There is stable elevation of the right hemidiaphragm with subsegmental atelectasis in the right lung base. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. No evidence of pneumonia. There is stable elevation of the right hemidiaphragm with interposition of colon between the anterior abdominal wall and the liver. Left-sided pacemaker is unchanged. There is stable subsegmental atelectasis in the right lung base. DISCHARGE LABS: =============== [MASKED] 06:42AM BLOOD WBC-9.3 RBC-4.88 Hgb-14.8 Hct-43.1 MCV-88 MCH-30.3 MCHC-34.3 RDW-12.1 RDWSD-39.1 Plt [MASKED] [MASKED] 06:42AM BLOOD Glucose-126* UreaN-23* Creat-0.9 Na-137 K-4.3 Cl-94* HCO3-28 AnGap-15 [MASKED] 06:42AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1 Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [] Follow up with device clinic [MASKED] [] Obtain repeat Chem7 on [MASKED] to assess electrolytes on new diuretic regimen. [MASKED] require adjustments in torsemide dose (discharged on 40mg daily). [] Follow up serum ACE for non-ischemic dilated cardiomyopathy work up DISCHARGE WEIGHT: 264lbs DISCHARGE Cr: 0.9 # CODE STATUS: Full, confirmed # CONTACT [MASKED] (Wife) [MASKED] BRIEF HOSPITAL SUMMARY: ======================= [MASKED] year old male with a past medical history significant for HFpEF, atrial fibrillation(on apixaban), and HTN who presented with exertional chest pain and SOB only partially relieved with rest concerning for unstable angina. On admission, troponins peaked at a mild elevation of 0.02. EKG was without any ischemic changes. Patient was initially on a nitro gtt which was discontinued upon resolution of CP. Patient underwent coronary angiography on [MASKED] which revealed no apparent CAD but did reveal elevated filling pressures. TTE on this admission revealed newly reduced EF of 30% with a dilated and dyssynchronous LV. Patient underwent inpatient CRT-D placement [MASKED]. He was further diuresed with IV Lasix boluses before transitioning to torsemide 40mg daily. Course complicated by short <6sec episodes of NSVT for which he was uptitrated on his nodal blocker, but continues to have intermittent palpitations upon discharge. CORONARIES: No obstructive CAD ([MASKED]) PUMP: LVEF 30% ([MASKED]) RHYTHM: AF =============== ACTIVE ISSUES: =============== # UA/NSTEMI Patient initially presented after experiencing L anterior chest pressure/discomfort that was provoked by exertion and only partially relieved with rest. Patient states that over the past several months he has had similar pains, although less severe. He notes they only occur with physical exertion or with emotion duress. Associated with this pain he found himself SOB and diaphoretic. On admission, he was noted to have a mild troponin elevation which peaked at 0.02. EKG was without ischemic changes. Patient was managed on a heparin gtt as well as daily aspirin and statin for concern for ACS. Patient was initially on a beta blocker; however, on [MASKED] this was held as patient was notably bradycardic overnight to [MASKED], albeit while asleep and otherwise asymptomatic. Patient underwent coronary angiography on [MASKED] which revealed no apparent CAD, but elevated filling pressures. # HFpEF --> HFrEF Patient with a history of non-ischemic cardiomyopathy and associated HFpEF of unclear etiology (suspected HTN heart disease). Throughout admission, patient appeared euvolemic and not otherwise decompensated. He exhibited some mild trace [MASKED] edema over the RLE, but he notes this is chronic and related to venous insufficiency. Patient did not have an elevated BNP on admission. On [MASKED], patient underwent repeat TTE as he had none prior since [MASKED]. Repeat TTE revealed newly reduced LVEF of 30% as well as dilated LV and underlying dssynchrony. EP was consulted, and patient underwent CRT-D placement. Workup for non-ischemic cardiomyopathy including TSH, HIV, and Iron panel. ACE level pending as above. Patient was subsequently actively diuresed with IV boluses of Lasix before transitioning to torsemide 40mg daily. [MASKED] CRT-D placement on [MASKED], patient was started back on metoprolol, titrated to 150mg daily. He is unable to life heavy objects for 6 weeks in setting of CRT-D (through [MASKED]. Will write work note to excuse from heavy duties at discharge. # Atrial Fibrillation Patient on metoprolol and apixaban at home. Apixaban was held initially during his hospitalization while on heparin gtt as above. His apixaban was restarted following cath. His metoprolol was initially held secondary to significant, albeit asymptomatic, bradycardia to [MASKED] while asleep. [MASKED] CRT-D placement, metoprolol was restarted and increased as above to attempt to address intermittent NSVT. CHRONIC ISSUES: ================ # OSA: Continued home CPAP. # HTN: Continued his home lisinopril. Metoprolol was held for reasons stated above and was continued upon discharge. >30 minutes spent at patient's bedside/coordination of care/discharge planning. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Lisinopril 10 mg PO DAILY 3. Metoprolol Succinate XL 12.5 mg PO DAILY 4. Simvastatin 40 mg PO QPM Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Metoprolol Succinate XL 150 mg PO DAILY 3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain 4. Torsemide 40 mg PO DAILY 5. Apixaban 5 mg PO BID 6. Lisinopril 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================== Atypical chest pain HFrEF, non-ischemic dilated cardiomyopathy [MASKED] CRT-D SECONDARY DIAGNOSES: ==================== Atrial fibrillation OSA HTN Non-sustained ventricular tachycardia 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 [MASKED] at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - [MASKED] were admitted because [MASKED] had chest pain and shortness of breath WHAT HAPPENED IN THE HOSPITAL? ============================== - [MASKED] received medications which helped your chest pain - [MASKED] underwent cardiac catheterization, a procedure that allowed us to visualize the arteries of your heart. This procedure revealed no blockages in your heart, but did show the pressures in your heart were high. - [MASKED] were treated with diuretic medications to lower the pressure in your heart - [MASKED] received [MASKED] CRT-D, a pace making device that may help your heart function better WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. - Your weight at discharge is 264lbs. Please weigh yourself today at home and use this as your new baseline - Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs. Thank [MASKED] for allowing us to be involved in your care, we wish [MASKED] all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
[]
[ "I110", "Z7902", "G4733", "E669" ]
[ "I110: Hypertensive heart disease with heart failure", "I4821: Permanent atrial fibrillation", "I472: Ventricular tachycardia", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I420: Dilated cardiomyopathy", "I5042: Chronic combined systolic (congestive) and diastolic (congestive) heart failure", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I872: Venous insufficiency (chronic) (peripheral)", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "I2720: Pulmonary hypertension, unspecified", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "I447: Left bundle-branch block, unspecified" ]
10,033,409
21,370,169
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___. Chief Complaint: Cough, fever, lethargy Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o woman with history of uncontrolled type 2 DM complicated by small vessel CVA ___, vascular dementia, recent L5 nerve root injection, and frequent UTI presenting with several days of cough and fever to 101. Patient's family, who she lives with, have noticed that patient has had progressive cough and general weakness over the last several days. They state that she is usually able to eat meals and walk to the bathroom independently, but that she was unable to do so yesterday and has just generally been weaker and slower in movement. She endorses mild shortness of breath, but denies any chest pain, headaches, lightheadedness, fainting, abdominal pain, changes in bowel movement or urination. She has recently had multiple sick contacts at home with runny nose and cough. In the ED: - Initial vital signs were notable for: T99.5, HR92, BP118/54, RR18, 97% RA - Exam notable for: coarse crackles on the right side - Labs were notable for: WBC: 9.2-->6.7 Hgb: 12.6--> 11.2 Plt: 175-->144 141|110| 14 AGap=8 -------------<152 3.9| 23|0.8 Lactate:2.2-->1.5-->1.2 VBG: 7.48/30--> 7.39/43 FluAPCR: Negative FluBPCR: Negative UA: notable for 100 protein, 100 glucose, no nitrites, ketones or leuks - Studies performed include: NCHCT: 1. No intracranial hemorrhage. 2. New hypodensities in the right thalamus and internal capsule are age indeterminate and subacute infarction not excluded. MRI could be performed for further assessment. 3. Stable chronic lacunar infarcts in the left basal ganglia and internal capsule. CXR: Heart size is mildly enlarged, unchanged. The mediastinal and hilar contours are similar to prior. The pulmonary vasculature is not engorged. Lung volumes are low with minimal patchy opacities at the lung bases. No focal consolidation, pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Low lung volumes with patchy opacities at the lung bases likely reflective of atelectasis. Infection, however, is difficult to exclude in the appropriate clinical context. - Patient was given: ___ ___ 22:43IVCefTRIAXone ___ 00:37IVAzithromycin 500mg ___ 01:02IVFNS 1000 mL ___ 02:09SCInsulin 10 Units ___ 06:52IVAcetaminophen IV 1000 mg ___ 08:30PO/NGCarbidopa-Levodopa (___) 1 TAB ___ 08:30PO/NGLevothyroxine Sodium 125 mcg - Consults: none Vitals on transfer: T98.6, HR76, BP123/60, RR20, 94% RA Upon arrival to the floor, patient states that she presented to the hospital yesterday due to difficulty walking, and her daughter ___ describes that she is normally able to ambulate independently with a walker. She endorses a cough over the last several days, which her daughter states is productive and has been worsening today. She denies headache, chills, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, dizziness, or pain with urination. She is intermittently somnolent. Patient has received an influenza vaccine and pneumonia vaccine this year. Patient's last hospitalization was ___ years ago for neurological symptoms of memory, speech, and gait difficulty. Collateral from daughter ___: Patient had a cough 2 weeks ago, which improved and was nearly resolved. However, two nights ago (___) patient began to have a wet cough (though without sputum) and began to make crying noises throughout the night. Yesterday (___), the patient began to have trouble walking. She normally ambulates with a walker independently, but yesterday she was unable to do so and was dragging her right leg. Her daughter took her temperature, which showed a fever of 101. Patient was also unable to eat independently yesterday as well, which is different from her baseline. She had chills and shortness of breath yesterday, but did not have headache, dizziness, lightheadedness, diarrhea, changes in sensation, or burning with urination. Past Medical History: - Vascular dementia without behavioral disturbance ___ - Vascular parkinsonism - Stroke, small vessel ___ (diffuse periventricular white matter disease. There was also a subacute, hemorrhagic infarct in the left lobe of the globus palates and the genu of the internal capsule) - Lumbar radiculitis - DM (diabetes mellitus), type 2, uncontrolled w/neurologic complication (CVA, retinopathy) - Mild nonproliferative diabetic retinopathy ___ - Nephrotic syndrome ___ - CKD stage G2/A3, GFR ___ and albumin creatinine ratio >300 mg/g ___ - Minimal change disease ___ - Hypothyroidism ___ - Hypertension, essential ___ - Hypercholesterolemia ___ - Depressed affect - Thrombophlebitis/phlebitis of deep veins - Gout - PVD (posterior vitreous detachment) Social History: ___ ___ History: Mother had DM2, lived to ___ No family hx of dementia Physical Exam: =========================== ADMISSION PHYSICAL EXAM: ============================ VITALS: ___ 1344 Temp: 98.4 PO BP: 115/72 HR: 70 RR: 18 O2 sat: 96% O2 delivery: Ra GENERAL: Somnolent In no acute distress. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Crackles in the base of the right lung. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowel sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout upper extremities, ___ left lower extremity. ___ strength in right lower extremity. Normal sensation. Gait deferred. States initially that she is in ___'s ___; unable to name the year. Mild bradykinesia, mild cogwheeling =========================== DISCHARGE PHYSICAL EXAM =========================== ___ ___ Temp: 97.5 PO BP: 147/83 R Lying HR: 71 RR: 16 O2 sat: 97% O2 delivery: Ra GENERAL: Lying in bed, covered in many blankets, drowsy CARDIAC: Regular rate and rhythm; II/VI systolic crescendo-decrescendo murmur at the right upper sternal border LUNG: breathing comfortably on room air; bibasilar crackles ABD: Abdomen soft, nontender, nondistended EXT: Warm, well perfused, no lower extremity edema NEURO: Awake, is able to state her name, location but not the date. She follows commands (squeezes hands, lifts legs). Overall mental status appears improved from yesterday. Pertinent Results: ==================== ADMISSION LABS ==================== ___ 08:26PM BLOOD WBC-9.2 RBC-3.94 Hgb-12.6 Hct-37.2 MCV-94 MCH-32.0 MCHC-33.9 RDW-11.9 RDWSD-41.1 Plt ___ ___ 08:26PM BLOOD Neuts-73.7* Lymphs-13.8* Monos-10.5 Eos-0.9* Baso-0.7 Im ___ AbsNeut-6.75* AbsLymp-1.26 AbsMono-0.96* AbsEos-0.08 AbsBaso-0.06 ___ 08:26PM BLOOD Plt ___ ___ 08:26PM BLOOD Glucose-421* UreaN-19 Creat-1.0 Na-131* K-6.1* Cl-100 HCO3-18* AnGap-13 ___ 08:31PM BLOOD pO2-162* pCO2-30* pH-7.48* calTCO2-23 Base XS-0 ___ 10:39PM BLOOD pO2-30* pCO2-43 pH-7.39 calTCO2-27 Base XS-0 ___ 08:31PM BLOOD Glucose-413* Lactate-2.2* K-5.4* ___ 06:11AM URINE Color-Straw Appear-Hazy* Sp ___ ___ 06:11AM URINE Blood-NEG Nitrite-NEG Protein-100* Glucose-100* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 06:11AM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 ==================== DISCHARGE LABS ==================== ___ 05:47AM BLOOD WBC-4.7 RBC-3.95 Hgb-12.5 Hct-37.8 MCV-96 MCH-31.6 MCHC-33.1 RDW-12.0 RDWSD-42.3 Plt ___ ___ 05:47AM BLOOD Plt ___ ___ 05:47AM BLOOD Glucose-164* UreaN-15 Creat-0.7 Na-143 K-4.2 Cl-110* HCO3-24 AnGap-9* ___ 05:47AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9 ___ 07:00AM BLOOD %HbA1c-8.7* eAG-203* ============ MICRO ============ ___ 6:11 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 9:50 pm URINE Source: ___. Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). =============== IMAGING/REPORTS =============== CXR ___ IMPRESSION: Low lung volumes with patchy opacities at the lung bases likely reflective of atelectasis. Infection, however, is difficult to exclude in the appropriate clinical context. NON-CON HEAD CT ___ IMPRESSION: 1. Study is degraded by motion. 2. No evidence of acute intracranial hemorrhage. 3. Age indeterminate right thalamus and internal capsule lesions as described, not definitely seen on most recent prior imaging of ___. While findings may represent microangiopathic changes, subacute infarction is not excluded on the basis examination. Please note MRI of the brain is more sensitive for the detection of acute infarct. 4. Stable chronic lacunar infarcts in the left basal ganglia and internal capsule. 5. Atrophy, probable small vessel ischemic changes, and atherosclerotic vascular disease as described. MRI BRAIN WITHOUT CONTRAST ___ IMPRESSION: 1. The study significantly degraded by patient motion. Allowing for this limitation there is no evidence large intracranial hemorrhage, obvious infarction or intracranial mass. 2. Nonspecific confluent white matter changes in the cerebral hemispheres bilaterally, likely sequela of chronic small vessel ischemic changes. 3. Old lacunar infarcts in the left basal ganglia region. CXR ___ IMPRESSION: Patchy opacities in the left lower lobe could reflect atelectasis, aspiration or pneumonia. NON-CON HEAD CT ___ IMPRESSION: No acute intracranial process. CHEST CTA ___ IMPRESSION: No evidence of pulmonary embolism or acute aortic abnormality. Circumflex aorta noted resulting in vascular sling which potentially could be contributing to patient's aspiration. Left greater than right lower lobe airspace disease compatible with pneumonia may be secondary to aspiration given the fluid seen within the proximal esophagus. Mildly prominent hilar lymph nodes which are likely reactive. Brief Hospital Course: ___ y/o woman with history of uncontrolled type 2 DM complicated by small vessel CVA ___, vascular dementia, recent L5 nerve root injection, and frequent UTIs presented with several days of cough, fever to 101, found to have pneumonia on CXR. Course was complicated by increased somnolence likely secondary to infection and concerns about new R sided leg weakness but stable MRI and clinical improvement in strength by discharge. ACUTE ISSUES: ============= # Aspiration pneumonia Patient's symptoms, crackles in the right lung base, and CXR demonstrative of patchy opacities in the lung bases c/f pneumonia. Empiric treatment for community-acquired pneumonia with ceftriaxone and azithromycin was initiated without significant improvement. Despite CAP therapy, patient continued to have mildly elevated temperatures (Tmax 100.3), concerning for inadequate source control. Patient did not demonstrate any symptoms and signs of other infections such as UTI (negative UA + UCx), skin (clean skin around PIVs, no new rashes) or CNS infection (no headache, blurry vision, no evidence of inflammation on MRI). Aspiration pneumonia was a possible cause of the patient's lack of improvement given patient's hx of stroke, dysarthria, recent difficulty with feeding herself independently, and aspiration risk determined by speech therapy. Flagyl was added for coverage of anaerobic organisms in aspiration pneumonia. Patient triggered due to tachypnea overnight ___ for likely aspiration event. PE was ruled out. Antibiotics were switched to augmentin on ___ in order to consolidate multiple antibiotics. She will complete Augmentin on ___ for a 7 day course for aspiration pneumonia. On the day of discharge, she was evaluated again by speech and swallow and was recommended to stay on a pureed diet and have further evaluation in rehab. #Somnolence Patient has waxing and waning alertness and is somnolent. Head CT and MRI negative for acute bleed or stroke. VBG without evidence of CO2 retention. Labs without significant electrolyte abnormalities. Her mental status improved as her infection was treated, however, she still remained intermittently confused. This appears to be consistent with her baseline, per family. #Gait instability #New findings on ___ Acute onset of gait instability on ___ different from her baseline. Patient has a significant history of vascular dementia with multiple prior infarcts. ___ demonstrated hypodensities in the right thalamus and internal capsule concerning for subacute infarcts, however MRI did not show any new lesions. Patient's gait instability may be re-crudescence of neurological symptoms from prior strokes in the acute setting of infection. CHRONIC ISSUES: =============== #Vascular dementia #Parkinsonism Patient sees outpatient neurologist at ___ and is taking carbidopa-levodopa and donepezil. We continued her carbidopa 25 mg-levodopa 100 mg 1.5 tablets PO TID, donepezil 5 mg tablet PO QHS, aspirin and statin. #DM type 2 Patient with poorly controlled T2DM. Her PCP has been following this. Last A1C was about 8.1% in ___, now increased further to 8.7%. His plan was to continue lifestyle modification unless her fasting glucose reached 200, at which point he planned to start metformin. While she was in the hospital, she required about 14 units insulin sliding scale daily. We discharged her with plan to start metformin for better diabetes control. #Nephrotic syndrome #CKD stage G2/A3 #Minimal change disease Home losartan-HCTZ was initially held in setting of normotension, but were restarted on ___. #Hypothyroidism Continued home levothyroxine 125 mcg capsule daily #Essential hypertension see above re:losartan-HCTZ. #Hypercholesterolemia We continued her home simvastatin 40 mg tablet daily #Depressed affect #Appetite We continued her home mirtazapine 7.5 mg disintegrating tablet daily QHS ====================== TRANSITIONAL ISSUES ====================== [ ] New medication: Metformin. Start metformin 500 mg BID and titrate/ adjust as appropriate. A1c ___ is 8.7%. [ ] New medication: Augmentin. Continue Augmentin 875 mg BID for aspiration pneumonia until ___ [ ] Maintain pureed solids and nectar thick liquids for aspiration risk [ ] Continue speech and swallow evaluations while in rehab #CODE: Full code #CONTACT: Daughter (HCP)- ___: ___ - ___: ___ work ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. losartan-hydrochlorothiazide 100-25 mg oral DAILY 2. Carbidopa-Levodopa (___) 1.5 TAB PO TID 3. Simvastatin 40 mg PO QPM 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Mirtazapine 7.5 mg PO QHS 6. Donepezil 5 mg PO QHS 7. Senna 17.2 mg PO QHS 8. Docusate Sodium 200 mg PO DAILY 9. Psyllium Wafer 1 WAF PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Artificial Tears ___ DROP BOTH EYES TID 12. Aspirin 81 mg PO DAILY 13. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days 2. MetFORMIN (Glucophage) 500 mg PO BID 3. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 4. Artificial Tears ___ DROP BOTH EYES TID 5. Aspirin 81 mg PO DAILY 6. Carbidopa-Levodopa (___) 1.5 TAB PO TID 7. Docusate Sodium 200 mg PO DAILY 8. Donepezil 5 mg PO QHS 9. Levothyroxine Sodium 125 mcg PO DAILY 10. losartan-hydrochlorothiazide 100-25 mg oral DAILY 11. Mirtazapine 7.5 mg PO QHS 12. Multivitamins 1 TAB PO DAILY 13. Psyllium Wafer 1 WAF PO DAILY 14. Senna 17.2 mg PO QHS 15. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES ================== Aspiration Pneumonia Oropharyngeal Dysphagia SECONDARY DIAGNOSES ===================== Vascular Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. Why did you come to the hospital? - You came into the hospital because you were having cough and your family was worried about your walking. What did you receive in the hospital? - While you were in the hospital we did some imaging studies to make sure you had not had another stroke or a clot in your lungs - We treated you with antibiotics for pneumonia - You were seen by our Speech & Swallow specialists who were concerned that food may be going into your lungs when you eat What should you do once you leave the hospital? - You should continue to take all your medications as prescribed and follow up with your medical appointments. We wish you all the best! Sincerely, - Your ___ Care Team Followup Instructions: ___
[ "J690", "G20", "F0280", "F0150", "I129", "E1122", "E1165", "N183", "E113299", "E785", "M109", "I69322", "E1151", "Z86718", "Z87440", "R400", "R1312" ]
Allergies: shellfish derived Chief Complaint: Cough, fever, lethargy Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o woman with history of uncontrolled type 2 DM complicated by small vessel CVA [MASKED], vascular dementia, recent L5 nerve root injection, and frequent UTI presenting with several days of cough and fever to 101. Patient's family, who she lives with, have noticed that patient has had progressive cough and general weakness over the last several days. They state that she is usually able to eat meals and walk to the bathroom independently, but that she was unable to do so yesterday and has just generally been weaker and slower in movement. She endorses mild shortness of breath, but denies any chest pain, headaches, lightheadedness, fainting, abdominal pain, changes in bowel movement or urination. She has recently had multiple sick contacts at home with runny nose and cough. In the ED: - Initial vital signs were notable for: T99.5, HR92, BP118/54, RR18, 97% RA - Exam notable for: coarse crackles on the right side - Labs were notable for: WBC: 9.2-->6.7 Hgb: 12.6--> 11.2 Plt: 175-->144 141|110| 14 AGap=8 -------------<152 3.9| 23|0.8 Lactate:2.2-->1.5-->1.2 VBG: 7.48/30--> 7.39/43 FluAPCR: Negative FluBPCR: Negative UA: notable for 100 protein, 100 glucose, no nitrites, ketones or leuks - Studies performed include: NCHCT: 1. No intracranial hemorrhage. 2. New hypodensities in the right thalamus and internal capsule are age indeterminate and subacute infarction not excluded. MRI could be performed for further assessment. 3. Stable chronic lacunar infarcts in the left basal ganglia and internal capsule. CXR: Heart size is mildly enlarged, unchanged. The mediastinal and hilar contours are similar to prior. The pulmonary vasculature is not engorged. Lung volumes are low with minimal patchy opacities at the lung bases. No focal consolidation, pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Low lung volumes with patchy opacities at the lung bases likely reflective of atelectasis. Infection, however, is difficult to exclude in the appropriate clinical context. - Patient was given: [MASKED] [MASKED] 22:43IVCefTRIAXone [MASKED] 00:37IVAzithromycin 500mg [MASKED] 01:02IVFNS 1000 mL [MASKED] 02:09SCInsulin 10 Units [MASKED] 06:52IVAcetaminophen IV 1000 mg [MASKED] 08:30PO/NGCarbidopa-Levodopa ([MASKED]) 1 TAB [MASKED] 08:30PO/NGLevothyroxine Sodium 125 mcg - Consults: none Vitals on transfer: T98.6, HR76, BP123/60, RR20, 94% RA Upon arrival to the floor, patient states that she presented to the hospital yesterday due to difficulty walking, and her daughter [MASKED] describes that she is normally able to ambulate independently with a walker. She endorses a cough over the last several days, which her daughter states is productive and has been worsening today. She denies headache, chills, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, dizziness, or pain with urination. She is intermittently somnolent. Patient has received an influenza vaccine and pneumonia vaccine this year. Patient's last hospitalization was [MASKED] years ago for neurological symptoms of memory, speech, and gait difficulty. Collateral from daughter [MASKED]: Patient had a cough 2 weeks ago, which improved and was nearly resolved. However, two nights ago ([MASKED]) patient began to have a wet cough (though without sputum) and began to make crying noises throughout the night. Yesterday ([MASKED]), the patient began to have trouble walking. She normally ambulates with a walker independently, but yesterday she was unable to do so and was dragging her right leg. Her daughter took her temperature, which showed a fever of 101. Patient was also unable to eat independently yesterday as well, which is different from her baseline. She had chills and shortness of breath yesterday, but did not have headache, dizziness, lightheadedness, diarrhea, changes in sensation, or burning with urination. Past Medical History: - Vascular dementia without behavioral disturbance [MASKED] - Vascular parkinsonism - Stroke, small vessel [MASKED] (diffuse periventricular white matter disease. There was also a subacute, hemorrhagic infarct in the left lobe of the globus palates and the genu of the internal capsule) - Lumbar radiculitis - DM (diabetes mellitus), type 2, uncontrolled w/neurologic complication (CVA, retinopathy) - Mild nonproliferative diabetic retinopathy [MASKED] - Nephrotic syndrome [MASKED] - CKD stage G2/A3, GFR [MASKED] and albumin creatinine ratio >300 mg/g [MASKED] - Minimal change disease [MASKED] - Hypothyroidism [MASKED] - Hypertension, essential [MASKED] - Hypercholesterolemia [MASKED] - Depressed affect - Thrombophlebitis/phlebitis of deep veins - Gout - PVD (posterior vitreous detachment) Social History: [MASKED] [MASKED] History: Mother had DM2, lived to [MASKED] No family hx of dementia Physical Exam: =========================== ADMISSION PHYSICAL EXAM: ============================ VITALS: [MASKED] 1344 Temp: 98.4 PO BP: 115/72 HR: 70 RR: 18 O2 sat: 96% O2 delivery: Ra GENERAL: Somnolent In no acute distress. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Crackles in the base of the right lung. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowel sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. [MASKED] strength throughout upper extremities, [MASKED] left lower extremity. [MASKED] strength in right lower extremity. Normal sensation. Gait deferred. States initially that she is in [MASKED]'s [MASKED]; unable to name the year. Mild bradykinesia, mild cogwheeling =========================== DISCHARGE PHYSICAL EXAM =========================== [MASKED] [MASKED] Temp: 97.5 PO BP: 147/83 R Lying HR: 71 RR: 16 O2 sat: 97% O2 delivery: Ra GENERAL: Lying in bed, covered in many blankets, drowsy CARDIAC: Regular rate and rhythm; II/VI systolic crescendo-decrescendo murmur at the right upper sternal border LUNG: breathing comfortably on room air; bibasilar crackles ABD: Abdomen soft, nontender, nondistended EXT: Warm, well perfused, no lower extremity edema NEURO: Awake, is able to state her name, location but not the date. She follows commands (squeezes hands, lifts legs). Overall mental status appears improved from yesterday. Pertinent Results: ==================== ADMISSION LABS ==================== [MASKED] 08:26PM BLOOD WBC-9.2 RBC-3.94 Hgb-12.6 Hct-37.2 MCV-94 MCH-32.0 MCHC-33.9 RDW-11.9 RDWSD-41.1 Plt [MASKED] [MASKED] 08:26PM BLOOD Neuts-73.7* Lymphs-13.8* Monos-10.5 Eos-0.9* Baso-0.7 Im [MASKED] AbsNeut-6.75* AbsLymp-1.26 AbsMono-0.96* AbsEos-0.08 AbsBaso-0.06 [MASKED] 08:26PM BLOOD Plt [MASKED] [MASKED] 08:26PM BLOOD Glucose-421* UreaN-19 Creat-1.0 Na-131* K-6.1* Cl-100 HCO3-18* AnGap-13 [MASKED] 08:31PM BLOOD pO2-162* pCO2-30* pH-7.48* calTCO2-23 Base XS-0 [MASKED] 10:39PM BLOOD pO2-30* pCO2-43 pH-7.39 calTCO2-27 Base XS-0 [MASKED] 08:31PM BLOOD Glucose-413* Lactate-2.2* K-5.4* [MASKED] 06:11AM URINE Color-Straw Appear-Hazy* Sp [MASKED] [MASKED] 06:11AM URINE Blood-NEG Nitrite-NEG Protein-100* Glucose-100* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [MASKED] 06:11AM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 ==================== DISCHARGE LABS ==================== [MASKED] 05:47AM BLOOD WBC-4.7 RBC-3.95 Hgb-12.5 Hct-37.8 MCV-96 MCH-31.6 MCHC-33.1 RDW-12.0 RDWSD-42.3 Plt [MASKED] [MASKED] 05:47AM BLOOD Plt [MASKED] [MASKED] 05:47AM BLOOD Glucose-164* UreaN-15 Creat-0.7 Na-143 K-4.2 Cl-110* HCO3-24 AnGap-9* [MASKED] 05:47AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9 [MASKED] 07:00AM BLOOD %HbA1c-8.7* eAG-203* ============ MICRO ============ [MASKED] 6:11 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 9:50 pm URINE Source: [MASKED]. Legionella Urinary Antigen (Final [MASKED]: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). =============== IMAGING/REPORTS =============== CXR [MASKED] IMPRESSION: Low lung volumes with patchy opacities at the lung bases likely reflective of atelectasis. Infection, however, is difficult to exclude in the appropriate clinical context. NON-CON HEAD CT [MASKED] IMPRESSION: 1. Study is degraded by motion. 2. No evidence of acute intracranial hemorrhage. 3. Age indeterminate right thalamus and internal capsule lesions as described, not definitely seen on most recent prior imaging of [MASKED]. While findings may represent microangiopathic changes, subacute infarction is not excluded on the basis examination. Please note MRI of the brain is more sensitive for the detection of acute infarct. 4. Stable chronic lacunar infarcts in the left basal ganglia and internal capsule. 5. Atrophy, probable small vessel ischemic changes, and atherosclerotic vascular disease as described. MRI BRAIN WITHOUT CONTRAST [MASKED] IMPRESSION: 1. The study significantly degraded by patient motion. Allowing for this limitation there is no evidence large intracranial hemorrhage, obvious infarction or intracranial mass. 2. Nonspecific confluent white matter changes in the cerebral hemispheres bilaterally, likely sequela of chronic small vessel ischemic changes. 3. Old lacunar infarcts in the left basal ganglia region. CXR [MASKED] IMPRESSION: Patchy opacities in the left lower lobe could reflect atelectasis, aspiration or pneumonia. NON-CON HEAD CT [MASKED] IMPRESSION: No acute intracranial process. CHEST CTA [MASKED] IMPRESSION: No evidence of pulmonary embolism or acute aortic abnormality. Circumflex aorta noted resulting in vascular sling which potentially could be contributing to patient's aspiration. Left greater than right lower lobe airspace disease compatible with pneumonia may be secondary to aspiration given the fluid seen within the proximal esophagus. Mildly prominent hilar lymph nodes which are likely reactive. Brief Hospital Course: [MASKED] y/o woman with history of uncontrolled type 2 DM complicated by small vessel CVA [MASKED], vascular dementia, recent L5 nerve root injection, and frequent UTIs presented with several days of cough, fever to 101, found to have pneumonia on CXR. Course was complicated by increased somnolence likely secondary to infection and concerns about new R sided leg weakness but stable MRI and clinical improvement in strength by discharge. ACUTE ISSUES: ============= # Aspiration pneumonia Patient's symptoms, crackles in the right lung base, and CXR demonstrative of patchy opacities in the lung bases c/f pneumonia. Empiric treatment for community-acquired pneumonia with ceftriaxone and azithromycin was initiated without significant improvement. Despite CAP therapy, patient continued to have mildly elevated temperatures (Tmax 100.3), concerning for inadequate source control. Patient did not demonstrate any symptoms and signs of other infections such as UTI (negative UA + UCx), skin (clean skin around PIVs, no new rashes) or CNS infection (no headache, blurry vision, no evidence of inflammation on MRI). Aspiration pneumonia was a possible cause of the patient's lack of improvement given patient's hx of stroke, dysarthria, recent difficulty with feeding herself independently, and aspiration risk determined by speech therapy. Flagyl was added for coverage of anaerobic organisms in aspiration pneumonia. Patient triggered due to tachypnea overnight [MASKED] for likely aspiration event. PE was ruled out. Antibiotics were switched to augmentin on [MASKED] in order to consolidate multiple antibiotics. She will complete Augmentin on [MASKED] for a 7 day course for aspiration pneumonia. On the day of discharge, she was evaluated again by speech and swallow and was recommended to stay on a pureed diet and have further evaluation in rehab. #Somnolence Patient has waxing and waning alertness and is somnolent. Head CT and MRI negative for acute bleed or stroke. VBG without evidence of CO2 retention. Labs without significant electrolyte abnormalities. Her mental status improved as her infection was treated, however, she still remained intermittently confused. This appears to be consistent with her baseline, per family. #Gait instability #New findings on [MASKED] Acute onset of gait instability on [MASKED] different from her baseline. Patient has a significant history of vascular dementia with multiple prior infarcts. [MASKED] demonstrated hypodensities in the right thalamus and internal capsule concerning for subacute infarcts, however MRI did not show any new lesions. Patient's gait instability may be re-crudescence of neurological symptoms from prior strokes in the acute setting of infection. CHRONIC ISSUES: =============== #Vascular dementia #Parkinsonism Patient sees outpatient neurologist at [MASKED] and is taking carbidopa-levodopa and donepezil. We continued her carbidopa 25 mg-levodopa 100 mg 1.5 tablets PO TID, donepezil 5 mg tablet PO QHS, aspirin and statin. #DM type 2 Patient with poorly controlled T2DM. Her PCP has been following this. Last A1C was about 8.1% in [MASKED], now increased further to 8.7%. His plan was to continue lifestyle modification unless her fasting glucose reached 200, at which point he planned to start metformin. While she was in the hospital, she required about 14 units insulin sliding scale daily. We discharged her with plan to start metformin for better diabetes control. #Nephrotic syndrome #CKD stage G2/A3 #Minimal change disease Home losartan-HCTZ was initially held in setting of normotension, but were restarted on [MASKED]. #Hypothyroidism Continued home levothyroxine 125 mcg capsule daily #Essential hypertension see above re:losartan-HCTZ. #Hypercholesterolemia We continued her home simvastatin 40 mg tablet daily #Depressed affect #Appetite We continued her home mirtazapine 7.5 mg disintegrating tablet daily QHS ====================== TRANSITIONAL ISSUES ====================== [ ] New medication: Metformin. Start metformin 500 mg BID and titrate/ adjust as appropriate. A1c [MASKED] is 8.7%. [ ] New medication: Augmentin. Continue Augmentin 875 mg BID for aspiration pneumonia until [MASKED] [ ] Maintain pureed solids and nectar thick liquids for aspiration risk [ ] Continue speech and swallow evaluations while in rehab #CODE: Full code #CONTACT: Daughter (HCP)- [MASKED]: [MASKED] - [MASKED]: [MASKED] work [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. losartan-hydrochlorothiazide 100-25 mg oral DAILY 2. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO TID 3. Simvastatin 40 mg PO QPM 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Mirtazapine 7.5 mg PO QHS 6. Donepezil 5 mg PO QHS 7. Senna 17.2 mg PO QHS 8. Docusate Sodium 200 mg PO DAILY 9. Psyllium Wafer 1 WAF PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Artificial Tears [MASKED] DROP BOTH EYES TID 12. Aspirin 81 mg PO DAILY 13. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 4 Days 2. MetFORMIN (Glucophage) 500 mg PO BID 3. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 4. Artificial Tears [MASKED] DROP BOTH EYES TID 5. Aspirin 81 mg PO DAILY 6. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO TID 7. Docusate Sodium 200 mg PO DAILY 8. Donepezil 5 mg PO QHS 9. Levothyroxine Sodium 125 mcg PO DAILY 10. losartan-hydrochlorothiazide 100-25 mg oral DAILY 11. Mirtazapine 7.5 mg PO QHS 12. Multivitamins 1 TAB PO DAILY 13. Psyllium Wafer 1 WAF PO DAILY 14. Senna 17.2 mg PO QHS 15. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES ================== Aspiration Pneumonia Oropharyngeal Dysphagia SECONDARY DIAGNOSES ===================== Vascular Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. Why did you come to the hospital? - You came into the hospital because you were having cough and your family was worried about your walking. What did you receive in the hospital? - While you were in the hospital we did some imaging studies to make sure you had not had another stroke or a clot in your lungs - We treated you with antibiotics for pneumonia - You were seen by our Speech & Swallow specialists who were concerned that food may be going into your lungs when you eat What should you do once you leave the hospital? - You should continue to take all your medications as prescribed and follow up with your medical appointments. We wish you all the best! Sincerely, - Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I129", "E1122", "E1165", "E785", "M109", "Z86718" ]
[ "J690: Pneumonitis due to inhalation of food and vomit", "G20: Parkinson's disease", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "F0150: Vascular dementia without behavioral disturbance", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1165: Type 2 diabetes mellitus with hyperglycemia", "N183: Chronic kidney disease, stage 3 (moderate)", "E113299: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye", "E785: Hyperlipidemia, unspecified", "M109: Gout, unspecified", "I69322: Dysarthria following cerebral infarction", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "Z86718: Personal history of other venous thrombosis and embolism", "Z87440: Personal history of urinary (tract) infections", "R400: Somnolence", "R1312: Dysphagia, oropharyngeal phase" ]
10,033,409
21,582,131
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___ Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx uncontrolled DM2 c/b small vessel CVA ___, vascular dementia, recent L5 nerve root injection, frequent UTI p/w one week AMS and nonfocal weakness, superimposed on months of chronic behavior changes. History obtained from daughter (long term care ___), as patient unable to remember recent history. At baseline pt gives conflicting answers and has very poor short term memory; however over the last week she is more confused talking to herself and seems to be hallucinating, crying inappropriately. Hard time mobilizing to car (?weakness). Crying in a wheelchair -- "lost her hope she couldn't walk at all". She usually only uses a wheelchair for longer trips outside the house and uses the rolling walker in the house. ___ night she could not hold herself at all, not even to transfer from wheelchair to bed. Since ___ she hasn't been able to go to day care, not able to bathe in tub. Patient was treated ___ with Cipro for UTI, however abx stopped after the cultures were negative. Has had months of intermittent urinary incontinence. Daughter has not noted any new breathing symptoms (has a chronic dry cough). No sputum production. Has chronic intermittent constipation. Intermittent enemas at home. No fevers. No chills. No clear sweats - maybe that one day it was very hot. No N/V/D. H/o small vessel CVA ___, vascular dementia. At baseline attends Adult Day Care 4x/week, uses rolling walker for ambulation, Mini-mental ___. Behavior changes noted in outpt notes ___. Pt has had at least 3 falls since ___. Fall ___ with head trauma and presented to BID ED, where ___ showed "No acute intracranial process. Chronic small vessel disease and old lacunar infarcts, unchanged from prior." In the ED, initial vitals: 97.1, 76, 123/67, 18, 98% RA Labs were significant for: Plt 141, Alb 2.9 CXR ED ___: "volumes are low with bibasal opacities most suggestive of atelectasis, though difficult to exclude a component of pneumonia in the correct clinical setting." EKG ED: In the ED, pt received: IV Ceftriaxone 1g, IV Azithromycin 500mg Vitals prior to transfer: , 83, 109/97, 16, 99% RA Currently, patient is laying comfortably in bed, afebrile ROS: No photophobia. No fevers/chills/HA/changes in vision/abd pain/burning on urination/dyspnea. Past Medical History: - Vascular dementia without behavioral disturbance ___ - Stroke, small vessel ___: "Around ___ she was noted to have problems with speaking, forgetfulness, and mild right sided weakness. She was seen at ___ for an MRI scan on ___ which showed diffuse periventricular white matter disease. There was also a subacute hemorrhagic infarct in the left lobe of the globus palates and the genu of the internal capsule. MR angiography of the ___ ___ and neck were normal" - Lumbar Radiculitis (sx include low back and R leg pain since ___ MRI lumbar spine ___ showed severe L4-L5 circumferential disc bulge with right neural foraminal stenosis) s/p R L5 lumbar transforaminal selective nerve root injection (2.0 cc of kenalog (40 mg/ml) and 1 cc of 1% of lidocaine) on ___ - DM (diabetes mellitus), type 2, uncontrolled w/neurologic complication (CVA, retinopathy) - Mild nonproliferative diabetic retinopathy ___ - Nephrotic syndrome ___ - CKD stage G2/A3, GFR ___ and albumin creatinine ratio >300 mg/g ___ - Minimal change disease ___ - Hypothyroidism ___: "atrophic thyroid on us ___- prob ___'s" - Hypertension, essential ___ - Hypercholesterolemia ___: "LDL Goal < 70" Social History: ___ Family History: Mother had DM2, lived to ___ No family hx of dementia Physical Exam: ======================= ADMISSION PHYSICAL ======================= VS: 97.6, 164 / 89, 101, 18, 97 RA GEN: Alert, lying in bed, no acute distress. Unable to sit up without assistance, apparently due to truncal weakness HEENT: Moist MM, anicteric sclerae, no conjunctival pallor. NECK: Supple PULM: Bibasilar crackles, no wheezes COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended, no lower abdominal TTP EXTREM: Warm, well-perfused, no edema, 2+ DP b/l NEURO: A&Ox2. Symmetric smile, grimace, shoulder shrug, head turn. Mild L ptosis. Neg pronator drift b/l. ___ strength RUE (limited by R shoulder pain), 4+/5 strength LUE, ___ strength b/l ___. ======================= DISCHARGE PHYSICAL ======================= Vitals: 98.7, 153 / 78, 73, 18, 98 Ra General: alert, laying in bed, no acute distress HEENT: MMM, anicteric sclera Lungs: clear to auscultation bilaterally, no wheezes CV: regular rate and rhythm, normal S1 + S2, no murmurs Abdomen: soft, non-distended Ext: warm, well perfused, no clubbing, cyanosis or edema Neuro: Does not cooperate fully with neuro exam. Oriented to self and "hospital", does not know year. Mild L ptosis. B/l stiffness on passive plantarflexion and dorsiflexion. Stiff (?Cogwheeling) at wrists b/l. Pertinent Results: ========================= ADMISSION LABS ========================= ___ 05:53PM BLOOD WBC-7.7 RBC-3.86* Hgb-12.6 Hct-36.8 MCV-95 MCH-32.6* MCHC-34.2 RDW-12.6 RDWSD-43.9 Plt ___ ___ 05:53PM BLOOD Neuts-64.0 ___ Monos-8.8 Eos-2.0 Baso-0.5 Im ___ AbsNeut-4.92 AbsLymp-1.87 AbsMono-0.68 AbsEos-0.15 AbsBaso-0.04 ___ 05:53PM BLOOD Glucose-227* UreaN-17 Creat-0.8 Na-133 K-3.4 Cl-100 HCO3-26 AnGap-10 ___ 05:53PM BLOOD ALT-22 AST-19 AlkPhos-51 TotBili-0.3 ___ 06:20AM BLOOD CK(CPK)-68 ___ 05:53PM BLOOD cTropnT-<0.01 ___ 07:20AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 05:53PM BLOOD Albumin-2.9* Calcium-9.2 ___ 07:20AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.7 ___ 06:20AM BLOOD TSH-13* ___ 06:20AM BLOOD Free T4-1.1 ___ 12:24AM BLOOD Lactate-1.3 ___ 05:53PM BLOOD Lipase-32 ========================= DISCHARGE LABS ========================= ___ 06:20AM BLOOD WBC-8.8 RBC-4.26 Hgb-14.0 Hct-40.3 MCV-95 MCH-32.9* MCHC-34.7 RDW-12.8 RDWSD-44.1 Plt ___ ___ 06:20AM BLOOD Neuts-63.4 ___ Monos-8.9 Eos-2.0 Baso-0.7 Im ___ AbsNeut-5.59 AbsLymp-2.18 AbsMono-0.79 AbsEos-0.18 AbsBaso-0.06 ___ 06:20AM BLOOD Glucose-182* UreaN-22* Creat-0.7 Na-138 K-3.5 Cl-103 HCO3-24 AnGap-15 ___ 06:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9 ========================= MICRO ========================= ___ 12:10 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:08 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 2:53 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ========================= IMAGING SUMMARIES ========================= ___ Imaging MRI CERVICAL, THORACIC, LUMBAR 1. Lumbar spondylosis, similar from examination of ___ with degenerative grade 1 anterolisthesis of L4 on L5 and L5 on S1, severe L4-L5 spinal canal narrowing crowding the cauda equina, severe L4-L5 right and moderate to severe neural foraminal narrowing and bilateral L5-S1 moderate to severe bilateral neural foraminal narrowing. 2. Cervical spondylosis results in bilateral moderate neural foraminal narrowing at multiple levels without high-grade spinal canal narrowing. 3. No significant spinal canal or neural foraminal narrowing at the thoracic spine. 4. No cord signal abnormality. 5. Additional findings as described above. ___ Imaging MR HEAD W/O CONTRAST 1. No acute infarct. 2. Confluent moderate to severe subcortical and periventricular T2/FLAIR white matter hyperintensities are nonspecific, but compatible with chronic microangiopathy in a patient of this age. 3. Moderate cerebral volume loss. 4. Additional findings as described above. ___ Imaging CT HEAD W/O CONTRAST No intracranial hemorrhage. Stable chronic lacunar infarct left basal ganglia, internal capsule. Severe chronic small vessel ischemic changes. ___ Imaging CHEST (PA & LAT) AP upright and lateral views of the chest provided. Lung volumes are low with bibasal opacities most suggestive of atelectasis, though difficult to exclude a component of pneumonia in the correct clinical setting. No large effusion, pneumothorax. No signs of congestion or edema. Cardiomediastinal silhouette is unchanged. Bony structures appear intact. ___BD & PELVIS WITH CO No acute findings to account for abdominal pain. Incidental findings as detailed above. Brief Hospital Course: Ms ___ is a ___ with poorly controlled DM2 c/b small vessel CVA ___ and vascular dementia who presents with one week of worse-than-usual confusion, increased frequency of urinary incontinence, and nonfocal weakness, superimposed on months of chronic behavior changes, likely progression of vascular dementia. She was noted to have intermittent urinary retention while admitted. ==================== ACUTE ISSUES ==================== # Altered Mental Status Believed to be progression of vascular dementia. ICH/ischemic stroke ruled out by NCHCT and MRI. Patient is afebrile, no leukocytosis, neg UCx from ___, CXR shows most likely atelectasis and no SOB/change in chronic dry cough. No current medications or electrolyte abnormalities that could cause toxic/metabolic AMS. NPH unlikely given imaging. Neuro consulted, recommended contrast MRI of brain, and C, T, L-spine. These spine MRIs showed no interval changes compared to prior in ___ (stable lumbar and cervical spondylosis with spinal canal narrowing and neural foramen narrowing). MRI brain shows no acute infarct, just confluent subcortical ___ changes c/w chronic microangiopathy. Ortho Spine does not think surgery is indicated in this pt because her neuro deficits do not correlate with MRI findings, so surgery not likely to improve her function. Per Neuro Movement Disorders, pt has Parkinsonism from either vascular dementia vs actual ___ dz. Plan is to trial Carbidopa-Levodopa (___) 0.5 TAB PO TID until follow up with Dr. ___ in ___ months. # Urinary incontinence Subacute vs chronic. Could be related to progression vascular dementia. Bladder scans this admission c/f retention, decided on straight cath BID with titration of frequency as needed. ==================== CHRONIC ISSUES ==================== # Nephrotic syndrome: high protein diet (Ensure). Chronic (last albumin also 2.9 in outpatient setting in ___ - monitor albumin - urine protein and albumin # HTN: continue home losartan 100mg PO QD and hydrochlorothiazide25mg PO QD # DM2: managed with lifestyle interventions at home. Started ISS ___ because ___ # Hypothyroidism: continue home levothyroxine 125 mcg PO QD # Hypercholesterolemia: continue home simvastatin 40 mg tablet PO QPM ===================== TRANSITIONAL ISSUES ===================== - re-check TSH in 2 weeks as outpt (was ___ here with normal free T4) - family education on physical assist, straight cathing (some of daughters are ___) - BID straight catherization, tirate frequency as needed - submitted requet for electric bed. Will also need ___ lift and ramp at home before returning home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 125 mcg PO DAILY 2. losartan-hydrochlorothiazide 100-25 mg oral DAILY 3. Simvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. Artificial Tears 1 DROP BOTH EYES TID 6. melatonin 1 mg oral QPM:PRN 7. Aspirin 81 mg PO DAILY 8. Acetaminophen 650 mg PO BID:PRN Pain - Mild 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Carbidopa-Levodopa (___) 0.5 TAB PO TID 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Senna 8.6 mg PO BID:PRN constipation 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 5. Artificial Tears 1 DROP BOTH EYES TID 6. Aspirin 81 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Levothyroxine Sodium 125 mcg PO DAILY 10. losartan-hydrochlorothiazide 100-25 mg oral DAILY 11. melatonin 1 mg oral QPM:PRN 12. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - Weakness - Acute on chronic encephalopathy or dementia - Urinary incontinence and urinary retention 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 ___ and family, WHY WAS I ADMITTED TO THE HOSPITAL? - you have been more confused over the past week - you have been having weakness as well WHAT WAS DONE FOR ME IN THE HOSPITAL? - we ruled out other causes of your confusion and believe it is due to progression of your vascular dementia - A head CT and brain MRI were performed - our Neurologist and Movement Disorder Specialists evaluated you for your weakness and rigidity and started you on Sinemet for ___ stiffness - we worked with case management to apply for more equipment at home for after rehab WHAT SHOULD I DO WHEN I GO BACK TO HOME? - review your medication list and take as prescribed - follow up with the neurology movement disorder clinic as recommended below - work with your rehab doctors - please work with physical therapy - Straight cath twice a day and record the values of how much urine comes out in a log to show your doctor. It was a pleasure to take part in your care. Sincerely, Your ___ team Followup Instructions: ___
[ "F0151", "E1121", "G20", "Z87440", "K5909", "Z8673", "E113299", "M4806", "R339", "M4726", "R32", "M47892", "I129", "N183", "E039", "E785" ]
Allergies: shellfish derived Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] hx uncontrolled DM2 c/b small vessel CVA [MASKED], vascular dementia, recent L5 nerve root injection, frequent UTI p/w one week AMS and nonfocal weakness, superimposed on months of chronic behavior changes. History obtained from daughter (long term care [MASKED]), as patient unable to remember recent history. At baseline pt gives conflicting answers and has very poor short term memory; however over the last week she is more confused talking to herself and seems to be hallucinating, crying inappropriately. Hard time mobilizing to car (?weakness). Crying in a wheelchair -- "lost her hope she couldn't walk at all". She usually only uses a wheelchair for longer trips outside the house and uses the rolling walker in the house. [MASKED] night she could not hold herself at all, not even to transfer from wheelchair to bed. Since [MASKED] she hasn't been able to go to day care, not able to bathe in tub. Patient was treated [MASKED] with Cipro for UTI, however abx stopped after the cultures were negative. Has had months of intermittent urinary incontinence. Daughter has not noted any new breathing symptoms (has a chronic dry cough). No sputum production. Has chronic intermittent constipation. Intermittent enemas at home. No fevers. No chills. No clear sweats - maybe that one day it was very hot. No N/V/D. H/o small vessel CVA [MASKED], vascular dementia. At baseline attends Adult Day Care 4x/week, uses rolling walker for ambulation, Mini-mental [MASKED]. Behavior changes noted in outpt notes [MASKED]. Pt has had at least 3 falls since [MASKED]. Fall [MASKED] with head trauma and presented to BID ED, where [MASKED] showed "No acute intracranial process. Chronic small vessel disease and old lacunar infarcts, unchanged from prior." In the ED, initial vitals: 97.1, 76, 123/67, 18, 98% RA Labs were significant for: Plt 141, Alb 2.9 CXR ED [MASKED]: "volumes are low with bibasal opacities most suggestive of atelectasis, though difficult to exclude a component of pneumonia in the correct clinical setting." EKG ED: In the ED, pt received: IV Ceftriaxone 1g, IV Azithromycin 500mg Vitals prior to transfer: , 83, 109/97, 16, 99% RA Currently, patient is laying comfortably in bed, afebrile ROS: No photophobia. No fevers/chills/HA/changes in vision/abd pain/burning on urination/dyspnea. Past Medical History: - Vascular dementia without behavioral disturbance [MASKED] - Stroke, small vessel [MASKED]: "Around [MASKED] she was noted to have problems with speaking, forgetfulness, and mild right sided weakness. She was seen at [MASKED] for an MRI scan on [MASKED] which showed diffuse periventricular white matter disease. There was also a subacute hemorrhagic infarct in the left lobe of the globus palates and the genu of the internal capsule. MR angiography of the [MASKED] [MASKED] and neck were normal" - Lumbar Radiculitis (sx include low back and R leg pain since [MASKED] MRI lumbar spine [MASKED] showed severe L4-L5 circumferential disc bulge with right neural foraminal stenosis) s/p R L5 lumbar transforaminal selective nerve root injection (2.0 cc of kenalog (40 mg/ml) and 1 cc of 1% of lidocaine) on [MASKED] - DM (diabetes mellitus), type 2, uncontrolled w/neurologic complication (CVA, retinopathy) - Mild nonproliferative diabetic retinopathy [MASKED] - Nephrotic syndrome [MASKED] - CKD stage G2/A3, GFR [MASKED] and albumin creatinine ratio >300 mg/g [MASKED] - Minimal change disease [MASKED] - Hypothyroidism [MASKED]: "atrophic thyroid on us [MASKED]- prob [MASKED]'s" - Hypertension, essential [MASKED] - Hypercholesterolemia [MASKED]: "LDL Goal < 70" Social History: [MASKED] Family History: Mother had DM2, lived to [MASKED] No family hx of dementia Physical Exam: ======================= ADMISSION PHYSICAL ======================= VS: 97.6, 164 / 89, 101, 18, 97 RA GEN: Alert, lying in bed, no acute distress. Unable to sit up without assistance, apparently due to truncal weakness HEENT: Moist MM, anicteric sclerae, no conjunctival pallor. NECK: Supple PULM: Bibasilar crackles, no wheezes COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended, no lower abdominal TTP EXTREM: Warm, well-perfused, no edema, 2+ DP b/l NEURO: A&Ox2. Symmetric smile, grimace, shoulder shrug, head turn. Mild L ptosis. Neg pronator drift b/l. [MASKED] strength RUE (limited by R shoulder pain), 4+/5 strength LUE, [MASKED] strength b/l [MASKED]. ======================= DISCHARGE PHYSICAL ======================= Vitals: 98.7, 153 / 78, 73, 18, 98 Ra General: alert, laying in bed, no acute distress HEENT: MMM, anicteric sclera Lungs: clear to auscultation bilaterally, no wheezes CV: regular rate and rhythm, normal S1 + S2, no murmurs Abdomen: soft, non-distended Ext: warm, well perfused, no clubbing, cyanosis or edema Neuro: Does not cooperate fully with neuro exam. Oriented to self and "hospital", does not know year. Mild L ptosis. B/l stiffness on passive plantarflexion and dorsiflexion. Stiff (?Cogwheeling) at wrists b/l. Pertinent Results: ========================= ADMISSION LABS ========================= [MASKED] 05:53PM BLOOD WBC-7.7 RBC-3.86* Hgb-12.6 Hct-36.8 MCV-95 MCH-32.6* MCHC-34.2 RDW-12.6 RDWSD-43.9 Plt [MASKED] [MASKED] 05:53PM BLOOD Neuts-64.0 [MASKED] Monos-8.8 Eos-2.0 Baso-0.5 Im [MASKED] AbsNeut-4.92 AbsLymp-1.87 AbsMono-0.68 AbsEos-0.15 AbsBaso-0.04 [MASKED] 05:53PM BLOOD Glucose-227* UreaN-17 Creat-0.8 Na-133 K-3.4 Cl-100 HCO3-26 AnGap-10 [MASKED] 05:53PM BLOOD ALT-22 AST-19 AlkPhos-51 TotBili-0.3 [MASKED] 06:20AM BLOOD CK(CPK)-68 [MASKED] 05:53PM BLOOD cTropnT-<0.01 [MASKED] 07:20AM BLOOD CK-MB-4 cTropnT-<0.01 [MASKED] 05:53PM BLOOD Albumin-2.9* Calcium-9.2 [MASKED] 07:20AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.7 [MASKED] 06:20AM BLOOD TSH-13* [MASKED] 06:20AM BLOOD Free T4-1.1 [MASKED] 12:24AM BLOOD Lactate-1.3 [MASKED] 05:53PM BLOOD Lipase-32 ========================= DISCHARGE LABS ========================= [MASKED] 06:20AM BLOOD WBC-8.8 RBC-4.26 Hgb-14.0 Hct-40.3 MCV-95 MCH-32.9* MCHC-34.7 RDW-12.8 RDWSD-44.1 Plt [MASKED] [MASKED] 06:20AM BLOOD Neuts-63.4 [MASKED] Monos-8.9 Eos-2.0 Baso-0.7 Im [MASKED] AbsNeut-5.59 AbsLymp-2.18 AbsMono-0.79 AbsEos-0.18 AbsBaso-0.06 [MASKED] 06:20AM BLOOD Glucose-182* UreaN-22* Creat-0.7 Na-138 K-3.5 Cl-103 HCO3-24 AnGap-15 [MASKED] 06:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9 ========================= MICRO ========================= [MASKED] 12:10 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 12:08 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 2:53 pm URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. ========================= IMAGING SUMMARIES ========================= [MASKED] Imaging MRI CERVICAL, THORACIC, LUMBAR 1. Lumbar spondylosis, similar from examination of [MASKED] with degenerative grade 1 anterolisthesis of L4 on L5 and L5 on S1, severe L4-L5 spinal canal narrowing crowding the cauda equina, severe L4-L5 right and moderate to severe neural foraminal narrowing and bilateral L5-S1 moderate to severe bilateral neural foraminal narrowing. 2. Cervical spondylosis results in bilateral moderate neural foraminal narrowing at multiple levels without high-grade spinal canal narrowing. 3. No significant spinal canal or neural foraminal narrowing at the thoracic spine. 4. No cord signal abnormality. 5. Additional findings as described above. [MASKED] Imaging MR HEAD W/O CONTRAST 1. No acute infarct. 2. Confluent moderate to severe subcortical and periventricular T2/FLAIR white matter hyperintensities are nonspecific, but compatible with chronic microangiopathy in a patient of this age. 3. Moderate cerebral volume loss. 4. Additional findings as described above. [MASKED] Imaging CT HEAD W/O CONTRAST No intracranial hemorrhage. Stable chronic lacunar infarct left basal ganglia, internal capsule. Severe chronic small vessel ischemic changes. [MASKED] Imaging CHEST (PA & LAT) AP upright and lateral views of the chest provided. Lung volumes are low with bibasal opacities most suggestive of atelectasis, though difficult to exclude a component of pneumonia in the correct clinical setting. No large effusion, pneumothorax. No signs of congestion or edema. Cardiomediastinal silhouette is unchanged. Bony structures appear intact. BD & PELVIS WITH CO No acute findings to account for abdominal pain. Incidental findings as detailed above. Brief Hospital Course: Ms [MASKED] is a [MASKED] with poorly controlled DM2 c/b small vessel CVA [MASKED] and vascular dementia who presents with one week of worse-than-usual confusion, increased frequency of urinary incontinence, and nonfocal weakness, superimposed on months of chronic behavior changes, likely progression of vascular dementia. She was noted to have intermittent urinary retention while admitted. ==================== ACUTE ISSUES ==================== # Altered Mental Status Believed to be progression of vascular dementia. ICH/ischemic stroke ruled out by NCHCT and MRI. Patient is afebrile, no leukocytosis, neg UCx from [MASKED], CXR shows most likely atelectasis and no SOB/change in chronic dry cough. No current medications or electrolyte abnormalities that could cause toxic/metabolic AMS. NPH unlikely given imaging. Neuro consulted, recommended contrast MRI of brain, and C, T, L-spine. These spine MRIs showed no interval changes compared to prior in [MASKED] (stable lumbar and cervical spondylosis with spinal canal narrowing and neural foramen narrowing). MRI brain shows no acute infarct, just confluent subcortical [MASKED] changes c/w chronic microangiopathy. Ortho Spine does not think surgery is indicated in this pt because her neuro deficits do not correlate with MRI findings, so surgery not likely to improve her function. Per Neuro Movement Disorders, pt has Parkinsonism from either vascular dementia vs actual [MASKED] dz. Plan is to trial Carbidopa-Levodopa ([MASKED]) 0.5 TAB PO TID until follow up with Dr. [MASKED] in [MASKED] months. # Urinary incontinence Subacute vs chronic. Could be related to progression vascular dementia. Bladder scans this admission c/f retention, decided on straight cath BID with titration of frequency as needed. ==================== CHRONIC ISSUES ==================== # Nephrotic syndrome: high protein diet (Ensure). Chronic (last albumin also 2.9 in outpatient setting in [MASKED] - monitor albumin - urine protein and albumin # HTN: continue home losartan 100mg PO QD and hydrochlorothiazide25mg PO QD # DM2: managed with lifestyle interventions at home. Started ISS [MASKED] because [MASKED] # Hypothyroidism: continue home levothyroxine 125 mcg PO QD # Hypercholesterolemia: continue home simvastatin 40 mg tablet PO QPM ===================== TRANSITIONAL ISSUES ===================== - re-check TSH in 2 weeks as outpt (was [MASKED] here with normal free T4) - family education on physical assist, straight cathing (some of daughters are [MASKED]) - BID straight catherization, tirate frequency as needed - submitted requet for electric bed. Will also need [MASKED] lift and ramp at home before returning home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 125 mcg PO DAILY 2. losartan-hydrochlorothiazide 100-25 mg oral DAILY 3. Simvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. Artificial Tears 1 DROP BOTH EYES TID 6. melatonin 1 mg oral QPM:PRN 7. Aspirin 81 mg PO DAILY 8. Acetaminophen 650 mg PO BID:PRN Pain - Mild 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Carbidopa-Levodopa ([MASKED]) 0.5 TAB PO TID 2. Polyethylene Glycol 17 g PO DAILY:PRN constipation 3. Senna 8.6 mg PO BID:PRN constipation 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 5. Artificial Tears 1 DROP BOTH EYES TID 6. Aspirin 81 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Levothyroxine Sodium 125 mcg PO DAILY 10. losartan-hydrochlorothiazide 100-25 mg oral DAILY 11. melatonin 1 mg oral QPM:PRN 12. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: - Weakness - Acute on chronic encephalopathy or dementia - Urinary incontinence and urinary retention Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear [MASKED] and family, WHY WAS I ADMITTED TO THE HOSPITAL? - you have been more confused over the past week - you have been having weakness as well WHAT WAS DONE FOR ME IN THE HOSPITAL? - we ruled out other causes of your confusion and believe it is due to progression of your vascular dementia - A head CT and brain MRI were performed - our Neurologist and Movement Disorder Specialists evaluated you for your weakness and rigidity and started you on Sinemet for [MASKED] stiffness - we worked with case management to apply for more equipment at home for after rehab WHAT SHOULD I DO WHEN I GO BACK TO HOME? - review your medication list and take as prescribed - follow up with the neurology movement disorder clinic as recommended below - work with your rehab doctors - please work with physical therapy - Straight cath twice a day and record the values of how much urine comes out in a log to show your doctor. It was a pleasure to take part in your care. Sincerely, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "Z8673", "I129", "E039", "E785" ]
[ "F0151: Vascular dementia with behavioral disturbance", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "G20: Parkinson's disease", "Z87440: Personal history of urinary (tract) infections", "K5909: Other constipation", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E113299: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye", "M4806: Spinal stenosis, lumbar region", "R339: Retention of urine, unspecified", "M4726: Other spondylosis with radiculopathy, lumbar region", "R32: Unspecified urinary incontinence", "M47892: Other spondylosis, cervical region", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified" ]
10,033,409
27,804,795
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: LABORATORY RESULTS: ___ 10:30PM BLOOD WBC-10.7* RBC-4.08 Hgb-13.0 Hct-40.3 MCV-99* MCH-31.9 MCHC-32.3 RDW-12.4 RDWSD-45.1 Plt ___ ___ 04:45AM BLOOD WBC-8.7 RBC-3.67* Hgb-11.5 Hct-35.5 MCV-97 MCH-31.3 MCHC-32.4 RDW-12.4 RDWSD-44.3 Plt ___ ___ 10:30PM BLOOD Neuts-74.8* Lymphs-14.3* Monos-9.3 Eos-0.5* Baso-0.7 Im ___ AbsNeut-8.01* AbsLymp-1.53 AbsMono-0.99* AbsEos-0.05 AbsBaso-0.07 ___ 10:30PM BLOOD Glucose-255* UreaN-23* Creat-1.0 Na-136 K-4.6 Cl-101 HCO3-20* AnGap-15 ___ 04:45AM BLOOD Glucose-150* UreaN-20 Creat-0.7 Na-141 K-4.1 Cl-107 HCO3-22 AnGap-12 ___ 10:30PM BLOOD ALT-8 AST-25 AlkPhos-59 TotBili-0.2 ___ 10:30PM BLOOD Albumin-3.0* ___ 12:32AM BLOOD Lactate-1.9 URINE CULTURE: 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------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: On admission, Ms. ___ was started empirically on cefepime to cover her previously resistant organisms. This was narrowed to oral ciprofloxacin after culture results revealed pan-sensitive e. coli. Her kidney injury resolved, and her mental status returned to her baseline. As she was at her physical baseline, she was discharged back to her home with home services. HOSPITAL COURSE BY PROBLEM: 1. E. Coli UTI - cipro 250 mg BID x 3 additional days 2. ___. Resolved completely. 3. T2DM. Metformin,. 4. HTN. Losartan-HCTZ home 5. History of CVA. Aspirin and simvastatin. 6. Vascular dementia. Continue home donepezil. 7. History of DVT. Continue home apixaban. 8. Hypothyroidism. Home levothyroxine. > 30 minutes spent on discharge activities. Patient examined on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 2. Artificial Tears ___ DROP BOTH EYES TID 3. Aspirin 81 mg PO DAILY 4. Carbidopa-Levodopa (___) 1.5 TAB PO TID 5. Donepezil 5 mg PO QHS 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Mirtazapine 7.5 mg PO QHS 8. Multivitamins 1 TAB PO DAILY 9. Senna 17.2 mg PO DAILY 10. Simvastatin 40 mg PO QPM 11. Docusate Sodium 200 mg PO DAILY 12. losartan-hydrochlorothiazide 100-25 mg oral DAILY 13. Psyllium Wafer 1 WAF PO DAILY 14. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Ciprofloxacin HCl 250 mg PO Q12H RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 2. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 3. Artificial Tears ___ DROP BOTH EYES TID 4. Aspirin 81 mg PO DAILY 5. Carbidopa-Levodopa (___) 1.5 TAB PO TID 6. Docusate Sodium 200 mg PO DAILY 7. Donepezil 5 mg PO QHS 8. Levothyroxine Sodium 125 mcg PO DAILY 9. losartan-hydrochlorothiazide 100-25 mg oral DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Mirtazapine 7.5 mg PO QHS 12. Multivitamins 1 TAB PO DAILY 13. Psyllium Wafer 1 WAF PO DAILY 14. Senna 17.2 mg PO DAILY 15. Simvastatin 40 mg PO QPM Discharge Disposition: Home with Service Discharge Diagnosis: E. Coli UTI Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Confused - always. Discharge Instructions: You were admitted to the hospital with a urinary tract infection. You were started on antibiotics and rapidly improved. Fortunately, your organism was sensitive to oral antibiotics. You will complete three additional days of ciprofloxacin. Followup Instructions: ___
[ "A4151", "N390", "N179", "F0150", "Z8673", "E039", "Z86718", "Z7984", "E1151", "I10", "Z87440", "G214", "E7800", "M5416", "E113299", "K5900", "M109", "F329", "E1165" ]
Allergies: shellfish derived Major Surgical or Invasive Procedure: None attach Pertinent Results: LABORATORY RESULTS: [MASKED] 10:30PM BLOOD WBC-10.7* RBC-4.08 Hgb-13.0 Hct-40.3 MCV-99* MCH-31.9 MCHC-32.3 RDW-12.4 RDWSD-45.1 Plt [MASKED] [MASKED] 04:45AM BLOOD WBC-8.7 RBC-3.67* Hgb-11.5 Hct-35.5 MCV-97 MCH-31.3 MCHC-32.4 RDW-12.4 RDWSD-44.3 Plt [MASKED] [MASKED] 10:30PM BLOOD Neuts-74.8* Lymphs-14.3* Monos-9.3 Eos-0.5* Baso-0.7 Im [MASKED] AbsNeut-8.01* AbsLymp-1.53 AbsMono-0.99* AbsEos-0.05 AbsBaso-0.07 [MASKED] 10:30PM BLOOD Glucose-255* UreaN-23* Creat-1.0 Na-136 K-4.6 Cl-101 HCO3-20* AnGap-15 [MASKED] 04:45AM BLOOD Glucose-150* UreaN-20 Creat-0.7 Na-141 K-4.1 Cl-107 HCO3-22 AnGap-12 [MASKED] 10:30PM BLOOD ALT-8 AST-25 AlkPhos-59 TotBili-0.2 [MASKED] 10:30PM BLOOD Albumin-3.0* [MASKED] 12:32AM BLOOD Lactate-1.9 URINE CULTURE: 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------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: On admission, Ms. [MASKED] was started empirically on cefepime to cover her previously resistant organisms. This was narrowed to oral ciprofloxacin after culture results revealed pan-sensitive e. coli. Her kidney injury resolved, and her mental status returned to her baseline. As she was at her physical baseline, she was discharged back to her home with home services. HOSPITAL COURSE BY PROBLEM: 1. E. Coli UTI - cipro 250 mg BID x 3 additional days 2. [MASKED]. Resolved completely. 3. T2DM. Metformin,. 4. HTN. Losartan-HCTZ home 5. History of CVA. Aspirin and simvastatin. 6. Vascular dementia. Continue home donepezil. 7. History of DVT. Continue home apixaban. 8. Hypothyroidism. Home levothyroxine. > 30 minutes spent on discharge activities. Patient examined on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 2. Artificial Tears [MASKED] DROP BOTH EYES TID 3. Aspirin 81 mg PO DAILY 4. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO TID 5. Donepezil 5 mg PO QHS 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Mirtazapine 7.5 mg PO QHS 8. Multivitamins 1 TAB PO DAILY 9. Senna 17.2 mg PO DAILY 10. Simvastatin 40 mg PO QPM 11. Docusate Sodium 200 mg PO DAILY 12. losartan-hydrochlorothiazide 100-25 mg oral DAILY 13. Psyllium Wafer 1 WAF PO DAILY 14. MetFORMIN (Glucophage) 500 mg PO BID Discharge Medications: 1. Ciprofloxacin HCl 250 mg PO Q12H RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 2. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever 3. Artificial Tears [MASKED] DROP BOTH EYES TID 4. Aspirin 81 mg PO DAILY 5. Carbidopa-Levodopa ([MASKED]) 1.5 TAB PO TID 6. Docusate Sodium 200 mg PO DAILY 7. Donepezil 5 mg PO QHS 8. Levothyroxine Sodium 125 mcg PO DAILY 9. losartan-hydrochlorothiazide 100-25 mg oral DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Mirtazapine 7.5 mg PO QHS 12. Multivitamins 1 TAB PO DAILY 13. Psyllium Wafer 1 WAF PO DAILY 14. Senna 17.2 mg PO DAILY 15. Simvastatin 40 mg PO QPM Discharge Disposition: Home with Service Discharge Diagnosis: E. Coli UTI Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Confused - always. Discharge Instructions: You were admitted to the hospital with a urinary tract infection. You were started on antibiotics and rapidly improved. Fortunately, your organism was sensitive to oral antibiotics. You will complete three additional days of ciprofloxacin. Followup Instructions: [MASKED]
[]
[ "N390", "N179", "Z8673", "E039", "Z86718", "I10", "K5900", "M109", "F329", "E1165" ]
[ "A4151: Sepsis due to Escherichia coli [E. coli]", "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "F0150: Vascular dementia without behavioral disturbance", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E039: Hypothyroidism, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z7984: Long term (current) use of oral hypoglycemic drugs", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "I10: Essential (primary) hypertension", "Z87440: Personal history of urinary (tract) infections", "G214: Vascular parkinsonism", "E7800: Pure hypercholesterolemia, unspecified", "M5416: Radiculopathy, lumbar region", "E113299: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye", "K5900: Constipation, unspecified", "M109: Gout, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia" ]
10,033,552
26,487,381
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Atenolol / Amlodipine / Tekturna / felodipine / lisinopril / Diovan Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac cath (___) History of Present Illness: Ms. ___ is a ___ yoF w metabolic syndrome, hx of diverticulitis, tension headaches and CKD stage II who presents with nonexertional chest discomfort. Patient reports an acute onset of chest tightness while at rest a few hours prior to arrival. She describes ___ pain with associated shortness of breath. She had a similar episode yesterday that improved with time. Her pain is sometimes worse with palpation and occasional improves after belching. Additionally, she reports ~one week of left upper extremity weakness, overall unchanged in the last day. She was given ASA during transfer to the hospital as well as a sublingual nitro, which provided some temporary relief. She denies any history of MIs and states she had a normal stress test a few years ago. Denies smoking cigarettes, drinking alcohol or using illicit drugs. She was briefly admitted to ___ ___ and treated for uncomplicated diverticulitis. She had chest pain this admission but no acute EKG changes and negative trops so no further diagnostics were pursued. Cards was consulted in the ED and given presentation and dynamic ECG changes most consistent with unstable angina they recommended nitro gtt, hep gtt, and admission to ___ for ?cath. While in the ED, her CP persisted with EKG showing new ST elevations in V2-V4 and she was taken to the cath lab for STEMI. In the cath lab, she was found to have 95-99% mid-LAD occlusion, s/p PCI with one stent w/o complications. Past Medical History: CAD ___ STEMI s/p ___ occlusion) HTN DMII (diet-controlled) CKD stage II: started after appendicitis and bacteremia in ___ Obesity Impingement syndrome, left shoulder GERD HLD TIA Social History: ___ Family History: FH: HTN in mother, CVA and prostate cancer in father Physical ___: ADMISSION EXAM ============== Gen: NAD CV: RRR w/ normal S1 and S2. No m/r/g. Pulm: CTAB. Abd: Soft, NT/ND Ext: No ___ edema or erythema. DISCHAGE EXAM ============= GEN: NAD, pleasant HEENT: NCAT, PERRL, EOMI, sclera anicteric NECK: supple, no visible JVD CV: RRR, s1/s2, no MGR PULM: CTAB, No crackles or wheezes ABD: Soft, NDNT, no rebound/guarding EXT: No ___ edema b/l. R radial site looks d/c/i Pertinent Results: ADMISSION LABS ============= ___ 11:40PM BLOOD WBC-6.9 RBC-4.78 Hgb-13.4 Hct-42.8 MCV-90 MCH-28.0 MCHC-31.3* RDW-13.1 RDWSD-42.8 Plt ___ ___ 11:40PM BLOOD Glucose-135* UreaN-16 Creat-1.2* Na-140 K-3.9 Cl-102 HCO3-23 AnGap-15 ___ 11:40PM BLOOD cTropnT-<0.01 ___ 07:30AM BLOOD cTropnT-0.02* STUDIES ======= Cardiac cath ___ Dominance: Co-dominant * Left Main Coronary Artery The LMCA is without flow limiting stenosis. * Left Anterior Descending The LAD has a mid 99% thrombotic, ulcerated stenosis with TIMI 2 flow. There is a 30% proximal LAD stenosis, otherwise without flow limiting stenosis. The vessel tappers down to a smaller caliber LAD with a larger D3.. * Circumflex The Circumflex is without flow limiting stenosis. * Right Coronary Artery The RCA is without flow limiting stenosis Impressions: Single vessel epicardial coronary artery disease with 99% stenosis in the mid LAD succesfully treated with 1 DES. TTE ___ The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >60%). 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 estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventriuclar chamber size and global/regional systolic function despite known anteriro wall STEMI/mid-LAD revascularization on ___. Compared with the prior study (images reviewed) of ___ there has not been a significant change. TTE ___ The left atrium is normal in size. Normal left ventricular wall thickness, cavity size, and global systolic function (3D LVEF = 66 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal left and right ventricular function. Normal valvular function. DISCHARGE LABS ============= ___ 07:35AM BLOOD WBC-6.8 RBC-4.53 Hgb-12.8 Hct-40.1 MCV-89 MCH-28.3 MCHC-31.9* RDW-13.2 RDWSD-42.9 Plt ___ ___ 07:35AM BLOOD Glucose-115* UreaN-20 Creat-1.2* Na-141 K-3.9 Cl-103 HCO3-24 AnGap-14 Brief Hospital Course: Ms. ___ is a ___ year old female with HTN, HLD, DM, CKD II presenting with CP, SOB consistent with STEMI with mid-LAD(95-99%) occlusion s/p DES. She had no post-catheterization complications and did well post procedurally. She was monitored for 72 hours, had TTE without wall motion abnormalities and was discharged home on ASA and Ticagrelor. #STEMI s/p PCI to mid-LAD (95-99%) occlusion #PUMP: LVEF 66% (___) #Rhythm: sinus bradycardia, rate 50 Largely normal TTE earlier this year. Cath w/o complications via R radial approach. TTE (___) did not show wall motion abnormalities. The following medication changes were made: - ASA 81mg - Ticagralor 90mg BID - atorvastatin 80 (monitor for myalgias Pt on rosuvastatin 10 but this was being held for one week prior to admission due to muscle aches) - Started Metop XL 50mg daily - Started Lisinopril 5mg daily - Stopped home diltiazem 240 PO CHRONIC ISSUES: ================ #HTN: Was on diltiazem at home. Per records, intolerant (cough) to atenolol but no other beta blocker exposure. Her diltiazem was stopped. She was started on lisinopril 5mg and Metoprolol 50mg XL at time of discharge with well controlled blood pressures. #GERD: pt reports feeling bloated with epigastric discomfort for ___ prior to presentation. Possibly angina equivalent vs GERD. Already on BID PPI. Epigastric symptoms resolving post-PCI. -cont home pantoprazole BID #Metabolic syndrome: hx of DM but no longer taking metformin after normalization of A1c. her A1c in house this admission was 5.6%. #CKD stage II: baseline appears to be ~1.1. Likely ___ DM and HTN. SCr 1.2 on admission and discharge, with baseline around 1.0. This is mildly elevated above her baseline of 1.0 and may be related to CIN. #Hx diverticulitis: treated for uncomplicated diverticulitis on last admission ___. Completed antibiotic course with resolution of abdominal pain. CT abd showed a right colonic lesion with mesenteric LNs with f/u recommended at 3 months. No abdominal pain, N/V, or diarrhea this admission. -f/u scheduled for ___ #Hx of transient paresthesia: Left finger tingling and left cheek numbness that lasted for ___ hours and completely resolved in ___ TRANSITIONAL ISSUES =================== [] ASA and Ticagrelor: DAPT for 12 months minimum. ___ years if patient can tolerate. [] Patient should go to cardiac rehab [] Changed HTN regimen from Dilt 240 to Lisinopril 5 and metop 50 XR [] F/u BPs, if high consider uptitrating lisinopril [] Please recheck Chem 10 panel within ___ weeks to ensure Creatinine back to baseline and to ensure no hyperK on lisinopril. [] Monitor for myalgias after initiation of atorvastatin 80. 1 week prior to admission she had had joint pains on rosuvastatin and her PCP had held it. Her Baseline CK measured on ___ was 101. [] Chronic L shoulder pain f/u [] Neurology f/u regarding transient paresthesia [] GI f/u diverticulitis >30 minutes spent on discharge planning/coordination of care. ***PLEASE NOTE: Patient with a history of angioedema (patient not aware and had not reported and was not listed in OMR) to both lisinopril and Diovan. Given that patient was discharged on lisinopril for her blood pressure she was contacted at home on ___ as soon as primary team became aware of this history and she was told to stop taking it. She denied any adverse symptoms. Allergies for both agents entered into OMR and communicated with PCP that completed. Patient plans to follow up with PCP and new cardiologist, Dr. ___ re; an alternative regimen for her long-standing hypertension.*** Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pantoprazole 40 mg PO Q12H 2. Aspirin EC 81 mg PO DAILY 3. Diltiazem Extended-Release 240 mg PO DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Rosuvastatin Calcium 10 mg PO QPM 6. Vitamin D ___ UNIT PO DAILY 7. Central-Vite Womens Mature (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 2. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 4. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*5 5. Aspirin 81 mg PO DAILY 6. Central-Vite Womens Mature (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. Pantoprazole 40 mg PO Q12H 9. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY ======= STEMI SECONDARY ========= HTN DM GERD CKD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had a heart attack WHAT HAPPENED IN THE HOSPITAL? ============================== - You were admitted to the hospital because you had chest pain. You were found to have had a heart attack. Your heart arteries were examined (cardiac catheterization) which showed a blockage of one of the arteries. This was opened by placing a tube called a stent in the artery. You were given medications to prevent future blockages. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Make sure to take your medication daily - It is VERY IMPORTANT to take your aspirin and ticagrelor (also known as Brilinta) every day. - These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. - If you stop these medications or miss ___ dose, you risk causing a blood clot forming in your heart stents and having another heart attack - Please do not stop taking either medication without taking to your heart doctor. - You are also on other new medications to help your heart, such as atorvastatin (a stronger statin), lisinopril and metoprolol. Lisinopril and metoprolol will also help with your blood pressure in the place of your previous diltiazem - If you start having muscle or joint pains it may be from the atorvastatin. Please call your primary care doctor or cardiologist to discuss. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
[ "I213", "E1122", "E8881", "I2510", "I129", "N182", "K219", "Z8673", "E7800" ]
Allergies: Atenolol / Amlodipine / Tekturna / felodipine / lisinopril / Diovan Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac cath ([MASKED]) History of Present Illness: Ms. [MASKED] is a [MASKED] yoF w metabolic syndrome, hx of diverticulitis, tension headaches and CKD stage II who presents with nonexertional chest discomfort. Patient reports an acute onset of chest tightness while at rest a few hours prior to arrival. She describes [MASKED] pain with associated shortness of breath. She had a similar episode yesterday that improved with time. Her pain is sometimes worse with palpation and occasional improves after belching. Additionally, she reports ~one week of left upper extremity weakness, overall unchanged in the last day. She was given ASA during transfer to the hospital as well as a sublingual nitro, which provided some temporary relief. She denies any history of MIs and states she had a normal stress test a few years ago. Denies smoking cigarettes, drinking alcohol or using illicit drugs. She was briefly admitted to [MASKED] [MASKED] and treated for uncomplicated diverticulitis. She had chest pain this admission but no acute EKG changes and negative trops so no further diagnostics were pursued. Cards was consulted in the ED and given presentation and dynamic ECG changes most consistent with unstable angina they recommended nitro gtt, hep gtt, and admission to [MASKED] for ?cath. While in the ED, her CP persisted with EKG showing new ST elevations in V2-V4 and she was taken to the cath lab for STEMI. In the cath lab, she was found to have 95-99% mid-LAD occlusion, s/p PCI with one stent w/o complications. Past Medical History: CAD [MASKED] STEMI s/p [MASKED] occlusion) HTN DMII (diet-controlled) CKD stage II: started after appendicitis and bacteremia in [MASKED] Obesity Impingement syndrome, left shoulder GERD HLD TIA Social History: [MASKED] Family History: FH: HTN in mother, CVA and prostate cancer in father Physical [MASKED]: ADMISSION EXAM ============== Gen: NAD CV: RRR w/ normal S1 and S2. No m/r/g. Pulm: CTAB. Abd: Soft, NT/ND Ext: No [MASKED] edema or erythema. DISCHAGE EXAM ============= GEN: NAD, pleasant HEENT: NCAT, PERRL, EOMI, sclera anicteric NECK: supple, no visible JVD CV: RRR, s1/s2, no MGR PULM: CTAB, No crackles or wheezes ABD: Soft, NDNT, no rebound/guarding EXT: No [MASKED] edema b/l. R radial site looks d/c/i Pertinent Results: ADMISSION LABS ============= [MASKED] 11:40PM BLOOD WBC-6.9 RBC-4.78 Hgb-13.4 Hct-42.8 MCV-90 MCH-28.0 MCHC-31.3* RDW-13.1 RDWSD-42.8 Plt [MASKED] [MASKED] 11:40PM BLOOD Glucose-135* UreaN-16 Creat-1.2* Na-140 K-3.9 Cl-102 HCO3-23 AnGap-15 [MASKED] 11:40PM BLOOD cTropnT-<0.01 [MASKED] 07:30AM BLOOD cTropnT-0.02* STUDIES ======= Cardiac cath [MASKED] Dominance: Co-dominant * Left Main Coronary Artery The LMCA is without flow limiting stenosis. * Left Anterior Descending The LAD has a mid 99% thrombotic, ulcerated stenosis with TIMI 2 flow. There is a 30% proximal LAD stenosis, otherwise without flow limiting stenosis. The vessel tappers down to a smaller caliber LAD with a larger D3.. * Circumflex The Circumflex is without flow limiting stenosis. * Right Coronary Artery The RCA is without flow limiting stenosis Impressions: Single vessel epicardial coronary artery disease with 99% stenosis in the mid LAD succesfully treated with 1 DES. TTE [MASKED] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >60%). 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 estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventriuclar chamber size and global/regional systolic function despite known anteriro wall STEMI/mid-LAD revascularization on [MASKED]. Compared with the prior study (images reviewed) of [MASKED] there has not been a significant change. TTE [MASKED] The left atrium is normal in size. Normal left ventricular wall thickness, cavity size, and global systolic function (3D LVEF = 66 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal left and right ventricular function. Normal valvular function. DISCHARGE LABS ============= [MASKED] 07:35AM BLOOD WBC-6.8 RBC-4.53 Hgb-12.8 Hct-40.1 MCV-89 MCH-28.3 MCHC-31.9* RDW-13.2 RDWSD-42.9 Plt [MASKED] [MASKED] 07:35AM BLOOD Glucose-115* UreaN-20 Creat-1.2* Na-141 K-3.9 Cl-103 HCO3-24 AnGap-14 Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old female with HTN, HLD, DM, CKD II presenting with CP, SOB consistent with STEMI with mid-LAD(95-99%) occlusion s/p DES. She had no post-catheterization complications and did well post procedurally. She was monitored for 72 hours, had TTE without wall motion abnormalities and was discharged home on ASA and Ticagrelor. #STEMI s/p PCI to mid-LAD (95-99%) occlusion #PUMP: LVEF 66% ([MASKED]) #Rhythm: sinus bradycardia, rate 50 Largely normal TTE earlier this year. Cath w/o complications via R radial approach. TTE ([MASKED]) did not show wall motion abnormalities. The following medication changes were made: - ASA 81mg - Ticagralor 90mg BID - atorvastatin 80 (monitor for myalgias Pt on rosuvastatin 10 but this was being held for one week prior to admission due to muscle aches) - Started Metop XL 50mg daily - Started Lisinopril 5mg daily - Stopped home diltiazem 240 PO CHRONIC ISSUES: ================ #HTN: Was on diltiazem at home. Per records, intolerant (cough) to atenolol but no other beta blocker exposure. Her diltiazem was stopped. She was started on lisinopril 5mg and Metoprolol 50mg XL at time of discharge with well controlled blood pressures. #GERD: pt reports feeling bloated with epigastric discomfort for [MASKED] prior to presentation. Possibly angina equivalent vs GERD. Already on BID PPI. Epigastric symptoms resolving post-PCI. -cont home pantoprazole BID #Metabolic syndrome: hx of DM but no longer taking metformin after normalization of A1c. her A1c in house this admission was 5.6%. #CKD stage II: baseline appears to be ~1.1. Likely [MASKED] DM and HTN. SCr 1.2 on admission and discharge, with baseline around 1.0. This is mildly elevated above her baseline of 1.0 and may be related to CIN. #Hx diverticulitis: treated for uncomplicated diverticulitis on last admission [MASKED]. Completed antibiotic course with resolution of abdominal pain. CT abd showed a right colonic lesion with mesenteric LNs with f/u recommended at 3 months. No abdominal pain, N/V, or diarrhea this admission. -f/u scheduled for [MASKED] #Hx of transient paresthesia: Left finger tingling and left cheek numbness that lasted for [MASKED] hours and completely resolved in [MASKED] TRANSITIONAL ISSUES =================== [] ASA and Ticagrelor: DAPT for 12 months minimum. [MASKED] years if patient can tolerate. [] Patient should go to cardiac rehab [] Changed HTN regimen from Dilt 240 to Lisinopril 5 and metop 50 XR [] F/u BPs, if high consider uptitrating lisinopril [] Please recheck Chem 10 panel within [MASKED] weeks to ensure Creatinine back to baseline and to ensure no hyperK on lisinopril. [] Monitor for myalgias after initiation of atorvastatin 80. 1 week prior to admission she had had joint pains on rosuvastatin and her PCP had held it. Her Baseline CK measured on [MASKED] was 101. [] Chronic L shoulder pain f/u [] Neurology f/u regarding transient paresthesia [] GI f/u diverticulitis >30 minutes spent on discharge planning/coordination of care. ***PLEASE NOTE: Patient with a history of angioedema (patient not aware and had not reported and was not listed in OMR) to both lisinopril and Diovan. Given that patient was discharged on lisinopril for her blood pressure she was contacted at home on [MASKED] as soon as primary team became aware of this history and she was told to stop taking it. She denied any adverse symptoms. Allergies for both agents entered into OMR and communicated with PCP that completed. Patient plans to follow up with PCP and new cardiologist, Dr. [MASKED] re; an alternative regimen for her long-standing hypertension.*** Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pantoprazole 40 mg PO Q12H 2. Aspirin EC 81 mg PO DAILY 3. Diltiazem Extended-Release 240 mg PO DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Rosuvastatin Calcium 10 mg PO QPM 6. Vitamin D [MASKED] UNIT PO DAILY 7. Central-Vite Womens Mature (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 2. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Metoprolol Tartrate 25 mg PO BID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 4. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*5 5. Aspirin 81 mg PO DAILY 6. Central-Vite Womens Mature (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. Pantoprazole 40 mg PO Q12H 9. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY ======= STEMI SECONDARY ========= HTN DM GERD CKD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had a heart attack WHAT HAPPENED IN THE HOSPITAL? ============================== - You were admitted to the hospital because you had chest pain. You were found to have had a heart attack. Your heart arteries were examined (cardiac catheterization) which showed a blockage of one of the arteries. This was opened by placing a tube called a stent in the artery. You were given medications to prevent future blockages. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Make sure to take your medication daily - It is VERY IMPORTANT to take your aspirin and ticagrelor (also known as Brilinta) every day. - These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. - If you stop these medications or miss [MASKED] dose, you risk causing a blood clot forming in your heart stents and having another heart attack - Please do not stop taking either medication without taking to your heart doctor. - You are also on other new medications to help your heart, such as atorvastatin (a stronger statin), lisinopril and metoprolol. Lisinopril and metoprolol will also help with your blood pressure in the place of your previous diltiazem - If you start having muscle or joint pains it may be from the atorvastatin. Please call your primary care doctor or cardiologist to discuss. Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
[]
[ "E1122", "I2510", "I129", "K219", "Z8673" ]
[ "I213: ST elevation (STEMI) myocardial infarction of unspecified site", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E8881: Metabolic syndrome", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N182: Chronic kidney disease, stage 2 (mild)", "K219: Gastro-esophageal reflux disease without esophagitis", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E7800: Pure hypercholesterolemia, unspecified" ]
10,033,552
28,741,297
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Atenolol / Amlodipine / Tekturna / felodipine Attending: ___. Chief Complaint: headache, chest pain, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with history of hypertension, hyperlipidemia, and metabolic syndrome on metformin presenting with headache, chest pain and abdominal pain. Patient reports since ___, she has had a few days of left-sided abdominal pain and gradual onset of headache. She reported associated chills and generalized weakness. Reports today, she had an episode of vomiting. Therefore presented for evaluation. Patient also reports few days of intermittent chest pain. It started on ___. She says she experiences chest pain occasionally and this feels very similar. Reports chest pain with radiation into the left side or the right side intermittently. Nonexertional without obvious triggers. States she burps a lot when she rubs her chest. Mostly chest pain comes when lying down. No relation to food. No alleviating or exacerbating factor. Associated shortness of breath. Denies diaphoresis, lightheadedness. Denies fever, diarrhea, melena, hematochezia, dysuria, hematuria. Denies leg pain, leg swelling, history DVT/PE. In regards to left lower quadrant pain: began a few days prior and has prior history of diverticulitis and this feels similar. She endorses constipation. Had associated chills, no recorded fevers, vomiting x1 today. Pain not radiating to back. In regards to headache: It started with a gradual onset headache which is similar to her prior tension type headaches which she gets occasionally by character and severity. Onset and early afternoon, maximal by evening. This is been waxing and waning since then. Dull dominantly frontal. No radiation or paresthesias. No vertigo. No lightheadedness. Past Medical History: CKD stage II: started after appendicitis and bacteremia in ___ HTN Metabolic syndrome Obesity Impingement syndrome, left shoulder GERD HLD TIA Social History: ___ Family History: FH: HTN in mother, CVA and prostate cancer in father Physical ___: ADMISSION PHYSICAL EXAM: VS: 98.2 20 163 / 80 70 96 Ra GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, tender to palpation in left lower quadrant, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL: VS: 98.9PO 143 / 78 71 18 95 RA General: NAD, laying back in bed HEENT: AT/NC, EOMI, no JVD, no LAD, neck supple Cardiac: RRR, s1+s2 normal, no m/g/r appreciated Pulm: CTAB Abd: +BS, non-distended, tender to deep palpation of left side particularly in the LLQ, no organomegaly, no guarding Ext: Pulses present, no edema Neuro: No motor/sensory deficits elicited Pertinent Results: ADMISSION LABS: ___ 06:50PM cTropnT-<0.01 ___ 12:45PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 12:45PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5 LEUK-NEG ___ 12:45PM URINE ___ BACTERIA-FEW* YEAST-NONE ___ 12:35PM GLUCOSE-118* UREA N-13 CREAT-1.1 SODIUM-141 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-30 ANION GAP-8* ___ 12:35PM estGFR-Using this ___ 12:35PM ALT(SGPT)-23 AST(SGOT)-20 ALK PHOS-86 TOT BILI-0.5 ___ 12:35PM LIPASE-27 ___ 12:35PM cTropnT-<0.01 ___ 12:35PM ALBUMIN-4.2 ___ 12:35PM WBC-5.9 RBC-4.52 HGB-12.9 HCT-39.9 MCV-88 MCH-28.5 MCHC-32.3 RDW-12.4 RDWSD-40.1 ___ 12:35PM NEUTS-65.1 ___ MONOS-4.9* EOS-1.2 BASOS-0.2 IM ___ AbsNeut-3.81 AbsLymp-1.66 AbsMono-0.29 AbsEos-0.07 AbsBaso-0.01 ___ 12:35PM PLT COUNT-180 ___ 12:35PM ___ PTT-28.6 ___ DISCHARGE LABS: ___ 05:05AM BLOOD WBC-6.5 RBC-4.44 Hgb-12.4 Hct-39.3 MCV-89 MCH-27.9 MCHC-31.6* RDW-12.6 RDWSD-40.9 Plt ___ ___ 05:05AM BLOOD Plt ___ ___ 05:05AM BLOOD Glucose-106* UreaN-8 Creat-1.0 Na-142 K-3.3 Cl-104 HCO3-23 AnGap-15 ___ 05:05AM BLOOD ALT-20 AST-17 AlkPhos-77 TotBili-0.6 ___ 05:05AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 IMAGING: ___ CT a/p w/ contrast: 1. Moderate wall thickening and fat stranding surrounding a few descending colonic diverticulum, compatible with acute uncomplicated diverticulitis. Specifically, there are no focal fluid collections or evidence of pneumoperitoneum. 2. Hyperdensity within the wall of the right colonic diverticula, which is new compared to prior, and may represent ingested material or mucosal hyperemia. In addition, there are few prominent mesenteric lymph nodes within the right hemiabdomen, which have increased in size compared to prior examinations. These findings should be followed up with CT in 3 months. 3. 6 mm ground-glass nodule within the right middle lobe, unchanged since ___. 4. Fibroid uterus. 5. Mild anterolisthesis of L5 on S1 due to bilateral pars defects. ___ CXR: No evidence of pneumonia. MICRO: ___ Urine cx: PND ___ Blood cx x2: PND Brief Hospital Course: Ms. ___ is a ___ w metabolic syndrome, previous diverticulitis, tension headaches and CKD stage II who presents with left lower quadrant pain, chest pain and headache for the last week, found to have uncomplicated diverticulitis on imaging. ACUTE ISSUES: #Diverticulitis: Patient has had gradual onset of left lower abdominal pain which is similar to previous bouts of diverticulitis. Imaging was notable for uncomplicated diverticulitis. Patient did not have leukocytosis or fever and there was not current concern for complicated diverticulitis based on imaging. Was started on Ciprofloxacin and metronidazole in addition to IVF. Her symptoms improved and she tolerated a regular diet so was discharged with plans for PCP ___. #Chest pain: In the ED there was initially concern for cardiac chest pain, but upon further review with the patient she has had the same intermittent chest pain for several years, which has been unchanged. The pain lacked characteristics suggestive of cardiac ischemia. Her EKG was unchanged from prior, troponins were negative, and her prior cardiac work-up (for the same symptoms) has been negative. Therefore further diagnostics were not pursued at this time. She had no chest pain after the time of admission. Her chest pain seemed most consistent with a GI cause such GERD given the report of improving with burping. #Headache: Currently resolved. Patient states that this is reminiscent of previous tension type headaches, which may have been exacerbated by dehydration in setting of vomiting/diverticulitis. Received Tylenol PRN. #CT finding requiring ___: "Hyperdensity within the wall of the right colonic diverticula, which is new compared to prior, and may represent ingested material or mucosal hyperemia. In addition, there are few prominent mesenteric lymph nodes within the right hemiabdomen, which have increased in size compared to prior examinations. These findings should be followed up with CT in 3 months or colonoscopy for the right colonic lesion." TRANSITIONAL ISSUES: #New Medications: -MetroNIDAZOLE 500 mg PO/NG Q8H -Ciprofloxacin 500 mg PO Q12H []Colonoscopy should be performed, except if she had colonoscopy within the previous year. []Chest pain workup, had a negative stress test ___ years ago and presentation much more likely consistent w/ GERD. Was told to sit upright after eating and eat foods that do not cause her reflux symptoms. []Complete 10 day course of cipro/flagyl until ___: (___) [] ___ CT in 3 months as per above #CODE: Full (presumed) #CONTACT: ___: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 240 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. Pantoprazole 40 mg PO Q12H 5. Rosuvastatin Calcium 10 mg PO QPM 6. Aspirin EC 81 mg PO DAILY 7. Vitamin D ___ UNIT PO DAILY 8. melatonin unknown mg oral DAILY 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Central-Vite Womens Mature (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*18 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*27 Tablet Refills:*0 3. Aspirin EC 81 mg PO DAILY 4. Central-Vite Womens Mature (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. melatonin unknown oral DAILY 9. MetFORMIN (Glucophage) 500 mg PO DAILY 10. Pantoprazole 40 mg PO Q12H 11. Rosuvastatin Calcium 10 mg PO QPM 12. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Diverticulitis Chest pain SECONDARY: Gastroesophageal reflux disease Diabetes Mellitus type II Hypertension Hyperlipidemia 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 in the hospital? - You were hospitalized because you had abdominal pain and were found to have a recurrent episode of your diverticulitis, which is an infection in a part of your large intestines. What was done while I was in the hospital? - Pictures were taken that showed you had an infection and inflammation in a part of your large intestines which you've experienced before. - Pictures were taken of your heart which did not show any concerning changes. You also had blood tests which showed that your heart was NOT experiencing any sudden injury. - You were started on medications called antibiotics to treat this infection in your intestines. What should I do when I go home? - It is very important that you take your medications as prescribed. - Please go to your scheduled appointment with your primary doctor. - If you have sudden chest pain which does not stop or gets worse or if your abdominal pain is much worse, please tell your primary doctor or go to the emergency room. ___ wishes, Your ___ team Followup Instructions: ___
[ "K5732", "R079", "K219", "E1122", "I129", "N182", "E785", "E860", "G44209", "E8881", "R933", "E669", "Z6830", "Z8673" ]
Allergies: Atenolol / Amlodipine / Tekturna / felodipine Chief Complaint: headache, chest pain, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female with history of hypertension, hyperlipidemia, and metabolic syndrome on metformin presenting with headache, chest pain and abdominal pain. Patient reports since [MASKED], she has had a few days of left-sided abdominal pain and gradual onset of headache. She reported associated chills and generalized weakness. Reports today, she had an episode of vomiting. Therefore presented for evaluation. Patient also reports few days of intermittent chest pain. It started on [MASKED]. She says she experiences chest pain occasionally and this feels very similar. Reports chest pain with radiation into the left side or the right side intermittently. Nonexertional without obvious triggers. States she burps a lot when she rubs her chest. Mostly chest pain comes when lying down. No relation to food. No alleviating or exacerbating factor. Associated shortness of breath. Denies diaphoresis, lightheadedness. Denies fever, diarrhea, melena, hematochezia, dysuria, hematuria. Denies leg pain, leg swelling, history DVT/PE. In regards to left lower quadrant pain: began a few days prior and has prior history of diverticulitis and this feels similar. She endorses constipation. Had associated chills, no recorded fevers, vomiting x1 today. Pain not radiating to back. In regards to headache: It started with a gradual onset headache which is similar to her prior tension type headaches which she gets occasionally by character and severity. Onset and early afternoon, maximal by evening. This is been waxing and waning since then. Dull dominantly frontal. No radiation or paresthesias. No vertigo. No lightheadedness. Past Medical History: CKD stage II: started after appendicitis and bacteremia in [MASKED] HTN Metabolic syndrome Obesity Impingement syndrome, left shoulder GERD HLD TIA Social History: [MASKED] Family History: FH: HTN in mother, CVA and prostate cancer in father Physical [MASKED]: ADMISSION PHYSICAL EXAM: VS: 98.2 20 163 / 80 70 96 Ra GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, tender to palpation in left lower quadrant, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL: VS: 98.9PO 143 / 78 71 18 95 RA General: NAD, laying back in bed HEENT: AT/NC, EOMI, no JVD, no LAD, neck supple Cardiac: RRR, s1+s2 normal, no m/g/r appreciated Pulm: CTAB Abd: +BS, non-distended, tender to deep palpation of left side particularly in the LLQ, no organomegaly, no guarding Ext: Pulses present, no edema Neuro: No motor/sensory deficits elicited Pertinent Results: ADMISSION LABS: [MASKED] 06:50PM cTropnT-<0.01 [MASKED] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 12:45PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5 LEUK-NEG [MASKED] 12:45PM URINE [MASKED] BACTERIA-FEW* YEAST-NONE [MASKED] 12:35PM GLUCOSE-118* UREA N-13 CREAT-1.1 SODIUM-141 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-30 ANION GAP-8* [MASKED] 12:35PM estGFR-Using this [MASKED] 12:35PM ALT(SGPT)-23 AST(SGOT)-20 ALK PHOS-86 TOT BILI-0.5 [MASKED] 12:35PM LIPASE-27 [MASKED] 12:35PM cTropnT-<0.01 [MASKED] 12:35PM ALBUMIN-4.2 [MASKED] 12:35PM WBC-5.9 RBC-4.52 HGB-12.9 HCT-39.9 MCV-88 MCH-28.5 MCHC-32.3 RDW-12.4 RDWSD-40.1 [MASKED] 12:35PM NEUTS-65.1 [MASKED] MONOS-4.9* EOS-1.2 BASOS-0.2 IM [MASKED] AbsNeut-3.81 AbsLymp-1.66 AbsMono-0.29 AbsEos-0.07 AbsBaso-0.01 [MASKED] 12:35PM PLT COUNT-180 [MASKED] 12:35PM [MASKED] PTT-28.6 [MASKED] DISCHARGE LABS: [MASKED] 05:05AM BLOOD WBC-6.5 RBC-4.44 Hgb-12.4 Hct-39.3 MCV-89 MCH-27.9 MCHC-31.6* RDW-12.6 RDWSD-40.9 Plt [MASKED] [MASKED] 05:05AM BLOOD Plt [MASKED] [MASKED] 05:05AM BLOOD Glucose-106* UreaN-8 Creat-1.0 Na-142 K-3.3 Cl-104 HCO3-23 AnGap-15 [MASKED] 05:05AM BLOOD ALT-20 AST-17 AlkPhos-77 TotBili-0.6 [MASKED] 05:05AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9 IMAGING: [MASKED] CT a/p w/ contrast: 1. Moderate wall thickening and fat stranding surrounding a few descending colonic diverticulum, compatible with acute uncomplicated diverticulitis. Specifically, there are no focal fluid collections or evidence of pneumoperitoneum. 2. Hyperdensity within the wall of the right colonic diverticula, which is new compared to prior, and may represent ingested material or mucosal hyperemia. In addition, there are few prominent mesenteric lymph nodes within the right hemiabdomen, which have increased in size compared to prior examinations. These findings should be followed up with CT in 3 months. 3. 6 mm ground-glass nodule within the right middle lobe, unchanged since [MASKED]. 4. Fibroid uterus. 5. Mild anterolisthesis of L5 on S1 due to bilateral pars defects. [MASKED] CXR: No evidence of pneumonia. MICRO: [MASKED] Urine cx: PND [MASKED] Blood cx x2: PND Brief Hospital Course: Ms. [MASKED] is a [MASKED] w metabolic syndrome, previous diverticulitis, tension headaches and CKD stage II who presents with left lower quadrant pain, chest pain and headache for the last week, found to have uncomplicated diverticulitis on imaging. ACUTE ISSUES: #Diverticulitis: Patient has had gradual onset of left lower abdominal pain which is similar to previous bouts of diverticulitis. Imaging was notable for uncomplicated diverticulitis. Patient did not have leukocytosis or fever and there was not current concern for complicated diverticulitis based on imaging. Was started on Ciprofloxacin and metronidazole in addition to IVF. Her symptoms improved and she tolerated a regular diet so was discharged with plans for PCP [MASKED]. #Chest pain: In the ED there was initially concern for cardiac chest pain, but upon further review with the patient she has had the same intermittent chest pain for several years, which has been unchanged. The pain lacked characteristics suggestive of cardiac ischemia. Her EKG was unchanged from prior, troponins were negative, and her prior cardiac work-up (for the same symptoms) has been negative. Therefore further diagnostics were not pursued at this time. She had no chest pain after the time of admission. Her chest pain seemed most consistent with a GI cause such GERD given the report of improving with burping. #Headache: Currently resolved. Patient states that this is reminiscent of previous tension type headaches, which may have been exacerbated by dehydration in setting of vomiting/diverticulitis. Received Tylenol PRN. #CT finding requiring [MASKED]: "Hyperdensity within the wall of the right colonic diverticula, which is new compared to prior, and may represent ingested material or mucosal hyperemia. In addition, there are few prominent mesenteric lymph nodes within the right hemiabdomen, which have increased in size compared to prior examinations. These findings should be followed up with CT in 3 months or colonoscopy for the right colonic lesion." TRANSITIONAL ISSUES: #New Medications: -MetroNIDAZOLE 500 mg PO/NG Q8H -Ciprofloxacin 500 mg PO Q12H []Colonoscopy should be performed, except if she had colonoscopy within the previous year. []Chest pain workup, had a negative stress test [MASKED] years ago and presentation much more likely consistent w/ GERD. Was told to sit upright after eating and eat foods that do not cause her reflux symptoms. []Complete 10 day course of cipro/flagyl until [MASKED]: ([MASKED]) [] [MASKED] CT in 3 months as per above #CODE: Full (presumed) #CONTACT: [MASKED]: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 240 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. Pantoprazole 40 mg PO Q12H 5. Rosuvastatin Calcium 10 mg PO QPM 6. Aspirin EC 81 mg PO DAILY 7. Vitamin D [MASKED] UNIT PO DAILY 8. melatonin unknown mg oral DAILY 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Central-Vite Womens Mature (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*18 Tablet Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*27 Tablet Refills:*0 3. Aspirin EC 81 mg PO DAILY 4. Central-Vite Womens Mature (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. melatonin unknown oral DAILY 9. MetFORMIN (Glucophage) 500 mg PO DAILY 10. Pantoprazole 40 mg PO Q12H 11. Rosuvastatin Calcium 10 mg PO QPM 12. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Diverticulitis Chest pain SECONDARY: Gastroesophageal reflux disease Diabetes Mellitus type II Hypertension Hyperlipidemia 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 in the hospital? - You were hospitalized because you had abdominal pain and were found to have a recurrent episode of your diverticulitis, which is an infection in a part of your large intestines. What was done while I was in the hospital? - Pictures were taken that showed you had an infection and inflammation in a part of your large intestines which you've experienced before. - Pictures were taken of your heart which did not show any concerning changes. You also had blood tests which showed that your heart was NOT experiencing any sudden injury. - You were started on medications called antibiotics to treat this infection in your intestines. What should I do when I go home? - It is very important that you take your medications as prescribed. - Please go to your scheduled appointment with your primary doctor. - If you have sudden chest pain which does not stop or gets worse or if your abdominal pain is much worse, please tell your primary doctor or go to the emergency room. [MASKED] wishes, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "K219", "E1122", "I129", "E785", "E669", "Z8673" ]
[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "R079: Chest pain, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N182: Chronic kidney disease, stage 2 (mild)", "E785: Hyperlipidemia, unspecified", "E860: Dehydration", "G44209: Tension-type headache, unspecified, not intractable", "E8881: Metabolic syndrome", "R933: Abnormal findings on diagnostic imaging of other parts of digestive tract", "E669: Obesity, unspecified", "Z6830: Body mass index [BMI]30.0-30.9, adult", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,033,552
29,061,116
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Atenolol / Amlodipine / Tekturna / felodipine / lisinopril / Diovan Attending: ___. Chief Complaint: Chest Pain, L Shoulder Pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/ PMHx CAD s/p STEMI w/ PCI to mid-LAD (___), HTN, previous hx of diverticulitis, and CKD stage II presenting with chest/L shoulder pain. Patient was in her USOH until over about the last week she noticed pain in her L shoulder which wrapped around into her L rib cage. She noted this pain first after raking some leaves in her yard and notes that she continued to have some symptoms at night if she slept on that shoulder. Noted that the pain improved with Tylenol and with topical mineral oil. She then woke up this morning and reports developing substernal chest "discomfort" that was constant for about an hour but resolved without intervention. She also experienced some SOB but denied diaphoresis or palpitations. Patient noted the pain is quite different than what she experienced during her MI which she described as an ___ on her chest. Past Medical History: CAD ___ STEMI s/p ___ occlusion) HTN DMII (diet-controlled) CKD stage II: started after appendicitis and bacteremia in ___ Obesity Impingement syndrome, left shoulder GERD HLD TIA Social History: ___ Family History: HTN in mother, CVA and prostate cancer in father Physical Exam: Admission PE: VITALS: 97.4 172 / 87 52 18 97 RA General: Pleasant F in NAD HEENT: NCAT, MMM CV: RRR, no m/r/g Lungs: CTAB Abdomen: Soft, NT/ND, BS+ Ext: WWP, no c/c/e Skin: Warm, dry, no rashes or notable lesions Neuro: AAOx3, grossly intact Discharge PE: VS: Temp: 97.8 PO BP: 126/77 HR: 49 O2 sat: 97% Today's Weight: 64.7 kg, 142.64 lb Tele: ___, SB, no ectopy General: Pleasant in NAD HEENT: NCAT, MMM CV: RRR, no m/r/g Lungs: CTAB Abdomen: Soft, NT/ND, BS+ Ext: WWP, no c/c/e Skin: Warm, dry, no rashes or notable lesions Neuro: AAOx3, grossly intact Pertinent Results: Admission Labs: ___ 01:45PM BLOOD WBC-5.8 RBC-4.39 Hgb-12.6 Hct-39.7 MCV-90 MCH-28.7 MCHC-31.7* RDW-13.1 RDWSD-42.9 Plt ___ ___ 01:45PM BLOOD Neuts-45.8 ___ Monos-8.5 Eos-1.7 Baso-0.5 Im ___ AbsNeut-2.65 AbsLymp-2.50 AbsMono-0.49 AbsEos-0.10 AbsBaso-0.03 ___ 01:45PM BLOOD ___ PTT-28.9 ___ ___ 01:45PM BLOOD Glucose-95 UreaN-16 Creat-1.0 Na-140 K-4.3 Cl-99 HCO3-25 AnGap-16 ___ 01:45PM BLOOD ALT-22 AST-27 AlkPhos-80 TotBili-0.9 ___ 01:45PM BLOOD cTropnT-<0.01 ___ 06:21PM BLOOD cTropnT-<0.01 ___ 01:45PM BLOOD Albumin-4.7 Chest PA/Lat ___: FINDINGS: PA and lateral views of the chest provided. Lungs are clear. There is no focal consolidation, effusion, or pneumothorax. There are no signs of congestion or edema. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Discharge Labs: ___ 07:45AM BLOOD WBC-5.7 RBC-4.29 Hgb-12.2 Hct-38.5 MCV-90 MCH-28.4 MCHC-31.7* RDW-13.2 RDWSD-43.2 Plt ___ ___ 07:45AM BLOOD ___ PTT-27.9 ___ ___ 07:45AM BLOOD Glucose-89 UreaN-17 Creat-1.0 Na-139 K-3.4* Cl-100 HCO3-23 AnGap-16 ___ 07:45AM BLOOD Calcium-9.9 Phos-3.8 Mg-1.___SSESSMENT & PLAN: ___ w/ PMHx CAD s/p STEMI w/ PCI to mid-LAD (___), HTN, previous hx of diverticulitis, and CKD stage II presented with chest/L shoulder pain. #Coronaries: 95-99% occlusion mid-LAD s/p PCI #PUMP: LVEF 66% (___) #Rhythm: Sinus brady #CAD s/p STEMI w/ PCI to mid-LAD #Chest pain: Patient presented with one day history of substernal CP which resolved prior to admission. Reassuringly w/o ischemic changes to ECG and trop negative x2. Has a history of STEMI in ___ s/p PCI to mid-LAD. Initially c/o shoulder pain which seems to be much more MSK and entirely different than the substernal "discomfort" and dyspnea which prompted her to be evaluated in the ED. Pt would like to go home and do stress test as outpatient. -Continue ASA 81mg -Continue Ticagralor 90mg BID -Continue Atorva 80 mg daily -Continue Carvedilol 6.25 mg BID -Nuclear stress test ordered to be done as outpt, possibly tomorrow #HTN: -Continue carvedilol, HCTZ #GERD: -Continue pantoprazole #CKD stage II: At baseline (appears to be around ___. Creat 1.0 today #Dispo: -Discharge home today with plans to have outpatient nuclear stress test in ___ days -Follow-up with Dr. ___ next week, pt will call for appointment #Transitional: none Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. Pantoprazole 40 mg PO Q12H 4. Atorvastatin 80 mg PO QPM 5. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 6. Vitamin D ___ UNIT PO DAILY 7. CARVedilol 6.25 mg PO BID 8. Hydrochlorothiazide 25 mg PO DAILY 9. Oxybutynin XL (*NF*) 5 mg Other DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. CARVedilol 6.25 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Oxybutynin XL (*NF*) 5 mg Other DAILY 7. Pantoprazole 40 mg PO Q12H 8. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 9. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Angina pectoris CAD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with left shoulder and left sided chest pain. Lab work and EKG did not show that you were having a heart attack. However, we would like to do a stress test on you in ___ days with your heart attack history last ___. Please call the number that was provided to you and schedule the test possibly tomorrow. Please call Dr. ___ tomorrow and make an appointment to see him early next week so Dr. ___ go over the stress results with you. Continue all of your medications without any changes. 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: ___
[ "I25119", "I129", "E1122", "N182", "Z955", "I252", "Z7902", "M7542", "E785", "K219", "Z8673", "E669", "Z6829" ]
Allergies: Atenolol / Amlodipine / Tekturna / felodipine / lisinopril / Diovan Chief Complaint: Chest Pain, L Shoulder Pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] w/ PMHx CAD s/p STEMI w/ PCI to mid-LAD ([MASKED]), HTN, previous hx of diverticulitis, and CKD stage II presenting with chest/L shoulder pain. Patient was in her USOH until over about the last week she noticed pain in her L shoulder which wrapped around into her L rib cage. She noted this pain first after raking some leaves in her yard and notes that she continued to have some symptoms at night if she slept on that shoulder. Noted that the pain improved with Tylenol and with topical mineral oil. She then woke up this morning and reports developing substernal chest "discomfort" that was constant for about an hour but resolved without intervention. She also experienced some SOB but denied diaphoresis or palpitations. Patient noted the pain is quite different than what she experienced during her MI which she described as an [MASKED] on her chest. Past Medical History: CAD [MASKED] STEMI s/p [MASKED] occlusion) HTN DMII (diet-controlled) CKD stage II: started after appendicitis and bacteremia in [MASKED] Obesity Impingement syndrome, left shoulder GERD HLD TIA Social History: [MASKED] Family History: HTN in mother, CVA and prostate cancer in father Physical Exam: Admission PE: VITALS: 97.4 172 / 87 52 18 97 RA General: Pleasant F in NAD HEENT: NCAT, MMM CV: RRR, no m/r/g Lungs: CTAB Abdomen: Soft, NT/ND, BS+ Ext: WWP, no c/c/e Skin: Warm, dry, no rashes or notable lesions Neuro: AAOx3, grossly intact Discharge PE: VS: Temp: 97.8 PO BP: 126/77 HR: 49 O2 sat: 97% Today's Weight: 64.7 kg, 142.64 lb Tele: [MASKED], SB, no ectopy General: Pleasant in NAD HEENT: NCAT, MMM CV: RRR, no m/r/g Lungs: CTAB Abdomen: Soft, NT/ND, BS+ Ext: WWP, no c/c/e Skin: Warm, dry, no rashes or notable lesions Neuro: AAOx3, grossly intact Pertinent Results: Admission Labs: [MASKED] 01:45PM BLOOD WBC-5.8 RBC-4.39 Hgb-12.6 Hct-39.7 MCV-90 MCH-28.7 MCHC-31.7* RDW-13.1 RDWSD-42.9 Plt [MASKED] [MASKED] 01:45PM BLOOD Neuts-45.8 [MASKED] Monos-8.5 Eos-1.7 Baso-0.5 Im [MASKED] AbsNeut-2.65 AbsLymp-2.50 AbsMono-0.49 AbsEos-0.10 AbsBaso-0.03 [MASKED] 01:45PM BLOOD [MASKED] PTT-28.9 [MASKED] [MASKED] 01:45PM BLOOD Glucose-95 UreaN-16 Creat-1.0 Na-140 K-4.3 Cl-99 HCO3-25 AnGap-16 [MASKED] 01:45PM BLOOD ALT-22 AST-27 AlkPhos-80 TotBili-0.9 [MASKED] 01:45PM BLOOD cTropnT-<0.01 [MASKED] 06:21PM BLOOD cTropnT-<0.01 [MASKED] 01:45PM BLOOD Albumin-4.7 Chest PA/Lat [MASKED]: FINDINGS: PA and lateral views of the chest provided. Lungs are clear. There is no focal consolidation, effusion, or pneumothorax. There are no signs of congestion or edema. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Discharge Labs: [MASKED] 07:45AM BLOOD WBC-5.7 RBC-4.29 Hgb-12.2 Hct-38.5 MCV-90 MCH-28.4 MCHC-31.7* RDW-13.2 RDWSD-43.2 Plt [MASKED] [MASKED] 07:45AM BLOOD [MASKED] PTT-27.9 [MASKED] [MASKED] 07:45AM BLOOD Glucose-89 UreaN-17 Creat-1.0 Na-139 K-3.4* Cl-100 HCO3-23 AnGap-16 [MASKED] 07:45AM BLOOD Calcium-9.9 Phos-3.8 Mg-1. SSESSMENT & PLAN: [MASKED] w/ PMHx CAD s/p STEMI w/ PCI to mid-LAD ([MASKED]), HTN, previous hx of diverticulitis, and CKD stage II presented with chest/L shoulder pain. #Coronaries: 95-99% occlusion mid-LAD s/p PCI #PUMP: LVEF 66% ([MASKED]) #Rhythm: Sinus brady #CAD s/p STEMI w/ PCI to mid-LAD #Chest pain: Patient presented with one day history of substernal CP which resolved prior to admission. Reassuringly w/o ischemic changes to ECG and trop negative x2. Has a history of STEMI in [MASKED] s/p PCI to mid-LAD. Initially c/o shoulder pain which seems to be much more MSK and entirely different than the substernal "discomfort" and dyspnea which prompted her to be evaluated in the ED. Pt would like to go home and do stress test as outpatient. -Continue ASA 81mg -Continue Ticagralor 90mg BID -Continue Atorva 80 mg daily -Continue Carvedilol 6.25 mg BID -Nuclear stress test ordered to be done as outpt, possibly tomorrow #HTN: -Continue carvedilol, HCTZ #GERD: -Continue pantoprazole #CKD stage II: At baseline (appears to be around [MASKED]. Creat 1.0 today #Dispo: -Discharge home today with plans to have outpatient nuclear stress test in [MASKED] days -Follow-up with Dr. [MASKED] next week, pt will call for appointment #Transitional: none Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. Pantoprazole 40 mg PO Q12H 4. Atorvastatin 80 mg PO QPM 5. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 6. Vitamin D [MASKED] UNIT PO DAILY 7. CARVedilol 6.25 mg PO BID 8. Hydrochlorothiazide 25 mg PO DAILY 9. Oxybutynin XL (*NF*) 5 mg Other DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. CARVedilol 6.25 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Oxybutynin XL (*NF*) 5 mg Other DAILY 7. Pantoprazole 40 mg PO Q12H 8. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis 9. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Angina pectoris CAD HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with left shoulder and left sided chest pain. Lab work and EKG did not show that you were having a heart attack. However, we would like to do a stress test on you in [MASKED] days with your heart attack history last [MASKED]. Please call the number that was provided to you and schedule the test possibly tomorrow. Please call Dr. [MASKED] tomorrow and make an appointment to see him early next week so Dr. [MASKED] go over the stress results with you. Continue all of your medications without any changes. 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]
[]
[ "I129", "E1122", "Z955", "I252", "Z7902", "E785", "K219", "Z8673", "E669" ]
[ "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N182: Chronic kidney disease, stage 2 (mild)", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "M7542: Impingement syndrome of left shoulder", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E669: Obesity, unspecified", "Z6829: Body mass index [BMI] 29.0-29.9, adult" ]
10,033,661
23,080,369
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Celebrex / codeine / Demerol / epinephrine / epinephrine / Penicillins / scallops / shellfish derived Attending: ___. Chief Complaint: LC1 pelvis fracture Major Surgical or Invasive Procedure: None History of Present Illness: ___ female history arthritis, COPD, osteoporosis, skin cancer, glaucoma who presents with right groin pain status post fall from bed. She states that she was trying get out of bed when she fell directly onto the ground onto her right side. She was unable to ambulate after then due to the pain. She was evaluated outside hospital where there was concern for possible periprosthetic fracture as well as subarachnoid hemorrhage, so she was transferred here for further evaluation. On repeat imaging, no periprosthetic fracture or subarachnoid hemorrhage, and no other injuries identified by trauma surgery. She is complaining of severe groin pain and inability to move the leg. No numbness or tingling. Endorses head strike, but denies loss of consciousness. Past Medical History: COPD, glaucoma, arthritis, osteoporosis, skin cancer Social History: ___ Family History: See OMR Physical Exam: Vitals: ___ 0720 Temp: 98.1 PO BP: 114/61 HR: 72 RR: 17 O2 sat: 94% O2 delivery: Ra General: Well-appearing, breathing comfortably MSK: - Pelvis stable - TTP in R groin - Grossly motor intact bilateral lower extremities - SILT bilateral lower extremities Pertinent Results: See OMR Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a LC1 minimally displaced pelvic fracture and was admitted to the orthopedic surgery service for pain control and placement. The patient was given anticoagulation with enoxaparin per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, and the patient was voiding/moving bowels spontaneously. The patient is weight-bearing as tolerated in the right lower extremity, and will be discharged on enoxaparin 40mg SC daily 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: Omeprazole Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 200 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain Please take with Tylenol, wean ASAP RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as needed Disp #*20 Tablet Refills:*0 5. Senna 17.2 mg PO BID 6. Gabapentin 100 mg PO TID 7. Omeprazole 20 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: R LC1 pelvis fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for monitoring after your pelvis fracture. This injury is treated non-operatively, and you may continue to work on walking and building your strength back at the rehab facility. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated, no ROM restrictions MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take ___ tablet every 4 hours as needed x 1 day, then ___ tablet every 6 hours as needed x 1 day, then ___ tablet every 8 hours as needed x 2 days, then ___ tablet every 12 hours as needed x 1 day, then ___ tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take enoxaparin 40mg daily for 4 weeks 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 - 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: WBAT bilateral lower extremities No braces needed Crutches or Walker PRN per physical therapy Treatments Frequency: No surgical incisions - non-operative treatment Followup Instructions: ___
[ "S32591A", "W06XXXA", "J449", "M810", "I10", "H409", "Z96641", "Z96651", "K449", "M1990" ]
Allergies: Celebrex / codeine / Demerol / epinephrine / epinephrine / Penicillins / scallops / shellfish derived Chief Complaint: LC1 pelvis fracture Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female history arthritis, COPD, osteoporosis, skin cancer, glaucoma who presents with right groin pain status post fall from bed. She states that she was trying get out of bed when she fell directly onto the ground onto her right side. She was unable to ambulate after then due to the pain. She was evaluated outside hospital where there was concern for possible periprosthetic fracture as well as subarachnoid hemorrhage, so she was transferred here for further evaluation. On repeat imaging, no periprosthetic fracture or subarachnoid hemorrhage, and no other injuries identified by trauma surgery. She is complaining of severe groin pain and inability to move the leg. No numbness or tingling. Endorses head strike, but denies loss of consciousness. Past Medical History: COPD, glaucoma, arthritis, osteoporosis, skin cancer Social History: [MASKED] Family History: See OMR Physical Exam: Vitals: [MASKED] 0720 Temp: 98.1 PO BP: 114/61 HR: 72 RR: 17 O2 sat: 94% O2 delivery: Ra General: Well-appearing, breathing comfortably MSK: - Pelvis stable - TTP in R groin - Grossly motor intact bilateral lower extremities - SILT bilateral lower extremities Pertinent Results: See OMR Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a LC1 minimally displaced pelvic fracture and was admitted to the orthopedic surgery service for pain control and placement. The patient was given anticoagulation with enoxaparin per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, and the patient was voiding/moving bowels spontaneously. The patient is weight-bearing as tolerated in the right lower extremity, and will be discharged on enoxaparin 40mg SC daily 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: Omeprazole Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 200 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain Please take with Tylenol, wean ASAP RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every [MASKED] hours as needed Disp #*20 Tablet Refills:*0 5. Senna 17.2 mg PO BID 6. Gabapentin 100 mg PO TID 7. Omeprazole 20 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: R LC1 pelvis fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for monitoring after your pelvis fracture. This injury is treated non-operatively, and you may continue to work on walking and building your strength back at the rehab facility. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated, no ROM restrictions MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take [MASKED] tablet every 4 hours as needed x 1 day, then [MASKED] tablet every 6 hours as needed x 1 day, then [MASKED] tablet every 8 hours as needed x 2 days, then [MASKED] tablet every 12 hours as needed x 1 day, then [MASKED] tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take enoxaparin 40mg daily for 4 weeks 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 - 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: WBAT bilateral lower extremities No braces needed Crutches or Walker PRN per physical therapy Treatments Frequency: No surgical incisions - non-operative treatment Followup Instructions: [MASKED]
[]
[ "J449", "I10" ]
[ "S32591A: Other specified fracture of right pubis, initial encounter for closed fracture", "W06XXXA: Fall from bed, initial encounter", "J449: Chronic obstructive pulmonary disease, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "I10: Essential (primary) hypertension", "H409: Unspecified glaucoma", "Z96641: Presence of right artificial hip joint", "Z96651: Presence of right artificial knee joint", "K449: Diaphragmatic hernia without obstruction or gangrene", "M1990: Unspecified osteoarthritis, unspecified site" ]
10,033,710
25,343,985
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: codeine Attending: ___. Chief Complaint: Right intertrochanteric femur fracture Major Surgical or Invasive Procedure: ___: Right trochanteric femoral nail History of Present Illness: This is a ___ female who presents to the emergency department at ___ in transfer from ___ with right intertrochanteric hip fracture, right fifth metacarpal neck fracture, and T/L-spine compression fractures status post an unwitnessed ground level fall. Patient is oriented only to self and so much of the history is obtained from discussion with members of the emergency department staff and review of the medical records from the outside facilities. Ms. ___ does endorse pain to her right hip and right hand. She denies pain elsewhere. She states she has no numbness or tingling of her right lower extremity. She denies head strike. She denies loss of consciousness. Per review of outside facility records the patient was brought into ___ by ambulance from ___ where the patient resides in the memory care unit. She reportedly was found down approximately 30 minutes prior to arrival at that hospital. She initially complained only of right hip pain. Evaluation at ___ demonstrated a right intertrochanteric hip fracture, right fifth metacarpal neck fracture, question of acute versus chronic right olecranon fracture, and T/L-spine vertebral compression fx. She was also found to have an abrasion over the posterior aspect of the elbow. Past Medical History: Atrial fibrillation not on anticoagulation dementia Depression History of clavicle fracture Glaucoma Hearing loss Orthostatic hypotension Osteoporosis Vertigo Open reduction internal fixation closed left hip fracture, ___ Cataract extraction, ___ Social History: ___ Family History: NC Pertinent Results: see OMR Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopaedic surgery team. The patient was found to have right intertrochanteric femur fracture and was admitted to the orthopaedic surgery service. The patient was taken to the operating room on ___ for right trochanteric femoral nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Brinzolamide 1% Ophth (*NF* ) 1 drop Other TID 4. Digoxin 0.0625 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Aspirin 325 mg PO DAILY 8. Sertraline 50 mg PO DAILY 9. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Right hip fracture 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: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Weightbearing as tolerated right lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add low-dose oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - 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 greater than 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 FOLLOW UP: Please call ___ to schedule a follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Physical Therapy: Activity: Activity: Activity as tolerated Right lower extremity: Full weight bearing Encourage turn, cough and deep breathe q2h when awake Treatments Frequency: Your incision is closed with Monocryl sutures that will be assessed at your 2-week postoperative visit. If the dressing falls off on its own three days after surgery, no need to replace the dressing unless actively draining. Followup Instructions: ___
[ "S72141A", "S22088A", "D62", "S52021A", "S62366A", "W1830XA", "Y92122", "Z66", "I4891", "F0390", "H409", "H9190", "M810", "Z87310", "Z961", "I440" ]
Allergies: codeine Chief Complaint: Right intertrochanteric femur fracture Major Surgical or Invasive Procedure: [MASKED]: Right trochanteric femoral nail History of Present Illness: This is a [MASKED] female who presents to the emergency department at [MASKED] in transfer from [MASKED] with right intertrochanteric hip fracture, right fifth metacarpal neck fracture, and T/L-spine compression fractures status post an unwitnessed ground level fall. Patient is oriented only to self and so much of the history is obtained from discussion with members of the emergency department staff and review of the medical records from the outside facilities. Ms. [MASKED] does endorse pain to her right hip and right hand. She denies pain elsewhere. She states she has no numbness or tingling of her right lower extremity. She denies head strike. She denies loss of consciousness. Per review of outside facility records the patient was brought into [MASKED] by ambulance from [MASKED] where the patient resides in the memory care unit. She reportedly was found down approximately 30 minutes prior to arrival at that hospital. She initially complained only of right hip pain. Evaluation at [MASKED] demonstrated a right intertrochanteric hip fracture, right fifth metacarpal neck fracture, question of acute versus chronic right olecranon fracture, and T/L-spine vertebral compression fx. She was also found to have an abrasion over the posterior aspect of the elbow. Past Medical History: Atrial fibrillation not on anticoagulation dementia Depression History of clavicle fracture Glaucoma Hearing loss Orthostatic hypotension Osteoporosis Vertigo Open reduction internal fixation closed left hip fracture, [MASKED] Cataract extraction, [MASKED] Social History: [MASKED] Family History: NC Pertinent Results: see OMR Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopaedic surgery team. The patient was found to have right intertrochanteric femur fracture and was admitted to the orthopaedic surgery service. The patient was taken to the operating room on [MASKED] for right trochanteric femoral nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Brinzolamide 1% Ophth (*NF* ) 1 drop Other TID 4. Digoxin 0.0625 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Aspirin 325 mg PO DAILY 8. Sertraline 50 mg PO DAILY 9. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Right hip fracture 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: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Weightbearing as tolerated right lower extremity MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add low-dose oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - 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 greater than 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 FOLLOW UP: Please call [MASKED] to schedule a follow up with your Orthopaedic Surgeon, Dr. [MASKED]. You will have follow up with [MASKED], NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call [MASKED] to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within [MASKED] weeks and for any new medications/refills. THIS PATIENT IS EXPECTED TO REQUIRE [MASKED] DAYS OF REHAB Physical Therapy: Activity: Activity: Activity as tolerated Right lower extremity: Full weight bearing Encourage turn, cough and deep breathe q2h when awake Treatments Frequency: Your incision is closed with Monocryl sutures that will be assessed at your 2-week postoperative visit. If the dressing falls off on its own three days after surgery, no need to replace the dressing unless actively draining. Followup Instructions: [MASKED]
[]
[ "D62", "Z66", "I4891" ]
[ "S72141A: Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture", "S22088A: Other fracture of T11-T12 vertebra, initial encounter for closed fracture", "D62: Acute posthemorrhagic anemia", "S52021A: Displaced fracture of olecranon process without intraarticular extension of right ulna, initial encounter for closed fracture", "S62366A: Nondisplaced fracture of neck of fifth metacarpal bone, right hand, initial encounter for closed fracture", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92122: Bedroom in nursing home as the place of occurrence of the external cause", "Z66: Do not resuscitate", "I4891: Unspecified atrial fibrillation", "F0390: Unspecified dementia without behavioral disturbance", "H409: Unspecified glaucoma", "H9190: Unspecified hearing loss, unspecified ear", "M810: Age-related osteoporosis without current pathological fracture", "Z87310: Personal history of (healed) osteoporosis fracture", "Z961: Presence of intraocular lens", "I440: Atrioventricular block, first degree" ]
10,033,887
25,791,193
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Psychiatry consulted by ED team for pt who was referred by therapist ___ at ___ following an incident last night in which he had his pants down and was yelling sexual obscenities. Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a ___ M with a history of schizophrenia with 1 prior hospitalization who was referred by therapist ___ at ___ following an incident last night in which he had his pants down and was yelling sexual obscenities. Pt lives at a group home in ___ and per the clinical director ___ ___ pt has been hypersexual with a number of patients including thrusting behaviors etc. The home is planning on expelling him on ___ as a result of these incidents. Pt denies these incidents, claiming his pants were sagging, etc. There is an open investigation into these incidents. Pt denies recent changes in mood, sleep, interest, energy, appetite, weight, concentration, and memory. Pt denies SI/HI, history of mania, panic symptoms and anxiety. He minimizes his prior psych history to a single incident, but on further questioning he has a history of paranoia. He denies recent worsening of paranoia, IOR, TC, TB. Past Medical History: PAST PSYCHIATRIC HISTORY: Hospitalizations: ___ Recovery ___ Current treaters and treatment: ___ pt, Invega Sustenna 117 qmonth last received ___. Medication and ECT trials: Unknown Self-injury: denies Harm to others: hit brother resulting in ___ hospitalization, hypersexual behavior per HPI Access to weapons:denies PAST MEDICAL HISTORY: None MEDICATIONS including vitamins, herbs, supplements, OTC: Invega Sustenna 117, Colace, cogentin ALLERGIES: NKDA Social History: SOCIAL HISTORY: - B/R: ___. 2 brothers - Family: Dad cell: ___ Mom ___: ___ - Education: Graduated high school - Employment: ___ - Living Situation: Lives at ___ home but will be evicted per HPI. - Relationships/Marriages/Children/Pets: single. Lives in group home as above. - Trauma: denies any physical/sexual abuse - Religion: ___ - Legal (Arrests/Probations/Prison): Hx of being held overnight for "annoying the police" but pt denies this as a true arrest. Patient also describes episode of going to Court after hitting his brother but brother is alive with no medical complications from incident. He notes that at that time he was found incompetent for trial due to his Schizophrenia. No ongoing legal issues - Access to Weapons: none. Pt states that he feels safe in the group home and that they have a system for ensuring that knives and scissors are hidden. SUBSTANCE ABUSE HISTORY: Pt endorses occasional alcohol use (2 beers several weeks ago) with 1 hospitalization due to intoxication. No hx withdrawal complications. Is daily MJ user, denies other illicit substances. Smokes ___ cigarettes/day. FORENSIC HISTORY: Arrests: arrested for "annoying the police" held overnight Convictions and jail terms:none Current status (pending charges, probation, parole) Family History: FAMILY PSYCHIATRIC HISTORY: Denies Physical Exam: ___: Weight: 168 (Estimated) (Entered in Nursing IPA) ___: Height: 68 (Patient Reported) (Entered in Nursing IPA) ___: BMI: 25.5 *VS: BP: 155/76 HR: 68 temp: 98.5 resp: 18 O2 sat: 100 height: ___ weight: 199 lbs Neurological: *station and gait: Both WNL, narrow-based *tone and strength: Normal tone; strength grossly WNL, moving all 4 extremities freely anti-gravity cranial nerves: PER, EOMI, face grossly symmetrical, moves facial musculature grossly symmetrically, not drooling nor dysarthric, hearing grossly intact, voice not hoarse, turns heads and shrugs shoulders freely abnormal movements: No abnormal movements noted, no tremor Mental Status Exam: *Appearance: tall well-built ___ male, calm and polite with good eye contact. Cooperative behavior and linear historian. Well groomed. * Behavior: Cooperative, well-related, appropriate eye contact; no notable PMR or PMA * Speech: Normal rate/tone/volume; prosody intact * Mood: "normal, a little anxious" * Affect: Flat * Thought process: linear * Thought Content: +paranoia as per HPI ("that people are thinking something negative"). Denies SI/HI/AVH/IOP/TC/TP *Judgment/Insight: poor / fair Cognition: *Arousal level & orientation: A&O x 3 to name, date, place *Memory: ___ immed recall, ___ delayed recall *Attention: Intact to MOYB *Calculations: $1.75= 7 quarters *Language: Fluent, no paraphasic errors, prosody intact Gen: NAD Cardiac: RRR Chest: CTAB, normal work of breathing Abdom: soft, non-tender Extremities: warm and dry Pertinent Results: ___ 05:30PM GLUCOSE-88 UREA N-19 CREAT-1.1 SODIUM-139 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 ___ 05:30PM WBC-4.1 RBC-4.72 HGB-13.7 HCT-40.5 MCV-86 MCH-29.0 MCHC-33.8 RDW-13.2 RDWSD-41.1 ___ 05:30PM ALT(SGPT)-10 AST(SGOT)-15 ALK PHOS-83 TOT BILI-0.7 ___ 05:30PM LIPASE-13 ___ 05:30PM ALBUMIN-4.8 ___ 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG Brief Hospital Course: SAFETY: The patient was placed on Q15 minute checks on admission and remained on that level of observation throughout. Patient was unit-restricted. There were no acute safety issues during this hospitalization. LEGAL: ___ PSYCHIATRIC: On admission to the inpatient unit, patient denied engaging in any sexually-inappropriate behaviors at his group home, either recently or in the past as his group home had reported. He felt his sexual urges were under control and had not been increasing in intensity of frequency. The patient also denied AVH, paranoia, changes in mood, SI or HI. Patient felt his thoughts had been organized (thought disorganization was formerly a prominent symptom of his schizophrenia exacerbations) but reported that he occasionally blocks things out/does not pay attention to things that bother him, especially in the setting of recent twice-daily marijuana use. During admission patient remained in good behavioral control and exhibited no sexually provocative/inappropriate gestures or speech. Home medications were continued, including Cogentin, vitamin D and Colace. Patient had last received his monthly Invega Sustenna ___ on ___ and did not require further dosing while admitted (next due on ___. Extensive counseling was provided on marijuana cessation and patient was encouraged to attend substance use support groups while on the unit. Due to his reported hypersexual behaviors the patient was evicted from his group home during the time he was admitted to Deac4, however his father agreed to let the patient live with him in ___ and picked him up on the day of discharge. Patient was set-up with outpatient follow-up (w/ therapist and new psychiatric provider at ___ and provided with paper prescriptions. The patient's current presentation was felt to be most consistent with a substance-induced exacerbation of disinhibition, impulsivity and poor judgment, on the background of chronic Schizophrenia. Notably, the patient did not appear grossly psychotic and he exhibited no hypersexual or inappropriate behaviors in the setting of abstinence from substance use. GENERAL MEDICAL CONDITIONS: Patient was continued on home Colace and vitamin D. PSYCHOSOCIAL: #) GROUPS/MILIEU: Patient was encouraged to participate in the unit’s groups/milieu/therapy opportunities. He attended the majority of groups and was noted to participate appropriately. Often seen conversing with staff. Use of coping skills and mindfulness/relaxation methods were encouraged. Therapy addressed family/social/work issues. #) COLLATERAL CONTACTS/FAMILY CONTACTS: Collateral was obtained from father, director of group home and director of The Spot program Family discussions were held with the patient, father, social work, nursing and treatment team MDs that focused psychoeducation and discharge planning. #) INTERVENTIONS: - Medications: home Cogentin - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: by treatment team and outpatient providers INFORMED CONSENT: No new medications were started during this hospitalization. RISK ASSESSMENT: #) Chronic/Static Risk Factors: age, male gender, chronic mental illness, history of substance use #) Modifiable Risk Factors: Recent, active, daily substance use - modified by providing a drug-free environment, drug-use counseling and unit AA/SMART recovery meetings #) Protective Factors: Medication adhearance (monthly Invega injections); connection to outpatient treaters; social support (parents); no active mood disturbance or suicidal ideation; no active psychosis; connection to stable living situation (with father) PROGNOSIS: Patient presented with significant reported behavioral disturbances that interfered with psychosocial functioning. Prognosis is guarded due to concern for continued substance use in the outpatient setting, however is improved by connection to outpatient treaters, social support and depot antipsychotic. The patient was taught about warning signs and understands that there are many resources, including the emergency department that he can follow-up with. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PALIperidone Palmitate 117 mg IM Q1MO (___) 2. Benztropine Mesylate 1 mg PO QHS 3. Docusate Sodium 100 mg PO QHS 4. Vitamin D 400 UNIT PO DAILY Discharge Medications: 1. Benztropine Mesylate 1 mg PO QHS RX *benztropine 1 mg 1 (One) tablet(s) by mouth at bedtime Disp #*7 Tablet Refills:*0 2. Docusate Sodium 100 mg PO QHS RX *docusate sodium 100 mg 1 (One) capsule(s) by mouth at bedtime Disp #*7 Capsule Refills:*0 3. PALIperidone Palmitate 117 mg IM Q1MO (___) 4. Vitamin D 400 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 1 (One) tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Schizophrenia Marijuana Use Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. *Appearance: tall, athletic-appearing male, well groomed, good hygiene, wearing own clothing * Behavior: Sitting with arms at side, polite and cooperative, appropriate eye contact * Speech: Normal rate/volume; prosody intact; monotonous * Mood/Affect: 'good' / blunted, mild fluctuations appropriate to topic of conversation * Thought process: linear, goal-directed * Thought Content: Denies SI/HI/AVH/IOP/TC/TP/paranoia *Judgment/Insight: fair/ fair *Memory: grossly intact *Attention: grossly intact to interview *Language: Fluent, no paraphasic errors, prosody intact *station and gait: Both ___ Discharge Instructions: You were hospitalized at ___ for reported concerning behaviors in the setting of substance use and concern for worsening Schizophrenia. While you were here we continued your medications and arranged a safe discharge plan. You are now ready for discharge with continued treatment with your outpatient providers. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please do not misuse alcohol or 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: ___
[ "F209", "F17210", "F1210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Psychiatry consulted by ED team for pt who was referred by therapist [MASKED] at [MASKED] following an incident last night in which he had his pants down and was yelling sexual obscenities. Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a [MASKED] M with a history of schizophrenia with 1 prior hospitalization who was referred by therapist [MASKED] at [MASKED] following an incident last night in which he had his pants down and was yelling sexual obscenities. Pt lives at a group home in [MASKED] and per the clinical director [MASKED] [MASKED] pt has been hypersexual with a number of patients including thrusting behaviors etc. The home is planning on expelling him on [MASKED] as a result of these incidents. Pt denies these incidents, claiming his pants were sagging, etc. There is an open investigation into these incidents. Pt denies recent changes in mood, sleep, interest, energy, appetite, weight, concentration, and memory. Pt denies SI/HI, history of mania, panic symptoms and anxiety. He minimizes his prior psych history to a single incident, but on further questioning he has a history of paranoia. He denies recent worsening of paranoia, IOR, TC, TB. Past Medical History: PAST PSYCHIATRIC HISTORY: Hospitalizations: [MASKED] Recovery [MASKED] Current treaters and treatment: [MASKED] pt, Invega Sustenna 117 qmonth last received [MASKED]. Medication and ECT trials: Unknown Self-injury: denies Harm to others: hit brother resulting in [MASKED] hospitalization, hypersexual behavior per HPI Access to weapons:denies PAST MEDICAL HISTORY: None MEDICATIONS including vitamins, herbs, supplements, OTC: Invega Sustenna 117, Colace, cogentin ALLERGIES: NKDA Social History: SOCIAL HISTORY: - B/R: [MASKED]. 2 brothers - Family: Dad cell: [MASKED] Mom [MASKED]: [MASKED] - Education: Graduated high school - Employment: [MASKED] - Living Situation: Lives at [MASKED] home but will be evicted per HPI. - Relationships/Marriages/Children/Pets: single. Lives in group home as above. - Trauma: denies any physical/sexual abuse - Religion: [MASKED] - Legal (Arrests/Probations/Prison): Hx of being held overnight for "annoying the police" but pt denies this as a true arrest. Patient also describes episode of going to Court after hitting his brother but brother is alive with no medical complications from incident. He notes that at that time he was found incompetent for trial due to his Schizophrenia. No ongoing legal issues - Access to Weapons: none. Pt states that he feels safe in the group home and that they have a system for ensuring that knives and scissors are hidden. SUBSTANCE ABUSE HISTORY: Pt endorses occasional alcohol use (2 beers several weeks ago) with 1 hospitalization due to intoxication. No hx withdrawal complications. Is daily MJ user, denies other illicit substances. Smokes [MASKED] cigarettes/day. FORENSIC HISTORY: Arrests: arrested for "annoying the police" held overnight Convictions and jail terms:none Current status (pending charges, probation, parole) Family History: FAMILY PSYCHIATRIC HISTORY: Denies Physical Exam: [MASKED]: Weight: 168 (Estimated) (Entered in Nursing IPA) [MASKED]: Height: 68 (Patient Reported) (Entered in Nursing IPA) [MASKED]: BMI: 25.5 *VS: BP: 155/76 HR: 68 temp: 98.5 resp: 18 O2 sat: 100 height: [MASKED] weight: 199 lbs Neurological: *station and gait: Both WNL, narrow-based *tone and strength: Normal tone; strength grossly WNL, moving all 4 extremities freely anti-gravity cranial nerves: PER, EOMI, face grossly symmetrical, moves facial musculature grossly symmetrically, not drooling nor dysarthric, hearing grossly intact, voice not hoarse, turns heads and shrugs shoulders freely abnormal movements: No abnormal movements noted, no tremor Mental Status Exam: *Appearance: tall well-built [MASKED] male, calm and polite with good eye contact. Cooperative behavior and linear historian. Well groomed. * Behavior: Cooperative, well-related, appropriate eye contact; no notable PMR or PMA * Speech: Normal rate/tone/volume; prosody intact * Mood: "normal, a little anxious" * Affect: Flat * Thought process: linear * Thought Content: +paranoia as per HPI ("that people are thinking something negative"). Denies SI/HI/AVH/IOP/TC/TP *Judgment/Insight: poor / fair Cognition: *Arousal level & orientation: A&O x 3 to name, date, place *Memory: [MASKED] immed recall, [MASKED] delayed recall *Attention: Intact to MOYB *Calculations: $1.75= 7 quarters *Language: Fluent, no paraphasic errors, prosody intact Gen: NAD Cardiac: RRR Chest: CTAB, normal work of breathing Abdom: soft, non-tender Extremities: warm and dry Pertinent Results: [MASKED] 05:30PM GLUCOSE-88 UREA N-19 CREAT-1.1 SODIUM-139 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 [MASKED] 05:30PM WBC-4.1 RBC-4.72 HGB-13.7 HCT-40.5 MCV-86 MCH-29.0 MCHC-33.8 RDW-13.2 RDWSD-41.1 [MASKED] 05:30PM ALT(SGPT)-10 AST(SGOT)-15 ALK PHOS-83 TOT BILI-0.7 [MASKED] 05:30PM LIPASE-13 [MASKED] 05:30PM ALBUMIN-4.8 [MASKED] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 07:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG Brief Hospital Course: SAFETY: The patient was placed on Q15 minute checks on admission and remained on that level of observation throughout. Patient was unit-restricted. There were no acute safety issues during this hospitalization. LEGAL: [MASKED] PSYCHIATRIC: On admission to the inpatient unit, patient denied engaging in any sexually-inappropriate behaviors at his group home, either recently or in the past as his group home had reported. He felt his sexual urges were under control and had not been increasing in intensity of frequency. The patient also denied AVH, paranoia, changes in mood, SI or HI. Patient felt his thoughts had been organized (thought disorganization was formerly a prominent symptom of his schizophrenia exacerbations) but reported that he occasionally blocks things out/does not pay attention to things that bother him, especially in the setting of recent twice-daily marijuana use. During admission patient remained in good behavioral control and exhibited no sexually provocative/inappropriate gestures or speech. Home medications were continued, including Cogentin, vitamin D and Colace. Patient had last received his monthly Invega Sustenna [MASKED] on [MASKED] and did not require further dosing while admitted (next due on [MASKED]. Extensive counseling was provided on marijuana cessation and patient was encouraged to attend substance use support groups while on the unit. Due to his reported hypersexual behaviors the patient was evicted from his group home during the time he was admitted to Deac4, however his father agreed to let the patient live with him in [MASKED] and picked him up on the day of discharge. Patient was set-up with outpatient follow-up (w/ therapist and new psychiatric provider at [MASKED] and provided with paper prescriptions. The patient's current presentation was felt to be most consistent with a substance-induced exacerbation of disinhibition, impulsivity and poor judgment, on the background of chronic Schizophrenia. Notably, the patient did not appear grossly psychotic and he exhibited no hypersexual or inappropriate behaviors in the setting of abstinence from substance use. GENERAL MEDICAL CONDITIONS: Patient was continued on home Colace and vitamin D. PSYCHOSOCIAL: #) GROUPS/MILIEU: Patient was encouraged to participate in the unit’s groups/milieu/therapy opportunities. He attended the majority of groups and was noted to participate appropriately. Often seen conversing with staff. Use of coping skills and mindfulness/relaxation methods were encouraged. Therapy addressed family/social/work issues. #) COLLATERAL CONTACTS/FAMILY CONTACTS: Collateral was obtained from father, director of group home and director of The Spot program Family discussions were held with the patient, father, social work, nursing and treatment team MDs that focused psychoeducation and discharge planning. #) INTERVENTIONS: - Medications: home Cogentin - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: by treatment team and outpatient providers INFORMED CONSENT: No new medications were started during this hospitalization. RISK ASSESSMENT: #) Chronic/Static Risk Factors: age, male gender, chronic mental illness, history of substance use #) Modifiable Risk Factors: Recent, active, daily substance use - modified by providing a drug-free environment, drug-use counseling and unit AA/SMART recovery meetings #) Protective Factors: Medication adhearance (monthly Invega injections); connection to outpatient treaters; social support (parents); no active mood disturbance or suicidal ideation; no active psychosis; connection to stable living situation (with father) PROGNOSIS: Patient presented with significant reported behavioral disturbances that interfered with psychosocial functioning. Prognosis is guarded due to concern for continued substance use in the outpatient setting, however is improved by connection to outpatient treaters, social support and depot antipsychotic. The patient was taught about warning signs and understands that there are many resources, including the emergency department that he can follow-up with. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PALIperidone Palmitate 117 mg IM Q1MO ([MASKED]) 2. Benztropine Mesylate 1 mg PO QHS 3. Docusate Sodium 100 mg PO QHS 4. Vitamin D 400 UNIT PO DAILY Discharge Medications: 1. Benztropine Mesylate 1 mg PO QHS RX *benztropine 1 mg 1 (One) tablet(s) by mouth at bedtime Disp #*7 Tablet Refills:*0 2. Docusate Sodium 100 mg PO QHS RX *docusate sodium 100 mg 1 (One) capsule(s) by mouth at bedtime Disp #*7 Capsule Refills:*0 3. PALIperidone Palmitate 117 mg IM Q1MO ([MASKED]) 4. Vitamin D 400 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 1 (One) tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Schizophrenia Marijuana Use Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. *Appearance: tall, athletic-appearing male, well groomed, good hygiene, wearing own clothing * Behavior: Sitting with arms at side, polite and cooperative, appropriate eye contact * Speech: Normal rate/volume; prosody intact; monotonous * Mood/Affect: 'good' / blunted, mild fluctuations appropriate to topic of conversation * Thought process: linear, goal-directed * Thought Content: Denies SI/HI/AVH/IOP/TC/TP/paranoia *Judgment/Insight: fair/ fair *Memory: grossly intact *Attention: grossly intact to interview *Language: Fluent, no paraphasic errors, prosody intact *station and gait: Both [MASKED] Discharge Instructions: You were hospitalized at [MASKED] for reported concerning behaviors in the setting of substance use and concern for worsening Schizophrenia. While you were here we continued your medications and arranged a safe discharge plan. You are now ready for discharge with continued treatment with your outpatient providers. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please do not misuse alcohol or 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]
[]
[ "F17210" ]
[ "F209: Schizophrenia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1210: Cannabis abuse, uncomplicated" ]
10,034,031
28,282,749
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: ___ CABG x 3 LIMA-> LAD, RSVG-> Ramus, PDA History of Present Illness: Mr. ___ is a ___ year old M w/ PMH HTN, HLD, BPH who presents with 1 week of chest pain. Pt has good ___ comprehension and limited expression, interviewed w/ son acting as interpreter. He reports that he started having DOE 2 weeks ago which started before going on a cruise last week. Had episodic CP, radiating to L shoulder, first occurring only with exertion, then occasionally at rest when he experienced anxiety, about 7 days. Got back from cruise ___, ate lunch with son, called PCP and had CP, so was BIBA. Got 2 NTG tabs and full dose ASA in the ambulance. At bedside, he is CP free, has no dyspnea, cough. In the ED, initial VS were: 99.3 100 151/90 16 98% RA. Exam notable for: JVP not elevated, CTAB, RRR, no m/r/g. No lower extremity edema. EKG from ambulance shows aVR elevation, ST depressions diffusely; EKG at bedside shows St depressions in 2, 3, aVF, J point elevation in V1, V2. Labs showed: WBC 10.5, Cr 1, trop 0.06. Imaging showed: CXR w/ no acute intrathoracic abnormality. Cardiology consulted and recommended admission and plan for cath tomorrow AM for NSTEMI. Patient received: Atorvastatin 80 mg, IV Heparin gtt. Transfer VS were: 97.8 69 105/56 16 98% RA. On arrival to the floor, patient reports that he has never had any chest pain or SOB like this. Generally active man and works in his garden without any symptoms. Feeling better now with no chest pain or left radiation of pain. No SOB. No lower extremity edema. Past Medical History: - HTN - HLD (diet-controlled) - BPH - Stomach ulcer s/p surgery ___ in ___ - Colonoscopies at BI-N in ___ w/ large tubular adenoma, last section removed ___ Social History: ___ Family History: None Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.6 158/78 67 18 99% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vital Signs and Intake/Output: ___ 1539 Temp: 98.1 PO BP: 104/65 L Lying HR: 60 RR: 18 O2 sat: 96% O2 delivery: 1l ___ Total Intake: 660ml ___ Total Output: 1325ml Physical Examination: General/Neuro: NAD [x] A/O x3 [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [x] Lungs: CTA [x] diminished bases, No resp distress [x] Abd: NBS [x]Soft [x] mildly distended [x] NT [x] Extremities: trace CCE[x] Pulses doppler [] palpable [x] Wounds: Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] Leg: Right [] Left[x] CDI [x] no erythema or drainage [x] Other: Pertinent Results: ___ 04:30AM BLOOD WBC-15.1* RBC-3.35* Hgb-10.0* Hct-30.5* MCV-91 MCH-29.9 MCHC-32.8 RDW-16.0* RDWSD-51.2* Plt ___ ___ 04:30AM BLOOD ___ ___ 04:30AM BLOOD Glucose-97 UreaN-27* Creat-1.3* Na-141 K-4.8 Cl-103 HCO3-25 AnGap-13 PA and Lateral ___ Compared the prior examination, right IJ central venous catheter remains in place. There remain postoperative changes from CABG. Mild-to-moderate cardiomegaly is unchanged. There remains central pulmonary vascular congestion with trace interstitial edema, perhaps slightly worsened compared to the prior examination. A small to moderate right-sided pleural effusion and small left-sided pleural effusion appears slightly increased in volume with adjacent compressive atelectasis. No other superimposed consolidation is seen. There is no pneumothorax. There is no acute osseous abnormality. Subcutaneous gas is likely postoperative and appears slightly improved. TTE ___ The estimated right atrial pressure is ___ mmHg. Overall left ventricular systolic function is normal (LVEF>55%). There is low normal free wall contractility. There is a small pericardial effusion loculated posteriorly along the inferolateral left ventricular free wall. There are no echocardiographic signs of tamponade. IMPRESSION: Small loculated pericardial effusion without echocardiographic signs of tampoande. A right pleural effusion is present. Compared with the prior study (images reviewed) of ___ left atrial diastolic collapse is not seen. Size of the effusion is similar. Intra-op TEE PRE-BYPASS: The left atrium is normal in size. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. There are complex (>4mm) atheroma in the ascending aorta. There are focal calcifications in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 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 an anterior fat pad. POST-BYPASS: The patient is in sinus rhythm and receiving a phenylephrine infusion. 1. Left ventricular function remains normal. 2. Right ventricular function is more vigorous and appears normal. 3. Valvular function remains unchanged. 4. There is no pericardial effusion. 5. The thoracic aorta is intact following decannulation. ___ was notified in person of the results at the time the exam was performed in the operating room. Brief Hospital Course: Mr. ___ is a ___ year old M w/ PMH HTN, HLD, BPH who presented with 1 week of chest pain. EKG with ST depressions, trops elevated, consistent with NSTEMI. The patient was started on medical management with heparin gtt, ASA, atorvastatin, Metoprolol. He underwent cardiac cath ___ which showed diffuse 3 vessel disease. He was thus continued on heparin drip until he underwent CABG ___. On ___ he was taken to the operating room where he underwent coronary artery bypass grafting. Please see operative note for detail. 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. He had a TTE on POD 1 due to acute hypotension which showed moderate sized serous loculated pericardial effusion inferior to the left atrium. He remained hemodynamically stable with this finding. POD 2 he went into rapid atrial fibrillation and was given an Amiodarone bolus and drip, which transitioned to oral Amiodarone. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He was started on Coumadin for post op atrial fibrillation. This converted to sinus rhythm by the time the patient was discharged. The patient was transferred to the telemetry floor for further recovery. He was transfused 1 unit l RBC on POD 4 due to post op anemia and soft blood pressure. Hematocrit was stable at the time of discharge. The patient underwent a TTE on ___ which showed that the pericardial effusion was unchanged in size. Due to mild orthostatic hypotension his Lasix was held and he will not be discharged on Lasix. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on POD 8 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to ___ at ___ in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Amiodarone 200 mg PO BID take 200mg BID for 2 weeks, then take 200mg daily for 2 weeks, then stop 3. Atorvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Metoprolol Tartrate 50 mg PO TID 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY 8. Senna 17.2 mg PO BID:PRN Constipation - First Line 9. ___ MD to order daily dose PO DAILY16 dose per rehab team. 5mg given on ___. Aspirin 81 mg PO DAILY 11. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: NSTEMI - HTN- denies - HLD (diet-controlled)-denies - BPH 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 trace Edema Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
[ "I214", "J90", "I4891", "D62", "I9581", "I2510", "I700", "I10", "E785", "N400", "Z8719", "Z8711", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: chest pain Major Surgical or Invasive Procedure: [MASKED] CABG x 3 LIMA-> LAD, RSVG-> Ramus, PDA History of Present Illness: Mr. [MASKED] is a [MASKED] year old M w/ PMH HTN, HLD, BPH who presents with 1 week of chest pain. Pt has good [MASKED] comprehension and limited expression, interviewed w/ son acting as interpreter. He reports that he started having DOE 2 weeks ago which started before going on a cruise last week. Had episodic CP, radiating to L shoulder, first occurring only with exertion, then occasionally at rest when he experienced anxiety, about 7 days. Got back from cruise [MASKED], ate lunch with son, called PCP and had CP, so was BIBA. Got 2 NTG tabs and full dose ASA in the ambulance. At bedside, he is CP free, has no dyspnea, cough. In the ED, initial VS were: 99.3 100 151/90 16 98% RA. Exam notable for: JVP not elevated, CTAB, RRR, no m/r/g. No lower extremity edema. EKG from ambulance shows aVR elevation, ST depressions diffusely; EKG at bedside shows St depressions in 2, 3, aVF, J point elevation in V1, V2. Labs showed: WBC 10.5, Cr 1, trop 0.06. Imaging showed: CXR w/ no acute intrathoracic abnormality. Cardiology consulted and recommended admission and plan for cath tomorrow AM for NSTEMI. Patient received: Atorvastatin 80 mg, IV Heparin gtt. Transfer VS were: 97.8 69 105/56 16 98% RA. On arrival to the floor, patient reports that he has never had any chest pain or SOB like this. Generally active man and works in his garden without any symptoms. Feeling better now with no chest pain or left radiation of pain. No SOB. No lower extremity edema. Past Medical History: - HTN - HLD (diet-controlled) - BPH - Stomach ulcer s/p surgery [MASKED] in [MASKED] - Colonoscopies at BI-N in [MASKED] w/ large tubular adenoma, last section removed [MASKED] Social History: [MASKED] Family History: None Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.6 158/78 67 18 99% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vital Signs and Intake/Output: [MASKED] 1539 Temp: 98.1 PO BP: 104/65 L Lying HR: 60 RR: 18 O2 sat: 96% O2 delivery: 1l [MASKED] Total Intake: 660ml [MASKED] Total Output: 1325ml Physical Examination: General/Neuro: NAD [x] A/O x3 [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [x] Lungs: CTA [x] diminished bases, No resp distress [x] Abd: NBS [x]Soft [x] mildly distended [x] NT [x] Extremities: trace CCE[x] Pulses doppler [] palpable [x] Wounds: Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] Leg: Right [] Left[x] CDI [x] no erythema or drainage [x] Other: Pertinent Results: [MASKED] 04:30AM BLOOD WBC-15.1* RBC-3.35* Hgb-10.0* Hct-30.5* MCV-91 MCH-29.9 MCHC-32.8 RDW-16.0* RDWSD-51.2* Plt [MASKED] [MASKED] 04:30AM BLOOD [MASKED] [MASKED] 04:30AM BLOOD Glucose-97 UreaN-27* Creat-1.3* Na-141 K-4.8 Cl-103 HCO3-25 AnGap-13 PA and Lateral [MASKED] Compared the prior examination, right IJ central venous catheter remains in place. There remain postoperative changes from CABG. Mild-to-moderate cardiomegaly is unchanged. There remains central pulmonary vascular congestion with trace interstitial edema, perhaps slightly worsened compared to the prior examination. A small to moderate right-sided pleural effusion and small left-sided pleural effusion appears slightly increased in volume with adjacent compressive atelectasis. No other superimposed consolidation is seen. There is no pneumothorax. There is no acute osseous abnormality. Subcutaneous gas is likely postoperative and appears slightly improved. TTE [MASKED] The estimated right atrial pressure is [MASKED] mmHg. Overall left ventricular systolic function is normal (LVEF>55%). There is low normal free wall contractility. There is a small pericardial effusion loculated posteriorly along the inferolateral left ventricular free wall. There are no echocardiographic signs of tamponade. IMPRESSION: Small loculated pericardial effusion without echocardiographic signs of tampoande. A right pleural effusion is present. Compared with the prior study (images reviewed) of [MASKED] left atrial diastolic collapse is not seen. Size of the effusion is similar. Intra-op TEE PRE-BYPASS: The left atrium is normal in size. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. There are complex (>4mm) atheroma in the ascending aorta. There are focal calcifications in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 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 an anterior fat pad. POST-BYPASS: The patient is in sinus rhythm and receiving a phenylephrine infusion. 1. Left ventricular function remains normal. 2. Right ventricular function is more vigorous and appears normal. 3. Valvular function remains unchanged. 4. There is no pericardial effusion. 5. The thoracic aorta is intact following decannulation. [MASKED] was notified in person of the results at the time the exam was performed in the operating room. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old M w/ PMH HTN, HLD, BPH who presented with 1 week of chest pain. EKG with ST depressions, trops elevated, consistent with NSTEMI. The patient was started on medical management with heparin gtt, ASA, atorvastatin, Metoprolol. He underwent cardiac cath [MASKED] which showed diffuse 3 vessel disease. He was thus continued on heparin drip until he underwent CABG [MASKED]. On [MASKED] he was taken to the operating room where he underwent coronary artery bypass grafting. Please see operative note for detail. 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. He had a TTE on POD 1 due to acute hypotension which showed moderate sized serous loculated pericardial effusion inferior to the left atrium. He remained hemodynamically stable with this finding. POD 2 he went into rapid atrial fibrillation and was given an Amiodarone bolus and drip, which transitioned to oral Amiodarone. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He was started on Coumadin for post op atrial fibrillation. This converted to sinus rhythm by the time the patient was discharged. The patient was transferred to the telemetry floor for further recovery. He was transfused 1 unit l RBC on POD 4 due to post op anemia and soft blood pressure. Hematocrit was stable at the time of discharge. The patient underwent a TTE on [MASKED] which showed that the pericardial effusion was unchanged in size. Due to mild orthostatic hypotension his Lasix was held and he will not be discharged on Lasix. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on POD 8 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [MASKED] at [MASKED] in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Amiodarone 200 mg PO BID take 200mg BID for 2 weeks, then take 200mg daily for 2 weeks, then stop 3. Atorvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Metoprolol Tartrate 50 mg PO TID 6. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*35 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY 8. Senna 17.2 mg PO BID:PRN Constipation - First Line 9. [MASKED] MD to order daily dose PO DAILY16 dose per rehab team. 5mg given on [MASKED]. Aspirin 81 mg PO DAILY 11. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: NSTEMI - HTN- denies - HLD (diet-controlled)-denies - BPH 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 trace Edema Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
[]
[ "I4891", "D62", "I2510", "I10", "E785", "N400", "Z87891" ]
[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J90: Pleural effusion, not elsewhere classified", "I4891: Unspecified atrial fibrillation", "D62: Acute posthemorrhagic anemia", "I9581: Postprocedural hypotension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I700: Atherosclerosis of aorta", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z8719: Personal history of other diseases of the digestive system", "Z8711: Personal history of peptic ulcer disease", "Z87891: Personal history of nicotine dependence" ]
10,034,049
20,053,563
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F w/ severe RA w/ leukocytoclastic vasculitis, venous insufficiency, hypothyroid, DM, presenting with abdominal pain and AMS. Per EMS, found seated hunched over on portable commode in bedroom of residence, alert and oriented x4 with warm, dry skin. Pt complained of constipation x2 days with associated abdominal pain. Family member reports pt had two bowel movements today but pt reports still feeling "urgent need to go." Pt reports that she is "very blocked up." On our assessment, patient intermittently reports abdominal pain. Also mentions a fall, unsure when. Reports some mid back pain. Unable to obtain other significant history. Recent ___ admission for fall, thought to be due to deconditioned/meds, also hypothyroid, restarted on levothyroxine. D/c to SAR. Noted to have difficulty with med compliance. EMS physical: L sided tenderness in LUQ on palpation. No distention, rigidity or masses felt. Pt had multiple large bruises all over her body which family member and pt report are from repeated falls in residence. Pt denied chest pain, shortness of breath, nausea, vomiting, fever or chills. Pt was extricated via stair chair, secured to stretcher and transported to BID with no further change in condition. In the ED: On EMS arrival, the patient endorsed LUQ tenderness. Notably, the patient recently had a ___ admission for a fall due to suspected deconditioning. The patient was noted to have difficulty with med compliance. The patient reports bilateral ___ pain. Denies fever, chills, dyspnea, chest pain, or n/v. Initial vital signs were notable for: 97.7 83 130/69 18 98% RA Exam notable for: Patient AAOx2, trying to get out of bed. PERLA, EOMI, no obvious head trauma No C spine tenderness, mild T spine tenderness Flinches with abdominal palpation, especially on the left side. But is soft and not notably distended LEs with bilaterally venous stasis changes and multiple open wounds that do not appear actively infected Labs were notable for: 141 95 12 ---------------< 147 3.6 28 1.0 8.3 > 10.7/33.6 < 207 UA: Large leuks, 30 protein, 40 WBCs Studies performed include: CT head: No acute intracranial process. Diffuse hypodensities in the white matter again seen, similar in extent to CT head dated ___ and ___ which could be related to prior therapy or due to extensive small vessel disease. CT C-Spine 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes including mild anterolisthesis of C2 on C3, intervertebral disc space narrowing, and osteophytosis worse at C4-C5. CT Abd/Pelvis with contrast: 1. Ground-glass opacification in the posterior segment of the right upper lobe that may represent infection. 2. No intrathoracic or intra-abdominal sequela of trauma. 3. Irregularity and lucency at the superior endplate of L5 and inferior endplate of L4 are slightly progressed when compared to prior dated ___ and infection cannot be excluded. 4. Nonspecific, unchanged prominent pelvic lymph nodes. 5. Prominent bilateral external iliac lymph node are again seen measuring up to 0.9 cm in short axis, nonspecific. 6. Mild stranding adjacent to the left adrenal may represent possible adrenal injury. 7. Unchanged, indeterminate renal lesion in the interpolar region of the right kidney seen since ___. Non emergent follow-up renal ultrasound is recommended if no prior characterization has been performed. Pt was given: Olanzapine for agitation Tylenol Cefpodoxime 200mg Ceftriaxone 1g Azithro IVF sitter for agitation Consults: None Vitals on transfer: T102.7, BP 171/92, HR90, RR20, 94% RA Upon arrival to the floor, pt was somnolent and stated she had L-sided pain of her torso. Her attention waxed/waned and she responded somewhat appropriately when prodded. Vital signs were significant for hypertension and febrile to 102.7 reduced to 100 with IV Tylenol. Her HCP, her son, was called for assessment of her baseline which he says is AOx4 and occasionally combative. She has a history of recurrent UTIs which present with similar delirium. Has mild baseline dementia with forgetfulness of certain memories but functional and independent otherwise. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy ___ ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Intermittent urinary retention Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: ___ Family History: Patient previously stated her family had "medical conditions" but she cannot describe more specifically. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T102.7, BP171/92, HR90, RR20, 94%RA GENERAL: Somnolent, responds appropriately intermittently. In mild distress ___ abd pain. HEENT: NCAT. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: Unable to evaluate for CVA tenderness ___ pt refusal. ABDOMEN: Soft, non distended, tender to palpation in left quadrants (LUQ worse than LLQ). Healed surgical scar on R. EXTREMITIES: B/L ___ erythema with multiple bruises and scars in various stages of healing with overlying blanching well-demarcated erythema. Warm to touch. L leg erythema outlined on ___. Pulses DP/Radial 2+ bilaterally. SKIN: See Ext above. Warm. NEUROLOGIC: Sensation intact in ___. DISCHARGE PHYSICAL EXAM: ============================ VITALS: 98.5 PO 99 / 58 71 16 95 RA GEN: Lying in bed on her left side, eyes closed CV: Normal rate, regular rhythm, no m/r/g Pulm: CTAB Abdomen: Deferred due to abdominal pain Ext: B/L ___ with erythema with bruising and skin breakdown c/w venous stasis changes Neuro: EOMI, R facial droop, R upper extremity can elevate without resistance, can move R toes and ankle, improved from prior, grossly normal on the Left side Pertinent Results: ADMISSION LABS: ================= ___ 03:31AM BLOOD WBC-8.3 RBC-3.80* Hgb-10.7* Hct-33.6* MCV-88 MCH-28.2 MCHC-31.8* RDW-15.5 RDWSD-49.9* Plt ___ ___ 03:31AM BLOOD Neuts-87.3* Lymphs-6.8* Monos-4.6* Eos-0.4* Baso-0.4 Im ___ AbsNeut-7.36* AbsLymp-0.57* AbsMono-0.39 AbsEos-0.03* AbsBaso-0.03 ___ 03:25AM BLOOD Glucose-147* UreaN-12 Creat-1.0 Na-141 K-3.6 Cl-95* HCO3-28 AnGap-18 ___ 03:25AM BLOOD ALT-9 AST-10 AlkPhos-113* TotBili-0.7 ___ 03:25AM BLOOD Lipase-10 ___ 10:45AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.4* ___ 03:25AM BLOOD Albumin-4.3 ___ 02:29AM BLOOD Glucose-112* Lactate-2.3* Na-139 K-3.4 Cl-98 calHCO3-26 INTERVAL LABS: =============== ___ 07:25AM BLOOD ___ PTT-28.5 ___ ___ 07:25AM BLOOD Ret Aut-2.3* Abs Ret-0.08 ___ 03:30AM BLOOD Lipase-79* ___ 03:00PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7 Cholest-118 ___ 07:25AM BLOOD calTIBC-229* VitB12-731 Ferritn-186* TRF-176* ___ 03:00PM BLOOD %HbA1c-6.1* eAG-128* ___ 03:00PM BLOOD Triglyc-181* HDL-40* CHOL/HD-3.0 LDLcalc-42 ___ 10:45AM BLOOD TSH-43* ___ 10:45AM BLOOD Free T4-0.7* ___ 10:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS: ================= ___ 06:43AM BLOOD WBC-4.9 RBC-3.51* Hgb-10.1* Hct-30.3* MCV-86 MCH-28.8 MCHC-33.3 RDW-15.1 RDWSD-47.8* Plt ___ ___ 06:43AM BLOOD Glucose-157* UreaN-19 Creat-0.8 Na-140 K-3.7 Cl-98 HCO3-26 AnGap-16 ___ 06:30AM BLOOD Glucose-137* UreaN-26* Creat-0.9 Na-139 K-3.8 Cl-98 HCO3-26 AnGap-15 ___ 06:43AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9 MICROBIOLOGY: =============== ___ AND ___ URINE CULTURES: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ URINE CULTURE: NO GROWTH. ___ 4:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. ___ BLOOD CULTURE: NO GROWTH ___ BLOOD CULTURE X2: NGTD ___ BLOOD CULTURE: NGTD IMAGING: =========== CT C-SPINE W/O CONTRAST Study Date of ___ 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes including mild anterolisthesis of C2 on C3, intervertebral disc space narrowing, and osteophytosis worse at C4-C5. 3. Multilevel posterior osteophytosis and calcified disc bulge result in moderate spinal canal narrowing most severe at C3-C4. 4. Multilevel uncovertebral facet joint hypertrophy resulting mild neural foraminal stenosis worse than right C3-C4 facet joint. CT HEAD W/O CONTRAST Study Date of ___ No acute intracranial process. Diffuse hypodensities in the white matter again seen, similar in extent to CT head dated ___ and ___ which could be related to prior therapy or due to extensive small vessel disease. CT CHEST a/p W/CONTRAST Study Date of ___ 1. Nodular, ground-glass opacification in the posterior right upper lobe concerning for pneumonia. In the setting of trauma, underlying pulmonary contusion is not excluded. 2. Mild stranding between the left adrenal gland and kidney is nonspecific, but may relate to acute injury or ascending GU infection. 3. Irregularity and lucency at the superior endplate of L5 and inferior endplate of L4 are slightly progressed when compared to prior dated ___ and infection cannot be excluded. 4. Nonspecific, unchanged prominent pelvic lymph nodes. CT ABD & PELVIS WITH CONTRAST Study Date of ___ 1. No etiology identified for severe abdominal pain. Specifically, no intra-abdominal abscess or small bowel obstruction. 2. The bladder wall appears mildly thickened, which may be related to nondistention, however, cystitis should be considered and correlation with urinalysis is recommended. 3. Redemonstration of the irregularity and lucency at the superior endplate of L5 in the inferior endplate of L4, which is unchanged compared to ___ but slightly progressed compared to ___. Findings may represent progressive neuropathic degenerative changes however underlying infection cannot be excluded. 4. Unchanged, nonspecific prominent/enlarged pelvic/inguinal lymph nodes. MR HEAD W/O CONTRAST Study Date of ___ 1. Late acute to subacute in the left corona radiata. No intracranial hemorrhage. 2. Atrophy and stable extensive white matter signal abnormality, possibly related to prior therapy or chronic small vessel ischemic disease. 3. Additional findings described above. CTA HEAD AND CTA NECK Study Date of ___ 1. Redemonstration of a focus of late acute to subacute infarct in the left corona radiata. No intracranial hemorrhage. 2. Atrophy and stable extensive white matter disease, possibly related to prior therapy or chronic small vessel ischemic disease. 3. No severe vascular stenosis, occlusion or aneurysm. Mild atherosclerotic disease is noted in the posterior cerebral arteries and cavernous internal carotid arteries. 4. Improved nodular and ground-glass opacities in the posterior right upper lobe, consistent with resolving infection or contusion. 5. Additional findings as described above. TTE Study Date of ___ IMPRESSION: Mild symmetric left ventricular hypertophy with normal cavity sizes, and regional/global systolic function. No definite structural cardiac source of embolism identified. Compared with the prior TTE (images not available for review) of ___, the findings are similar. Brief Hospital Course: Ms. ___ is a ___ year old lady with history of rheumatoid arthritis on chronic prednisone, leukocytoclastic vasculitis, hypothyroidism, diabetes, and question of recent stroke with residual R sided weakness, who presents with toxic metabolic encephalopathy in setting of pyelonephritis, with MRI confirming subacute left corona radiata CVA. # Pyelonephritis # Abdominal pain Patient presented with fever to 102.7F and diffuse abdominal pain, with pyuria on U/A as well as CTA/P remarkable for stranding surrounding bladder and near L adrenal/kidney, which was repeated later in hospital course for ongoing abdominal pain and distension, unrevealing for a new source of pain. Other sources of fever considered included possible PNA, given ground glass changes in RUL seen on CT chest, however patient without cough or hypoxia. She completed 7 day course of antibiotics with vancomycin + ceftriaxone ending ___, given history of MRSA UTI (at that time with indwelling foley cathether), with resolution of fever. Urine cultures returned as mixed bacterial flora, and blood cultures notable for only 1 bottle in one set positive for coag negative staph after >48 hours, thought to be a contaminant. Given clinical stability patient did not receive stress dose steroids. # Toxic metabolic encephalopathy # Delirium In ED patient was very agitated, refusing care, requiring multiple doses of IM zyprexa, then on medical floor was initially somnolent, with negative CTH. By hospital day 2 was AO x 3 after treatment of infection as above. Throughout hospital course mental status waxed and waned, likely with component of delirium, but improved back to her baseline by discharge (oriented and able to perform ___ backwards) as her antibiotics course was ending. ___ oxycodone, methadone, gabapentin were held in setting of altered mental status, restarted methadone partway through hospital course, held others, to be restarted at rehab if needed. # Right hemiparesis # Subacute L corona radiata stroke On HD1, patient noted to have R sided hemiparesis. This was previously documented in PCP note from ___, and upon further investigation, appeared that patient had presented to ___ ___ in ___ with complaint of right sided weakness. Per their discharge summary, "patient was not a candidate for intravenous alteplase, MRI/MRA of brain was ordered but patient was not cooperative. We spoke again with her and family members and patient is insisting in refusing brain MRI." She was discharged with aspirin 324 mg and Lipitor 80 mg daily. Their exam documents "AOx2 strength ___ in LUE, ___ ___ in L leg and ___ in R leg. Sensation in L arm dull when compared to right". There was also report of patient saying "this is not the first time she is having this right sided weakness and usually recovers". After prolonged discussion, MRI ___ was obtained showing late acute to subacute infarct in the left corona radiata, no intracranial hemorrhage. Note was also made of extensive white matter signal abnormality likely related to chronic small vessel ischemic disease. CTA head and neck revealed no severe vascular stenosis, occlusion or aneurysm. TTE with no definite structural cardiac source of embolism identified. Patient was initially maintained on telemetry without any report of atrial fibrillation but ultimately declined to continue monitoring. Long-term event monitoring could be discussed as an outpatient. Regarding other stroke risk factors, LDL was 42, TSH 43/fT4 0.7, A1c 6.1. She was placed on aspirin 81 mg, atorvastatin 80 mg. ___ and OT evaluated patient and recommended rehab, and she was agreeable. # +BCx for coag negative staph: Aerobic bottle from ___ positive for coag negative staph ___ bottles) after >48 hours of growth, likely contaminant. However, patient did receive vancomycin x 7 days given history of MRSA UTI. # Hypothyroidism: Note patient with TSH 43, fT4 0.7, was evaluated by endocrine at ___ and also seen for this at ___, attributed to medication noncompliance, started 125 mcg daily weight based in ___ which was continued this stay. She will need repeat TSH within 6 weeks. # Hypertension: Continued ___ amlodipine. Initially held ___ triamterene-HCTZ and losartan I/s/o normotension, held on discharge for mild ___. # ___: Noted to have elevated Creatinine 1.2 from 0.9 and BUN 26 from 12 one day prior to discharge I/s/o receiving multiple contrast loads. Held ___ antihypertensives as above. # Chronic back and ___ pain: Continued ___ methadone 10 mg TID:PRN (confirmed with ___ that patient takes methadone 10 mg TID:PRN + oxycodone 5 mg TID). ___ oxycodone and gabapentin held as above. Please note that per last pain clinic note ___, there may be an element of opioid induced hyperalgesia as well as opioid tolerance. There was recommendation for continued gradual taper 10% reduction starting with breakthrough oxycodone over ___ intervals then methadone. Her narcotics contract from ___ was reviewed (Dr. ___, with documentation of plan for taper by 10% every 4 weeks- does not appear that this had been done. ___ benefit from new pain clinic referral. CHRONIC ISSUES: ================= # Diabetes: Continued on SSI while in house, resumed ___ metformin on discharge. # Rheumatoid arthritis with leukocytoclastic vasculitis: Continued ___ prednisone 5mg daily # Urinary retention: # Recurrent UTIs: Patient at baseline requires intermittent straight catheterizations due to intermittent trouble with initiating urinary stream. Previously referred to uro-gyn by her ___ PCP, unclear if followed up. Required intermittent straight cath during hospitalization. # Normocytic anemia: Mixed iron deficiency and anemia of chronic inflammation # Chronic venous stasis ulcerations: ___ care RN previously recommended waffle boots, ace wraps to b/l LEs. TRANSITIONAL ISSUES: ==================== [] Neurology follow up for CVA [] Started aspirin 81 mg, atorvastatin 80 mg daily [] Resumed Levothyroxine 125 mg daily [] Held gabapentin and oxycodone for altered mental status, consider pain clinic followup to taper off methadone [] Held ___ triamterene-HCTZ and losartan for mild ___, please restart in 1 week if needed for BP control [] Consider re-referral to uro-gyn for ongoing urinary retention [] Monitor BMs and uptitrate bowel regimen as needed [] Continue to address long term event monitor as outpatient to workup stroke [] Social work in contact with ___ to increase patient's ___ services, which she adamantly refused, would continue to readdress at rehab [] Please recheck TSH ___ (TSH 43, Free T4 0.7 on ___ [] Noted on CT A/P incidentally: fusion of the L3-L4 vertebral bodies with irregularity and lucency of the superior endplate L5 and the inferior endplate L4, which is similar compared to prior but mildly progressed compared to ___, Unchanged, nonspecific prominent/enlarged pelvic/inguinal lymph nodes. Further followup if clinically warranted. #CODE: DNR/DNI (MOLST in chart, ___ #CONTACT: ___ (HCP, noted in chart, Son): ___ Greater than 30 minutes was spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE (Immediate Release) 5 mg PO Q12H 2. Methadone 10 mg PO Q8H:PRN moderate pain 3. Gabapentin 600 mg PO QID 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 6. Sertraline 100 mg PO BID 7. PredniSONE 5 mg PO DAILY 8. Nabumetone 500 mg PO BID 9. MetFORMIN (Glucophage) 500 mg PO DAILY 10. Losartan Potassium 50 mg PO DAILY 11. Levothyroxine Sodium 1000 mcg PO 1X/WEEK (___) 12. amLODIPine 10 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Atorvastatin 20 mg PO QPM 15. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Polyethylene Glycol 17 g PO DAILY 4. Simethicone 80 mg PO QID dyspepsia, gas 5. Atorvastatin 80 mg PO QPM 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Methadone 10 mg PO TID:PRN moderate-severe pain RX *methadone 10 mg 1 tab by mouth three times per day Disp #*9 Tablet Refills:*0 8. Senna 8.6 mg PO BID 9. amLODIPine 10 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. MetFORMIN (Glucophage) 500 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. PredniSONE 5 mg PO DAILY 14. Sertraline 200 mg PO DAILY 15. HELD- Gabapentin 600 mg PO QID This medication was held. Do not restart Gabapentin until there is need for it 16. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until your kidneys recover and your blood pressure is higher 17. HELD- Nabumetone 500 mg PO BID This medication was held. Do not restart Nabumetone until you have more pain 18. HELD- OxyCODONE (Immediate Release) 5 mg PO Q12H This medication was held. Do not restart OxyCODONE (Immediate Release) until your kidneys recover and your blood pressure is higher 19. HELD- Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY This medication was held. Do not restart Triamterene-HCTZ (37.5/25) until your kidneys recover and your blood pressure is higher Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Toxic metabolic encephalopathy Sepsis Urinary tract infection/pyelonephritis Right-sided weakness Late acute to subacute stroke in the left corona radiata Abdominal pain Constipation Secondary: Hypertension Hypothyroidism Type 2 diabetes Rheumatoid arthritis with a history of leukocytoclastic vasculitis Venous insufficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? You came to the hospital because of confusion and belly pain. WHAT HAPPENED TO ME IN THE HOSPITAL? - You got antibiotics for a urinary tract infection that went to your kidneys (pyelonephritis) - You had pictures of your brain that confirmed you had a stroke, which is the cause of the weakness on your right side. - You had pictures taken of your belly which did not show why you were having so much pain, but restarting your ___ methadone was helpful for your pain. - You were evaluated by our physical therapists, who recommended that you go to rehab to get stronger before you go ___. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - It is very important to participate in the rehab program so you can get as much of your strength back as possible before you go ___. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "A419", "G92", "N12", "F05", "I69351", "M0520", "E119", "Z9181", "Z87440", "F0390", "Z7952", "D509", "Z66", "N289", "E039", "K5903", "T402X5A", "I878", "J45909", "R339", "M549", "M79605" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] yo F w/ severe RA w/ leukocytoclastic vasculitis, venous insufficiency, hypothyroid, DM, presenting with abdominal pain and AMS. Per EMS, found seated hunched over on portable commode in bedroom of residence, alert and oriented x4 with warm, dry skin. Pt complained of constipation x2 days with associated abdominal pain. Family member reports pt had two bowel movements today but pt reports still feeling "urgent need to go." Pt reports that she is "very blocked up." On our assessment, patient intermittently reports abdominal pain. Also mentions a fall, unsure when. Reports some mid back pain. Unable to obtain other significant history. Recent [MASKED] admission for fall, thought to be due to deconditioned/meds, also hypothyroid, restarted on levothyroxine. D/c to SAR. Noted to have difficulty with med compliance. EMS physical: L sided tenderness in LUQ on palpation. No distention, rigidity or masses felt. Pt had multiple large bruises all over her body which family member and pt report are from repeated falls in residence. Pt denied chest pain, shortness of breath, nausea, vomiting, fever or chills. Pt was extricated via stair chair, secured to stretcher and transported to BID with no further change in condition. In the ED: On EMS arrival, the patient endorsed LUQ tenderness. Notably, the patient recently had a [MASKED] admission for a fall due to suspected deconditioning. The patient was noted to have difficulty with med compliance. The patient reports bilateral [MASKED] pain. Denies fever, chills, dyspnea, chest pain, or n/v. Initial vital signs were notable for: 97.7 83 130/69 18 98% RA Exam notable for: Patient AAOx2, trying to get out of bed. PERLA, EOMI, no obvious head trauma No C spine tenderness, mild T spine tenderness Flinches with abdominal palpation, especially on the left side. But is soft and not notably distended LEs with bilaterally venous stasis changes and multiple open wounds that do not appear actively infected Labs were notable for: 141 95 12 ---------------< 147 3.6 28 1.0 8.3 > 10.7/33.6 < 207 UA: Large leuks, 30 protein, 40 WBCs Studies performed include: CT head: No acute intracranial process. Diffuse hypodensities in the white matter again seen, similar in extent to CT head dated [MASKED] and [MASKED] which could be related to prior therapy or due to extensive small vessel disease. CT C-Spine 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes including mild anterolisthesis of C2 on C3, intervertebral disc space narrowing, and osteophytosis worse at C4-C5. CT Abd/Pelvis with contrast: 1. Ground-glass opacification in the posterior segment of the right upper lobe that may represent infection. 2. No intrathoracic or intra-abdominal sequela of trauma. 3. Irregularity and lucency at the superior endplate of L5 and inferior endplate of L4 are slightly progressed when compared to prior dated [MASKED] and infection cannot be excluded. 4. Nonspecific, unchanged prominent pelvic lymph nodes. 5. Prominent bilateral external iliac lymph node are again seen measuring up to 0.9 cm in short axis, nonspecific. 6. Mild stranding adjacent to the left adrenal may represent possible adrenal injury. 7. Unchanged, indeterminate renal lesion in the interpolar region of the right kidney seen since [MASKED]. Non emergent follow-up renal ultrasound is recommended if no prior characterization has been performed. Pt was given: Olanzapine for agitation Tylenol Cefpodoxime 200mg Ceftriaxone 1g Azithro IVF sitter for agitation Consults: None Vitals on transfer: T102.7, BP 171/92, HR90, RR20, 94% RA Upon arrival to the floor, pt was somnolent and stated she had L-sided pain of her torso. Her attention waxed/waned and she responded somewhat appropriately when prodded. Vital signs were significant for hypertension and febrile to 102.7 reduced to 100 with IV Tylenol. Her HCP, her son, was called for assessment of her baseline which he says is AOx4 and occasionally combative. She has a history of recurrent UTIs which present with similar delirium. Has mild baseline dementia with forgetfulness of certain memories but functional and independent otherwise. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy [MASKED] ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Intermittent urinary retention Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: [MASKED] Family History: Patient previously stated her family had "medical conditions" but she cannot describe more specifically. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T102.7, BP171/92, HR90, RR20, 94%RA GENERAL: Somnolent, responds appropriately intermittently. In mild distress [MASKED] abd pain. HEENT: NCAT. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: Unable to evaluate for CVA tenderness [MASKED] pt refusal. ABDOMEN: Soft, non distended, tender to palpation in left quadrants (LUQ worse than LLQ). Healed surgical scar on R. EXTREMITIES: B/L [MASKED] erythema with multiple bruises and scars in various stages of healing with overlying blanching well-demarcated erythema. Warm to touch. L leg erythema outlined on [MASKED]. Pulses DP/Radial 2+ bilaterally. SKIN: See Ext above. Warm. NEUROLOGIC: Sensation intact in [MASKED]. DISCHARGE PHYSICAL EXAM: ============================ VITALS: 98.5 PO 99 / 58 71 16 95 RA GEN: Lying in bed on her left side, eyes closed CV: Normal rate, regular rhythm, no m/r/g Pulm: CTAB Abdomen: Deferred due to abdominal pain Ext: B/L [MASKED] with erythema with bruising and skin breakdown c/w venous stasis changes Neuro: EOMI, R facial droop, R upper extremity can elevate without resistance, can move R toes and ankle, improved from prior, grossly normal on the Left side Pertinent Results: ADMISSION LABS: ================= [MASKED] 03:31AM BLOOD WBC-8.3 RBC-3.80* Hgb-10.7* Hct-33.6* MCV-88 MCH-28.2 MCHC-31.8* RDW-15.5 RDWSD-49.9* Plt [MASKED] [MASKED] 03:31AM BLOOD Neuts-87.3* Lymphs-6.8* Monos-4.6* Eos-0.4* Baso-0.4 Im [MASKED] AbsNeut-7.36* AbsLymp-0.57* AbsMono-0.39 AbsEos-0.03* AbsBaso-0.03 [MASKED] 03:25AM BLOOD Glucose-147* UreaN-12 Creat-1.0 Na-141 K-3.6 Cl-95* HCO3-28 AnGap-18 [MASKED] 03:25AM BLOOD ALT-9 AST-10 AlkPhos-113* TotBili-0.7 [MASKED] 03:25AM BLOOD Lipase-10 [MASKED] 10:45AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.4* [MASKED] 03:25AM BLOOD Albumin-4.3 [MASKED] 02:29AM BLOOD Glucose-112* Lactate-2.3* Na-139 K-3.4 Cl-98 calHCO3-26 INTERVAL LABS: =============== [MASKED] 07:25AM BLOOD [MASKED] PTT-28.5 [MASKED] [MASKED] 07:25AM BLOOD Ret Aut-2.3* Abs Ret-0.08 [MASKED] 03:30AM BLOOD Lipase-79* [MASKED] 03:00PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7 Cholest-118 [MASKED] 07:25AM BLOOD calTIBC-229* VitB12-731 Ferritn-186* TRF-176* [MASKED] 03:00PM BLOOD %HbA1c-6.1* eAG-128* [MASKED] 03:00PM BLOOD Triglyc-181* HDL-40* CHOL/HD-3.0 LDLcalc-42 [MASKED] 10:45AM BLOOD TSH-43* [MASKED] 10:45AM BLOOD Free T4-0.7* [MASKED] 10:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS: ================= [MASKED] 06:43AM BLOOD WBC-4.9 RBC-3.51* Hgb-10.1* Hct-30.3* MCV-86 MCH-28.8 MCHC-33.3 RDW-15.1 RDWSD-47.8* Plt [MASKED] [MASKED] 06:43AM BLOOD Glucose-157* UreaN-19 Creat-0.8 Na-140 K-3.7 Cl-98 HCO3-26 AnGap-16 [MASKED] 06:30AM BLOOD Glucose-137* UreaN-26* Creat-0.9 Na-139 K-3.8 Cl-98 HCO3-26 AnGap-15 [MASKED] 06:43AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9 MICROBIOLOGY: =============== [MASKED] AND [MASKED] URINE CULTURES: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] URINE CULTURE: NO GROWTH. [MASKED] 4:00 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. [MASKED] BLOOD CULTURE: NO GROWTH [MASKED] BLOOD CULTURE X2: NGTD [MASKED] BLOOD CULTURE: NGTD IMAGING: =========== CT C-SPINE W/O CONTRAST Study Date of [MASKED] 1. No acute fracture or traumatic malalignment. 2. Multilevel degenerative changes including mild anterolisthesis of C2 on C3, intervertebral disc space narrowing, and osteophytosis worse at C4-C5. 3. Multilevel posterior osteophytosis and calcified disc bulge result in moderate spinal canal narrowing most severe at C3-C4. 4. Multilevel uncovertebral facet joint hypertrophy resulting mild neural foraminal stenosis worse than right C3-C4 facet joint. CT HEAD W/O CONTRAST Study Date of [MASKED] No acute intracranial process. Diffuse hypodensities in the white matter again seen, similar in extent to CT head dated [MASKED] and [MASKED] which could be related to prior therapy or due to extensive small vessel disease. CT CHEST a/p W/CONTRAST Study Date of [MASKED] 1. Nodular, ground-glass opacification in the posterior right upper lobe concerning for pneumonia. In the setting of trauma, underlying pulmonary contusion is not excluded. 2. Mild stranding between the left adrenal gland and kidney is nonspecific, but may relate to acute injury or ascending GU infection. 3. Irregularity and lucency at the superior endplate of L5 and inferior endplate of L4 are slightly progressed when compared to prior dated [MASKED] and infection cannot be excluded. 4. Nonspecific, unchanged prominent pelvic lymph nodes. CT ABD & PELVIS WITH CONTRAST Study Date of [MASKED] 1. No etiology identified for severe abdominal pain. Specifically, no intra-abdominal abscess or small bowel obstruction. 2. The bladder wall appears mildly thickened, which may be related to nondistention, however, cystitis should be considered and correlation with urinalysis is recommended. 3. Redemonstration of the irregularity and lucency at the superior endplate of L5 in the inferior endplate of L4, which is unchanged compared to [MASKED] but slightly progressed compared to [MASKED]. Findings may represent progressive neuropathic degenerative changes however underlying infection cannot be excluded. 4. Unchanged, nonspecific prominent/enlarged pelvic/inguinal lymph nodes. MR HEAD W/O CONTRAST Study Date of [MASKED] 1. Late acute to subacute in the left corona radiata. No intracranial hemorrhage. 2. Atrophy and stable extensive white matter signal abnormality, possibly related to prior therapy or chronic small vessel ischemic disease. 3. Additional findings described above. CTA HEAD AND CTA NECK Study Date of [MASKED] 1. Redemonstration of a focus of late acute to subacute infarct in the left corona radiata. No intracranial hemorrhage. 2. Atrophy and stable extensive white matter disease, possibly related to prior therapy or chronic small vessel ischemic disease. 3. No severe vascular stenosis, occlusion or aneurysm. Mild atherosclerotic disease is noted in the posterior cerebral arteries and cavernous internal carotid arteries. 4. Improved nodular and ground-glass opacities in the posterior right upper lobe, consistent with resolving infection or contusion. 5. Additional findings as described above. TTE Study Date of [MASKED] IMPRESSION: Mild symmetric left ventricular hypertophy with normal cavity sizes, and regional/global systolic function. No definite structural cardiac source of embolism identified. Compared with the prior TTE (images not available for review) of [MASKED], the findings are similar. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old lady with history of rheumatoid arthritis on chronic prednisone, leukocytoclastic vasculitis, hypothyroidism, diabetes, and question of recent stroke with residual R sided weakness, who presents with toxic metabolic encephalopathy in setting of pyelonephritis, with MRI confirming subacute left corona radiata CVA. # Pyelonephritis # Abdominal pain Patient presented with fever to 102.7F and diffuse abdominal pain, with pyuria on U/A as well as CTA/P remarkable for stranding surrounding bladder and near L adrenal/kidney, which was repeated later in hospital course for ongoing abdominal pain and distension, unrevealing for a new source of pain. Other sources of fever considered included possible PNA, given ground glass changes in RUL seen on CT chest, however patient without cough or hypoxia. She completed 7 day course of antibiotics with vancomycin + ceftriaxone ending [MASKED], given history of MRSA UTI (at that time with indwelling foley cathether), with resolution of fever. Urine cultures returned as mixed bacterial flora, and blood cultures notable for only 1 bottle in one set positive for coag negative staph after >48 hours, thought to be a contaminant. Given clinical stability patient did not receive stress dose steroids. # Toxic metabolic encephalopathy # Delirium In ED patient was very agitated, refusing care, requiring multiple doses of IM zyprexa, then on medical floor was initially somnolent, with negative CTH. By hospital day 2 was AO x 3 after treatment of infection as above. Throughout hospital course mental status waxed and waned, likely with component of delirium, but improved back to her baseline by discharge (oriented and able to perform [MASKED] backwards) as her antibiotics course was ending. [MASKED] oxycodone, methadone, gabapentin were held in setting of altered mental status, restarted methadone partway through hospital course, held others, to be restarted at rehab if needed. # Right hemiparesis # Subacute L corona radiata stroke On HD1, patient noted to have R sided hemiparesis. This was previously documented in PCP note from [MASKED], and upon further investigation, appeared that patient had presented to [MASKED] [MASKED] in [MASKED] with complaint of right sided weakness. Per their discharge summary, "patient was not a candidate for intravenous alteplase, MRI/MRA of brain was ordered but patient was not cooperative. We spoke again with her and family members and patient is insisting in refusing brain MRI." She was discharged with aspirin 324 mg and Lipitor 80 mg daily. Their exam documents "AOx2 strength [MASKED] in LUE, [MASKED] [MASKED] in L leg and [MASKED] in R leg. Sensation in L arm dull when compared to right". There was also report of patient saying "this is not the first time she is having this right sided weakness and usually recovers". After prolonged discussion, MRI [MASKED] was obtained showing late acute to subacute infarct in the left corona radiata, no intracranial hemorrhage. Note was also made of extensive white matter signal abnormality likely related to chronic small vessel ischemic disease. CTA head and neck revealed no severe vascular stenosis, occlusion or aneurysm. TTE with no definite structural cardiac source of embolism identified. Patient was initially maintained on telemetry without any report of atrial fibrillation but ultimately declined to continue monitoring. Long-term event monitoring could be discussed as an outpatient. Regarding other stroke risk factors, LDL was 42, TSH 43/fT4 0.7, A1c 6.1. She was placed on aspirin 81 mg, atorvastatin 80 mg. [MASKED] and OT evaluated patient and recommended rehab, and she was agreeable. # +BCx for coag negative staph: Aerobic bottle from [MASKED] positive for coag negative staph [MASKED] bottles) after >48 hours of growth, likely contaminant. However, patient did receive vancomycin x 7 days given history of MRSA UTI. # Hypothyroidism: Note patient with TSH 43, fT4 0.7, was evaluated by endocrine at [MASKED] and also seen for this at [MASKED], attributed to medication noncompliance, started 125 mcg daily weight based in [MASKED] which was continued this stay. She will need repeat TSH within 6 weeks. # Hypertension: Continued [MASKED] amlodipine. Initially held [MASKED] triamterene-HCTZ and losartan I/s/o normotension, held on discharge for mild [MASKED]. # [MASKED]: Noted to have elevated Creatinine 1.2 from 0.9 and BUN 26 from 12 one day prior to discharge I/s/o receiving multiple contrast loads. Held [MASKED] antihypertensives as above. # Chronic back and [MASKED] pain: Continued [MASKED] methadone 10 mg TID:PRN (confirmed with [MASKED] that patient takes methadone 10 mg TID:PRN + oxycodone 5 mg TID). [MASKED] oxycodone and gabapentin held as above. Please note that per last pain clinic note [MASKED], there may be an element of opioid induced hyperalgesia as well as opioid tolerance. There was recommendation for continued gradual taper 10% reduction starting with breakthrough oxycodone over [MASKED] intervals then methadone. Her narcotics contract from [MASKED] was reviewed (Dr. [MASKED], with documentation of plan for taper by 10% every 4 weeks- does not appear that this had been done. [MASKED] benefit from new pain clinic referral. CHRONIC ISSUES: ================= # Diabetes: Continued on SSI while in house, resumed [MASKED] metformin on discharge. # Rheumatoid arthritis with leukocytoclastic vasculitis: Continued [MASKED] prednisone 5mg daily # Urinary retention: # Recurrent UTIs: Patient at baseline requires intermittent straight catheterizations due to intermittent trouble with initiating urinary stream. Previously referred to uro-gyn by her [MASKED] PCP, unclear if followed up. Required intermittent straight cath during hospitalization. # Normocytic anemia: Mixed iron deficiency and anemia of chronic inflammation # Chronic venous stasis ulcerations: [MASKED] care RN previously recommended waffle boots, ace wraps to b/l LEs. TRANSITIONAL ISSUES: ==================== [] Neurology follow up for CVA [] Started aspirin 81 mg, atorvastatin 80 mg daily [] Resumed Levothyroxine 125 mg daily [] Held gabapentin and oxycodone for altered mental status, consider pain clinic followup to taper off methadone [] Held [MASKED] triamterene-HCTZ and losartan for mild [MASKED], please restart in 1 week if needed for BP control [] Consider re-referral to uro-gyn for ongoing urinary retention [] Monitor BMs and uptitrate bowel regimen as needed [] Continue to address long term event monitor as outpatient to workup stroke [] Social work in contact with [MASKED] to increase patient's [MASKED] services, which she adamantly refused, would continue to readdress at rehab [] Please recheck TSH [MASKED] (TSH 43, Free T4 0.7 on [MASKED] [] Noted on CT A/P incidentally: fusion of the L3-L4 vertebral bodies with irregularity and lucency of the superior endplate L5 and the inferior endplate L4, which is similar compared to prior but mildly progressed compared to [MASKED], Unchanged, nonspecific prominent/enlarged pelvic/inguinal lymph nodes. Further followup if clinically warranted. #CODE: DNR/DNI (MOLST in chart, [MASKED] #CONTACT: [MASKED] (HCP, noted in chart, Son): [MASKED] Greater than 30 minutes was spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE (Immediate Release) 5 mg PO Q12H 2. Methadone 10 mg PO Q8H:PRN moderate pain 3. Gabapentin 600 mg PO QID 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 6. Sertraline 100 mg PO BID 7. PredniSONE 5 mg PO DAILY 8. Nabumetone 500 mg PO BID 9. MetFORMIN (Glucophage) 500 mg PO DAILY 10. Losartan Potassium 50 mg PO DAILY 11. Levothyroxine Sodium 1000 mcg PO 1X/WEEK ([MASKED]) 12. amLODIPine 10 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Atorvastatin 20 mg PO QPM 15. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Polyethylene Glycol 17 g PO DAILY 4. Simethicone 80 mg PO QID dyspepsia, gas 5. Atorvastatin 80 mg PO QPM 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Methadone 10 mg PO TID:PRN moderate-severe pain RX *methadone 10 mg 1 tab by mouth three times per day Disp #*9 Tablet Refills:*0 8. Senna 8.6 mg PO BID 9. amLODIPine 10 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. MetFORMIN (Glucophage) 500 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. PredniSONE 5 mg PO DAILY 14. Sertraline 200 mg PO DAILY 15. HELD- Gabapentin 600 mg PO QID This medication was held. Do not restart Gabapentin until there is need for it 16. HELD- Losartan Potassium 50 mg PO DAILY This medication was held. Do not restart Losartan Potassium until your kidneys recover and your blood pressure is higher 17. HELD- Nabumetone 500 mg PO BID This medication was held. Do not restart Nabumetone until you have more pain 18. HELD- OxyCODONE (Immediate Release) 5 mg PO Q12H This medication was held. Do not restart OxyCODONE (Immediate Release) until your kidneys recover and your blood pressure is higher 19. HELD- Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY This medication was held. Do not restart Triamterene-HCTZ (37.5/25) until your kidneys recover and your blood pressure is higher Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: Toxic metabolic encephalopathy Sepsis Urinary tract infection/pyelonephritis Right-sided weakness Late acute to subacute stroke in the left corona radiata Abdominal pain Constipation Secondary: Hypertension Hypothyroidism Type 2 diabetes Rheumatoid arthritis with a history of leukocytoclastic vasculitis Venous insufficiency 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 [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? You came to the hospital because of confusion and belly pain. WHAT HAPPENED TO ME IN THE HOSPITAL? - You got antibiotics for a urinary tract infection that went to your kidneys (pyelonephritis) - You had pictures of your brain that confirmed you had a stroke, which is the cause of the weakness on your right side. - You had pictures taken of your belly which did not show why you were having so much pain, but restarting your [MASKED] methadone was helpful for your pain. - You were evaluated by our physical therapists, who recommended that you go to rehab to get stronger before you go [MASKED]. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - It is very important to participate in the rehab program so you can get as much of your strength back as possible before you go [MASKED]. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "E119", "D509", "Z66", "E039", "J45909" ]
[ "A419: Sepsis, unspecified organism", "G92: Toxic encephalopathy", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "F05: Delirium due to known physiological condition", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "M0520: Rheumatoid vasculitis with rheumatoid arthritis of unspecified site", "E119: Type 2 diabetes mellitus without complications", "Z9181: History of falling", "Z87440: Personal history of urinary (tract) infections", "F0390: Unspecified dementia without behavioral disturbance", "Z7952: Long term (current) use of systemic steroids", "D509: Iron deficiency anemia, unspecified", "Z66: Do not resuscitate", "N289: Disorder of kidney and ureter, unspecified", "E039: Hypothyroidism, unspecified", "K5903: Drug induced constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "I878: Other specified disorders of veins", "J45909: Unspecified asthma, uncomplicated", "R339: Retention of urine, unspecified", "M549: Dorsalgia, unspecified", "M79605: Pain in left leg" ]
10,034,049
20,693,789
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: abdominal pain, AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ PMHx chronic pain on methadone, chronic BLE venous stasis ulcers and recurrent UTIs who presents with AMS and abdominal pain. History is predominant obtained from son and ___ sign-out as patient is limited by her mental status. Patient at baseline requires intermittent straight catheterizations due to intermittent trouble with initiating urinary stream. 2 days ago, she reportedly developed new urinary incontinence and symptoms of dysuria as well as malorous urine c/w prior UTI. She also has been having 2 days of suprapubic abdominal pain. Since yesterday, she also developed new intermittent confusion and disorientation. In the ___, initial VS 97.1, 83, 178/96, 18, 97% on RA. Initial labs were notable for Na 137, K 3.1, Cr 0.8, WBC 6.3, Hgb 10.8 (baseline Hgb ~12), Plt 182. Lactate 2.1. UA grossly positive with mod leuks, sm bld, positive nitrites, 69 WBC, and few bacteria. She was given ceftriaxone prior to transfer to the floor. Given agitation, she required olanzapine x 1 in the ___ prior to transfer. Upon arrival to the floor, the patient states that her son is transitioning her care from ___ to ___. The patient reports significant suprapubic discomfort and states that she has to urinate. She states that she self-catheterizes herself at home intermittently, but cannot explain to me what her underlying urologic issue is and if she has seen urology in the past. She does not know if her BLE edema is stable. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HTN hypothyroidism chronic venous stasis ulcers recurrent UTIs chronic pain back injury NOS asthma COPD ?rheumatoid arthritis T2DM Social History: ___ Family History: NC Physical Exam: Admission Physical Exam Vitals- 98.3 159 / 88 84 20 96 RA GENERAL: well-appearing elderly female lying in bed in NAD HEENT: MMM, NCAT, EOMI, anicteric sclera CARDIAC: RRR, nml S1 and S2, no m/r/g LUNGS: Clear to auscultation bilaterally, unlabored respirations ABDOMEN: soft, obese, somewhat distended EXTREMITIES: wwp, chronic venous stasis changes bilaterally with scattered healing wounds SKIN: chronic venous stasis changes as above NEUROLOGIC: AOx2 (able to state month, states she is in a "hospital", and to self), grossly nonfocal Discharge Physical Exam: Vital Signs: 98.2 PO 137 / 73 74 18 94 RA GENERAL: elderly woman sitting up in bed. HEENT: MMM, anicteric sclera CARDIAC: RRR LUNGS: CTAB, no accessory muscle use ABDOMEN: soft, obese, non-tender, non distended. EXTREMITIES: wwp, chronic venous stasis changes bilaterally with scattered healing wounds, dressing that is C/D/I. SKIN: chronic venous stasis changes as above NEUROLOGIC: alert, oriented to hospital and to self, moving all extremities Pertinent Results: ___ 08:54PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 08:54PM URINE BLOOD-SM NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-MOD ___ 08:54PM URINE RBC-4* WBC-69* BACTERIA-FEW YEAST-NONE EPI-1 ___ 08:54PM URINE MUCOUS-OCC ___ 07:57PM LACTATE-2.1* ___ 07:48PM GLUCOSE-201* UREA N-7 CREAT-0.8 SODIUM-137 POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-30 ANION GAP-16 ___ 07:48PM WBC-6.3 RBC-3.74* HGB-10.8* HCT-31.6* MCV-85 MCH-28.9 MCHC-34.2 RDW-14.1 RDWSD-43.6 ___ 07:48PM NEUTS-75.0* LYMPHS-16.1* MONOS-6.6 EOS-1.3 BASOS-0.5 IM ___ AbsNeut-4.75 AbsLymp-1.02* AbsMono-0.42 AbsEos-0.08 AbsBaso-0.03 ___ 07:48PM PLT COUNT-182 Micro: ___ BCx x 2 pending ___ UCx pending Imaging/Studies: none Micro: ___ 8:54 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: STAPH AUREUS COAG +. >100,000 CFU/mL. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S Blood Cultures: Negative TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No echocardiographic evidence of endocarditis or pathologic flow. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Elevated PCWP suggested. MRI: IMPRESSION: 1. Incomplete examination with acquisition of localizer and sagittal T2 images only. 2. Provided images demonstrate levoscoliosis with moderate to severe L3-L4 and severe L4-L5 spinal canal stenosis with moderate to severe multilevel neural foraminal narrowing, as detailed above. Recommend repeat examination when the patient is able to better tolerate the entire exam. 3. Suboptimal evaluation for epidural fluid collection on this study although there is no obvious evidence. Discharge Labs: ___ 06:57AM BLOOD WBC-4.7 RBC-3.84* Hgb-10.7* Hct-32.2* MCV-84 MCH-27.9 MCHC-33.2 RDW-14.0 RDWSD-42.3 Plt ___ ___ 06:57AM BLOOD Glucose-208* UreaN-13 Creat-0.8 Na-136 K-4.4 Cl-95* HCO3-30 AnGap-15 Brief Hospital Course: Ms. ___ is a ___ PMHx chronic BLE venous stasis ulcers and recurrent UTIs who presents with AMS and UTI. # abdominal pain likely ___ # complicated MRSA UTI. # urinary retention Patient with history of recurrent UTIs (6 within past ___ years per son); she is likely at risk for UTIs in the setting of urinary stasis. It is unclear why the patient requires intermittent self-catheterization. She has been referred to uro-gyn by her ___ PCP but unclear if she actually attended any visits. Per son, she has history of a "lady cancer" with episodes of recurrence necessitating chemo/randiation, last was ~ ___ years ago. CT scan without clear etiology for pain. Urine culture with MRSA in urine. No growth in blood cultures. MRI as suboptimal study but without clear epidural collection. In the setting of MRSA bactermia up to 27% of patients with have bacteruria but in studies of patients with MRSA bacteruria only 1 in 30 patients has MRSA bactermia. MRI L-spine incomplete study but no definitive abscess and patient would like to not complete pain at baseline level. TTE suboptimal study but no frank vegetations and negative blood cultures make risk of TEE higher than benefit. She was treated with IV vancomycin and then transitioned to doxycycline (given sulfa allergy will not use Bactrim) for complicated UTI for 10 day course when her blood culture finalized as negative. # Encephalopathy Likely induced in the setting of acute infection as described above. Patient without other evidence of metabolic derangements at this time. Home methadone and pain regimen initially held and then restarted slowly as mental status improved. She returned to her baseline mental status. # Concern for elder abuse: Patient reported verbal abuse from her son with whom she lives with. No evidence of physical abuse on my exam. Mental status is improved and long discussion with PCP and SW. I spoke for some time about the situation with her son. She reports that he is not physically abusive but is verbally and is nervous about him. When we discussed she reports that she does not want to move forward with a police filing or a restraining order because of what it would do to her family. I was also able to speak with her PCP for about ___ minutes who reports that they have had similar concerns but that she has declined reporting in the past due to the same concerns. Her PCP reports that she can be difficult to engage in follow up be reported that at her baseline (which she is at) she has been found to have capacity to make her own decisions.as well. Social work was involoved and relayed information to the open elder services case. # Hypothyroidism TSH is very abnormal though notably with normal free T4. Home levothyroxine continued. # Chronic pain # Rheumatoid arthritis Home prednisone continued. Home methadone continued. Home oxycodone restarted. # HTN: Continued home losartan, amlodipine, triamterene-HCTZ # HLD: Continued home statin # Depression. Continued home sertraline # GERD. Continued home omeprazole # T2DM: Home metformin held and patient managed with ISS. Restarted at discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 2. amLODIPine 10 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Gabapentin 300 mg PO QID 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Losartan Potassium 50 mg PO DAILY 7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 8. Methadone 10 mg PO QHS 9. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 10. Aspirin 81 mg PO DAILY 11. Methotrexate 2.5 mg PO Frequency is Unknown 12. Nabumetone 500 mg PO BID 13. Omeprazole 20 mg PO DAILY 14. Sertraline 100 mg PO DAILY 15. PredniSONE 5 mg PO DAILY 16. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*14 Capsule Refills:*0 3. Senna 8.6 mg PO BID:PRN constipation 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain - Severe RX *oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours Disp #*10 Tablet Refills:*0 5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Levothyroxine Sodium 150 mcg PO DAILY 11. Losartan Potassium 50 mg PO DAILY 12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 13. Methadone 10 mg PO QHS RX *methadone 10 mg 10 mg by mouth at bedtime Disp #*3 Tablet Refills:*0 14. Methotrexate 10 mg PO QSUN 15. Multivitamins 1 TAB PO DAILY 16. Nabumetone 500 mg PO BID 17. Omeprazole 20 mg PO DAILY 18. PredniSONE 5 mg PO DAILY 19. Sertraline 100 mg PO DAILY 20. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 21. HELD- Gabapentin 300 mg PO QID This medication was held. Do not restart Gabapentin until follow up with PCP. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: urinary tract infection encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for confusion and concern for urinary tract infection. You were treated with IV antibiotics and found to have a MRSA UTI. You were investigated for a bloodstream source ant it was negative. Both TTE and MRI did not show any focus of infection. Please take your medications as directed and follow up with your PCP once discharge. Followup Instructions: ___
[ "N390", "G92", "J449", "F05", "B9562", "I10", "E119", "F329", "E785", "G8929", "Z79899", "E039", "J45998", "Z7952", "K219", "R339", "I872", "M069", "E876" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: abdominal pain, AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] PMHx chronic pain on methadone, chronic BLE venous stasis ulcers and recurrent UTIs who presents with AMS and abdominal pain. History is predominant obtained from son and [MASKED] sign-out as patient is limited by her mental status. Patient at baseline requires intermittent straight catheterizations due to intermittent trouble with initiating urinary stream. 2 days ago, she reportedly developed new urinary incontinence and symptoms of dysuria as well as malorous urine c/w prior UTI. She also has been having 2 days of suprapubic abdominal pain. Since yesterday, she also developed new intermittent confusion and disorientation. In the [MASKED], initial VS 97.1, 83, 178/96, 18, 97% on RA. Initial labs were notable for Na 137, K 3.1, Cr 0.8, WBC 6.3, Hgb 10.8 (baseline Hgb ~12), Plt 182. Lactate 2.1. UA grossly positive with mod leuks, sm bld, positive nitrites, 69 WBC, and few bacteria. She was given ceftriaxone prior to transfer to the floor. Given agitation, she required olanzapine x 1 in the [MASKED] prior to transfer. Upon arrival to the floor, the patient states that her son is transitioning her care from [MASKED] to [MASKED]. The patient reports significant suprapubic discomfort and states that she has to urinate. She states that she self-catheterizes herself at home intermittently, but cannot explain to me what her underlying urologic issue is and if she has seen urology in the past. She does not know if her BLE edema is stable. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HTN hypothyroidism chronic venous stasis ulcers recurrent UTIs chronic pain back injury NOS asthma COPD ?rheumatoid arthritis T2DM Social History: [MASKED] Family History: NC Physical Exam: Admission Physical Exam Vitals- 98.3 159 / 88 84 20 96 RA GENERAL: well-appearing elderly female lying in bed in NAD HEENT: MMM, NCAT, EOMI, anicteric sclera CARDIAC: RRR, nml S1 and S2, no m/r/g LUNGS: Clear to auscultation bilaterally, unlabored respirations ABDOMEN: soft, obese, somewhat distended EXTREMITIES: wwp, chronic venous stasis changes bilaterally with scattered healing wounds SKIN: chronic venous stasis changes as above NEUROLOGIC: AOx2 (able to state month, states she is in a "hospital", and to self), grossly nonfocal Discharge Physical Exam: Vital Signs: 98.2 PO 137 / 73 74 18 94 RA GENERAL: elderly woman sitting up in bed. HEENT: MMM, anicteric sclera CARDIAC: RRR LUNGS: CTAB, no accessory muscle use ABDOMEN: soft, obese, non-tender, non distended. EXTREMITIES: wwp, chronic venous stasis changes bilaterally with scattered healing wounds, dressing that is C/D/I. SKIN: chronic venous stasis changes as above NEUROLOGIC: alert, oriented to hospital and to self, moving all extremities Pertinent Results: [MASKED] 08:54PM URINE COLOR-Yellow APPEAR-Hazy SP [MASKED] [MASKED] 08:54PM URINE BLOOD-SM NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-MOD [MASKED] 08:54PM URINE RBC-4* WBC-69* BACTERIA-FEW YEAST-NONE EPI-1 [MASKED] 08:54PM URINE MUCOUS-OCC [MASKED] 07:57PM LACTATE-2.1* [MASKED] 07:48PM GLUCOSE-201* UREA N-7 CREAT-0.8 SODIUM-137 POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-30 ANION GAP-16 [MASKED] 07:48PM WBC-6.3 RBC-3.74* HGB-10.8* HCT-31.6* MCV-85 MCH-28.9 MCHC-34.2 RDW-14.1 RDWSD-43.6 [MASKED] 07:48PM NEUTS-75.0* LYMPHS-16.1* MONOS-6.6 EOS-1.3 BASOS-0.5 IM [MASKED] AbsNeut-4.75 AbsLymp-1.02* AbsMono-0.42 AbsEos-0.08 AbsBaso-0.03 [MASKED] 07:48PM PLT COUNT-182 Micro: [MASKED] BCx x 2 pending [MASKED] UCx pending Imaging/Studies: none Micro: [MASKED] 8:54 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: STAPH AUREUS COAG +. >100,000 CFU/mL. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S Blood Cultures: Negative TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No echocardiographic evidence of endocarditis or pathologic flow. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Elevated PCWP suggested. MRI: IMPRESSION: 1. Incomplete examination with acquisition of localizer and sagittal T2 images only. 2. Provided images demonstrate levoscoliosis with moderate to severe L3-L4 and severe L4-L5 spinal canal stenosis with moderate to severe multilevel neural foraminal narrowing, as detailed above. Recommend repeat examination when the patient is able to better tolerate the entire exam. 3. Suboptimal evaluation for epidural fluid collection on this study although there is no obvious evidence. Discharge Labs: [MASKED] 06:57AM BLOOD WBC-4.7 RBC-3.84* Hgb-10.7* Hct-32.2* MCV-84 MCH-27.9 MCHC-33.2 RDW-14.0 RDWSD-42.3 Plt [MASKED] [MASKED] 06:57AM BLOOD Glucose-208* UreaN-13 Creat-0.8 Na-136 K-4.4 Cl-95* HCO3-30 AnGap-15 Brief Hospital Course: Ms. [MASKED] is a [MASKED] PMHx chronic BLE venous stasis ulcers and recurrent UTIs who presents with AMS and UTI. # abdominal pain likely [MASKED] # complicated MRSA UTI. # urinary retention Patient with history of recurrent UTIs (6 within past [MASKED] years per son); she is likely at risk for UTIs in the setting of urinary stasis. It is unclear why the patient requires intermittent self-catheterization. She has been referred to uro-gyn by her [MASKED] PCP but unclear if she actually attended any visits. Per son, she has history of a "lady cancer" with episodes of recurrence necessitating chemo/randiation, last was ~ [MASKED] years ago. CT scan without clear etiology for pain. Urine culture with MRSA in urine. No growth in blood cultures. MRI as suboptimal study but without clear epidural collection. In the setting of MRSA bactermia up to 27% of patients with have bacteruria but in studies of patients with MRSA bacteruria only 1 in 30 patients has MRSA bactermia. MRI L-spine incomplete study but no definitive abscess and patient would like to not complete pain at baseline level. TTE suboptimal study but no frank vegetations and negative blood cultures make risk of TEE higher than benefit. She was treated with IV vancomycin and then transitioned to doxycycline (given sulfa allergy will not use Bactrim) for complicated UTI for 10 day course when her blood culture finalized as negative. # Encephalopathy Likely induced in the setting of acute infection as described above. Patient without other evidence of metabolic derangements at this time. Home methadone and pain regimen initially held and then restarted slowly as mental status improved. She returned to her baseline mental status. # Concern for elder abuse: Patient reported verbal abuse from her son with whom she lives with. No evidence of physical abuse on my exam. Mental status is improved and long discussion with PCP and SW. I spoke for some time about the situation with her son. She reports that he is not physically abusive but is verbally and is nervous about him. When we discussed she reports that she does not want to move forward with a police filing or a restraining order because of what it would do to her family. I was also able to speak with her PCP for about [MASKED] minutes who reports that they have had similar concerns but that she has declined reporting in the past due to the same concerns. Her PCP reports that she can be difficult to engage in follow up be reported that at her baseline (which she is at) she has been found to have capacity to make her own decisions.as well. Social work was involoved and relayed information to the open elder services case. # Hypothyroidism TSH is very abnormal though notably with normal free T4. Home levothyroxine continued. # Chronic pain # Rheumatoid arthritis Home prednisone continued. Home methadone continued. Home oxycodone restarted. # HTN: Continued home losartan, amlodipine, triamterene-HCTZ # HLD: Continued home statin # Depression. Continued home sertraline # GERD. Continued home omeprazole # T2DM: Home metformin held and patient managed with ISS. Restarted at discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 2. amLODIPine 10 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Gabapentin 300 mg PO QID 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Losartan Potassium 50 mg PO DAILY 7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 8. Methadone 10 mg PO QHS 9. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 10. Aspirin 81 mg PO DAILY 11. Methotrexate 2.5 mg PO Frequency is Unknown 12. Nabumetone 500 mg PO BID 13. Omeprazole 20 mg PO DAILY 14. Sertraline 100 mg PO DAILY 15. PredniSONE 5 mg PO DAILY 16. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*14 Capsule Refills:*0 3. Senna 8.6 mg PO BID:PRN constipation 4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain - Severe RX *oxycodone 5 mg [MASKED] tablet(s) by mouth Every 6 hours Disp #*10 Tablet Refills:*0 5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Levothyroxine Sodium 150 mcg PO DAILY 11. Losartan Potassium 50 mg PO DAILY 12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 13. Methadone 10 mg PO QHS RX *methadone 10 mg 10 mg by mouth at bedtime Disp #*3 Tablet Refills:*0 14. Methotrexate 10 mg PO QSUN 15. Multivitamins 1 TAB PO DAILY 16. Nabumetone 500 mg PO BID 17. Omeprazole 20 mg PO DAILY 18. PredniSONE 5 mg PO DAILY 19. Sertraline 100 mg PO DAILY 20. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 21. HELD- Gabapentin 300 mg PO QID This medication was held. Do not restart Gabapentin until follow up with PCP. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: urinary tract infection encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for confusion and concern for urinary tract infection. You were treated with IV antibiotics and found to have a MRSA UTI. You were investigated for a bloodstream source ant it was negative. Both TTE and MRI did not show any focus of infection. Please take your medications as directed and follow up with your PCP once discharge. Followup Instructions: [MASKED]
[]
[ "N390", "J449", "I10", "E119", "F329", "E785", "G8929", "E039", "K219" ]
[ "N390: Urinary tract infection, site not specified", "G92: Toxic encephalopathy", "J449: Chronic obstructive pulmonary disease, unspecified", "F05: Delirium due to known physiological condition", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "F329: Major depressive disorder, single episode, unspecified", "E785: Hyperlipidemia, unspecified", "G8929: Other chronic pain", "Z79899: Other long term (current) drug therapy", "E039: Hypothyroidism, unspecified", "J45998: Other asthma", "Z7952: Long term (current) use of systemic steroids", "K219: Gastro-esophageal reflux disease without esophagitis", "R339: Retention of urine, unspecified", "I872: Venous insufficiency (chronic) (peripheral)", "M069: Rheumatoid arthritis, unspecified", "E876: Hypokalemia" ]
10,034,049
22,185,456
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ CT-guided L4-L5 spine biopsy History of Present Illness: Ms. ___ is a ___ year-old female with medical history notable for stroke (right sided weakness), rheumatoid arthritis on prednisone, leukocytoclastic vasculitis, venous insufficiency and hypothyroidism who was recently admitted from ___ for abdominal pain with course with concern for pylenephritis, presented on ___ from rehab with acute onset abdominal pain. The patient reported diffuse abdominal pain that increases with food intake. She reports a ___ periumbilical pain, similar to her last admission. The pain is relieved by not eating. She reports 15 lb unintentional weight loss over the last month which concerns her. She has her usual chronic back pain but this is no worse. She denies any problems urinating or with her bowel movements; specifically she denies black/bloody bowel movements, diarrhea or constipation. 10 point ROS otherwise negative. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy ___ ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Intermittent urinary retention Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: ___ Family History: Patient previously stated her family had "medical conditions" but she cannot describe more specifically. Physical Exam: ============================= ADMISSION PHYSICAL EXAMINATION ============================= VITALS: 98.5 187/94 54 18 99 RA General: Alert, oriented, sleepy but arousable, intermittently groaning and grabbing her abdomen near her umbilicus HEENT: MMM with upper dentures in place CV: Mild bradycardia, no murmurs Lungs: Clear anteriorly, pt did not want to sit up for posterior lung exam Abdomen: Soft, +moderate tenderness along periumbilicus and epigastrum, voluntary guarding but no rebound, no masses GU: No foley Ext: Warm, well perfused, 2+ pulses, wrapped in clean/dry guaze Neuro: AOx3, mild right sided facial droop (present on d/c exam), moving extremities with purpose, decreased power in her right arm and leg ___. Back: would not sit up for proper back exam ============================= DISCHARGE PHYSICAL EXAMINATION ============================= PHYSICAL EXAM: VITALS: 98.4 144/79 76 18 98 GEN: Older woman lying in bed asleep; easily roused; in NAD HEENT: NC/AT, MMM NECK: supple HEART: RRR, no m/r/g LUNGS: CTAB EXTR: chronic skin changes on shins, 1+ pitting edema BLE NEURO: alert, moving all extremities Pertinent Results: ============== ADMISSION LABS ============== ___ 08:07AM BLOOD WBC-6.6 RBC-3.75* Hgb-11.0* Hct-32.0* MCV-85 MCH-29.3 MCHC-34.4 RDW-15.0 RDWSD-46.0 Plt ___ ___ 05:40AM BLOOD ___ ___ 08:07AM BLOOD Glucose-156* UreaN-16 Creat-0.8 Na-141 K-4.6 Cl-100 HCO3-26 AnGap-15 ___ 08:07AM BLOOD ALT-25 AST-21 AlkPhos-99 TotBili-0.4 ___ 08:07AM BLOOD Lipase-17 ___ 05:40AM BLOOD TotProt-6.9 Calcium-9.3 Phos-4.8* Mg-2.0 ___ 05:40AM BLOOD TSH-98* ___ 08:07AM BLOOD T3-37* Free T4-0.7* ___ 05:40AM BLOOD CRP-3.7 antiTPO-LESS THAN ___ 08:07AM BLOOD PEP-M-SPIKE NO FreeKap-25.9* FreeLam-14.8 Fr K/L-1.8* IgG-1076 IgA-288 IgM-214 IFE-VERY FAINT ============== RELEVANT LABS: ============== ___ 08:07AM BLOOD Lipase-17 ___ 01:10PM BLOOD hsCRP-89.1 ___ 05:20AM BLOOD TSH-33* ___ 11:10AM BLOOD TSH-46* ___ 05:40AM BLOOD TSH-98* ___ 05:20AM BLOOD T4-5.4 T3-47* calcTBG-1.07 TUptake-0.93 T4Index-5.0 ___ 11:10AM BLOOD T3-37* Free T4-0.9* ___ 05:40AM BLOOD T3-39* Free T4-0.6* ___ 08:07AM BLOOD T3-37* Free T4-0.7* ___ 05:40AM BLOOD Cortsol-9.3 ___ 03:30PM BLOOD CRP-12.6* ___ 01:10PM BLOOD CRP-90.9* ___ 05:40AM BLOOD CRP-3.7 antiTPO-LESS THAN ___ 08:07AM BLOOD CRP-4.4 ___ 05:40AM BLOOD PEP-NO M-SPIKE FreeKap-27.9* FreeLam-15.5 Fr K/L-1.8* IgG-1014 IgA-296 IgM-198 IFE-FAINT FREE ___ 08:07AM BLOOD PEP-M-SPIKE NO FreeKap-25.9* FreeLam-14.8 Fr K/L-1.8* IgG-1076 IgA-288 IgM-214 IFE-VERY FAINT ============== DISCHARGE LABS ============== Not obtained ======= IMAGING ======= CXR - ___ No acute radiographic cardiopulmonary process. CT ABDOMEN WITH CONTRAST - ___ 1. Endplate irregularity of L4/5 is similar to the most recent examination but MRI of the lumbar spine must be performed to exclude osteomyelitis. 2. Similar severe scoliosis of the lumbar spine secondary to L3-L4 and L4-L5 lateral subluxation. 3. Similar severe lower lumbar spine degenerative disc disease and facet arthropathy. ====== MICRO ====== Blood Culture, Routine (Final ___: VIRIDANS STREPTOCOCCI. Isolated from only one set in the previous five days. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Blood Culture, Routine (Final ___: NO GROWTH. URINE CULTURE (Final ___: NO GROWTH. ___ 3:30 pm TISSUE Source: surgical - vertebral/intervertebral biopsy. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Brief Hospital Course: ASSESSMENT & PLAN: ===================== ___ year old lady with complex medical history including chronic pain/rheumatoid arthritis on prednisone, leukocytoclastic vasculitis, uterine cancer s/p hysterectomy, recent CVA in ___, recently admitted for abdominal pain concerning for pyelonephritis, who represented with worsening of her periumbilical abdominal pain and back pain. She was found to have an abnormal lucency on L4/L5 on CT scan with c/f chronic osteomyelitis/discitis vs severe degenerative joint disease. She underwent ___ spine biopsy of the lesion, with cultures negative to date. ACUTE/ACTIVE PROBLEMS: ====================== # Back pain # L4/L5 lesion Due to complaints of back pain and abdominal pain (as below), patient underwent CT A/P that noted a lucency on L4/L5 c/f chronic discitis/osteomyelitis vs severe DJD. This was in the setting of one positive blood culture with strep viridans. MRI was recommended for further evaluation; however, patient refused. Repeat blood cultures were all negative; it is possible strep viridans could have represented contaminant. However, repeat CRP obtained this admission elevated at 90 (WNL at presentation, and also normalized later this admission without intervention). ID was consulted and recommended intervertebral disc biopsy and cultures. We deferred MRI based on ID and radiology recommendations that a negative MRI would not definitively rule out osteomyelitis (would also show inflammation even if it were DJD). We proceeded with ___ spine biopsy on ___ with both the patient and the patient's HCP agreeing with the procedure; the patient did not require chemical sedation prior to the procedure. Gram stain demonstrated 3+ polymorphonuclear cells. Cultures are negative, though acid fast culture and fungal culture are still preliminary results. Patient was discharged afebrile and clinically stable to a rehabilitation facility with plan to follow up on final culture results. ID (attending Dr. ___ ___ was aware of discharge plan and in agreement; ID has low suspicion for infection at this point and recommend no antibiotics. Plan is for ongoing monitoring of her symptoms and clinical status at rehab/as an outpatient; if there is any recurrent concern for infection (fevers, worsening symptoms, persistently elevated CRP, etc), she should be referred to see Dr. ___ (ID fellow) as an outpatient. # Hypothyroidism: Patient exhibited symptoms of depression and withdrawal in the setting of hypothyroidism (___: 98). Of note, the patient is known to have hypothyroidism non-compliant on levothyroxine. Last hospital admission (___), TSH: 43, fT4: 0.7. On this hospital admission, TSH was initially found to be 98. She was continued on 150 mcg daily. IV levothyroxine was considered; however, patient was unwilling to undergo pIV placement and HCP was not established at that time. ___ on ___ was 33 and patient was continued on PO regimen at 137 mcg daily, with endocrinology input. She will need to follow up with endocrinology ___ weeks after discharge for repeat TFTs at that time. # Abdominal pain Patient complained of diffuse abdominal pain that increased with food intake and decreased when applying heat. Patient underwent CT A/P in ED due to abdominal pain. Imaging noted possible lucency on L4/L5 c/f discitis/osteomyelitis (see back pain/GPC bacteremia above). The patient refused MRI and IV medications. Bowel regimen was initiated with patient demonstrating relief from abdominal pain after bowel movements. Abdominal pain was possibly related to constipation. She did not have abdominal pain by discharge. # Health care proxy (HCP) # Patient refusal of care The patient declined IV therapy during the majority of her hospitalization. She also refused most blood tests. The patient has one biological child: ___, and two step children: ___ and ___. In ___, ___ was the health care proxy but was changed one month later to son ___ was contacted but stated she did not wish to serve the role of HCP. Following meeting with ___, we filed for HCP affirmation. ___ was established as HCP on ___ and was kept informed of all medical decision making throughout the patient's hospitalization. # Weight loss Endorses unintentional weight loss. Per OMR sheets, her standard bed weight was 193 lbs on ___ and down to 171 lbs on ___. Nutrition was consulted but it was felt that tube feeds would be unfeasible given patient's failure to comply with medical interventions and refusal to discuss nutritional intervention. We encouraged PO intake throughout the hospitalization, provided a multivitamin with minerals and initiated mirtazapine to stimulate the patient's appetite. She will need to follow up with her PCP outpatient regarding this weight loss. CHRONIC/STABLE PROBLEMS: ======================= # Prediabetes: HbA1c 6.1% on last admission. Patient's home metformin was held while inpatient and restarted for discharge. # Hyperlipidemia: # History of CVA: Patient was continued home atorvastatin and aspirin. # Rheumatoid arthritis: Patient was continued on home prednisone 5 mg daily, home tylenol, home methadone. # Depression and anxiety Patient was continued on home sertraline 200 mg daily TRANSITIONAL ISSUES: ================== [] Outpatient endocrinology follow up in ___ weeks post discharge is being arranged with ___ MD. ___ will need repeat TFTs at that time. Endocrinology was notified of discharge and is working on an appointment. Please call ___ endocrinology department if you do not hear back with an appointment time within the next 3 days. [] Needs ongoing monitoring of her back pain and vitals at rehab/as an outpatient; if there is any recurrent concern for infection (fevers, worsening symptoms, persistently elevated CRP, leukocytosis, etc.), she should be referred to see Dr. ___ ___ ID fellow) as an outpatient. [] Follow up on finalized spine biopsy cultures (fungal cultures and acid fast cultures were still preliminary negative at time of discharge) ___ [] Needs ___ at rehab to regain mobility/strength. [] After rehab discharge, should f/u with PCP regarding weight loss and consider referral to outpatient nutrition if patient amenable [] Recheck labs including CBC and CRP in ___ weeks post discharge, to assess if any ongoing c/f infection. [] Upon discharge from rehab, please write HCP son ___ work letter to allow him to time off to care for the patient. [] Please give ___ son ___ of the HCP affirmation form and also the discharge summary, which are being sent with the patient to rehab, as son requested this. Code status: DNR/DNI Contact: ___ (___): ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Methadone 10 mg PO TID:PRN moderate-severe pain 6. Omeprazole 20 mg PO DAILY 7. PredniSONE 5 mg PO DAILY 8. Senna 8.6 mg PO BID 9. Sertraline 200 mg PO DAILY 10. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 11. Docusate Sodium 100 mg PO BID 12. Polyethylene Glycol 17 g PO DAILY 13. Simethicone 80 mg PO QID dyspepsia, gas 14. MetFORMIN (Glucophage) 500 mg PO DAILY 15. Bisacodyl ___AILY:PRN Constipation - First Line 16. Methadone 10 mg PO DAILY Discharge Medications: 1. Mirtazapine 15 mg PO DAILY 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Mupirocin Ointment 2% 1 Appl TP TID 4. Levothyroxine Sodium 137 mcg PO DAILY 5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 6. amLODIPine 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Bisacodyl ___AILY:PRN Constipation - First Line 10. Docusate Sodium 100 mg PO BID 11. MetFORMIN (Glucophage) 500 mg PO DAILY 12. Methadone 10 mg PO TID:PRN moderate-severe pain 13. Methadone 10 mg PO DAILY Consider prescribing naloxone at discharge 14. Omeprazole 20 mg PO DAILY 15. Polyethylene Glycol 17 g PO DAILY 16. PredniSONE 5 mg PO DAILY 17. Senna 8.6 mg PO BID 18. Sertraline 200 mg PO DAILY 19. Simethicone 80 mg PO QID dyspepsia, gas Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ================= PRIMARY DIAGNOSIS ================= Degenerative joint disease - severe Back pain =================== SECONDARY DIAGNOSIS =================== Hypothyroidism Rheumatoid arthritis Depression 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 ___, It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? - You came to the hospital because you experienced belly and back pains. You also complained of poor appetite and weight loss. What did you receive in the hospital? - You underwent CT imaging for your abdomen and back. You were found to have a lesion in your lower spine - You underwent a bone biopsy of the spine lesion. - Biopsy showed no evidence of infection in the bone; however, we are awaiting final results and will inform you when they are available. - You were also found to have low levels of thyroid hormones. You were seen by a specialized doctor in thyroid diseases (endocrinologist). The dose of thyroid hormone was set at 137 mcg. What should you do once you leave the hospital? - Please work at rehab to regain your strength. - Please take all your medication as advised. - Please follow-up with your doctors ___ below) We wish you the best! Your ___ Care Team Followup Instructions: ___
[ "M47816", "G9340", "L97919", "D696", "I83009", "M069", "D649", "R109", "L739", "Z66", "Z5329", "R7303", "K5900", "F419", "F329", "E039", "E785", "F17210", "Z9114", "Z8673", "Z8542" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED] CT-guided L4-L5 spine biopsy History of Present Illness: Ms. [MASKED] is a [MASKED] year-old female with medical history notable for stroke (right sided weakness), rheumatoid arthritis on prednisone, leukocytoclastic vasculitis, venous insufficiency and hypothyroidism who was recently admitted from [MASKED] for abdominal pain with course with concern for pylenephritis, presented on [MASKED] from rehab with acute onset abdominal pain. The patient reported diffuse abdominal pain that increases with food intake. She reports a [MASKED] periumbilical pain, similar to her last admission. The pain is relieved by not eating. She reports 15 lb unintentional weight loss over the last month which concerns her. She has her usual chronic back pain but this is no worse. She denies any problems urinating or with her bowel movements; specifically she denies black/bloody bowel movements, diarrhea or constipation. 10 point ROS otherwise negative. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy [MASKED] ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Intermittent urinary retention Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: [MASKED] Family History: Patient previously stated her family had "medical conditions" but she cannot describe more specifically. Physical Exam: ============================= ADMISSION PHYSICAL EXAMINATION ============================= VITALS: 98.5 187/94 54 18 99 RA General: Alert, oriented, sleepy but arousable, intermittently groaning and grabbing her abdomen near her umbilicus HEENT: MMM with upper dentures in place CV: Mild bradycardia, no murmurs Lungs: Clear anteriorly, pt did not want to sit up for posterior lung exam Abdomen: Soft, +moderate tenderness along periumbilicus and epigastrum, voluntary guarding but no rebound, no masses GU: No foley Ext: Warm, well perfused, 2+ pulses, wrapped in clean/dry guaze Neuro: AOx3, mild right sided facial droop (present on d/c exam), moving extremities with purpose, decreased power in her right arm and leg [MASKED]. Back: would not sit up for proper back exam ============================= DISCHARGE PHYSICAL EXAMINATION ============================= PHYSICAL EXAM: VITALS: 98.4 144/79 76 18 98 GEN: Older woman lying in bed asleep; easily roused; in NAD HEENT: NC/AT, MMM NECK: supple HEART: RRR, no m/r/g LUNGS: CTAB EXTR: chronic skin changes on shins, 1+ pitting edema BLE NEURO: alert, moving all extremities Pertinent Results: ============== ADMISSION LABS ============== [MASKED] 08:07AM BLOOD WBC-6.6 RBC-3.75* Hgb-11.0* Hct-32.0* MCV-85 MCH-29.3 MCHC-34.4 RDW-15.0 RDWSD-46.0 Plt [MASKED] [MASKED] 05:40AM BLOOD [MASKED] [MASKED] 08:07AM BLOOD Glucose-156* UreaN-16 Creat-0.8 Na-141 K-4.6 Cl-100 HCO3-26 AnGap-15 [MASKED] 08:07AM BLOOD ALT-25 AST-21 AlkPhos-99 TotBili-0.4 [MASKED] 08:07AM BLOOD Lipase-17 [MASKED] 05:40AM BLOOD TotProt-6.9 Calcium-9.3 Phos-4.8* Mg-2.0 [MASKED] 05:40AM BLOOD TSH-98* [MASKED] 08:07AM BLOOD T3-37* Free T4-0.7* [MASKED] 05:40AM BLOOD CRP-3.7 antiTPO-LESS THAN [MASKED] 08:07AM BLOOD PEP-M-SPIKE NO FreeKap-25.9* FreeLam-14.8 Fr K/L-1.8* IgG-1076 IgA-288 IgM-214 IFE-VERY FAINT ============== RELEVANT LABS: ============== [MASKED] 08:07AM BLOOD Lipase-17 [MASKED] 01:10PM BLOOD hsCRP-89.1 [MASKED] 05:20AM BLOOD TSH-33* [MASKED] 11:10AM BLOOD TSH-46* [MASKED] 05:40AM BLOOD TSH-98* [MASKED] 05:20AM BLOOD T4-5.4 T3-47* calcTBG-1.07 TUptake-0.93 T4Index-5.0 [MASKED] 11:10AM BLOOD T3-37* Free T4-0.9* [MASKED] 05:40AM BLOOD T3-39* Free T4-0.6* [MASKED] 08:07AM BLOOD T3-37* Free T4-0.7* [MASKED] 05:40AM BLOOD Cortsol-9.3 [MASKED] 03:30PM BLOOD CRP-12.6* [MASKED] 01:10PM BLOOD CRP-90.9* [MASKED] 05:40AM BLOOD CRP-3.7 antiTPO-LESS THAN [MASKED] 08:07AM BLOOD CRP-4.4 [MASKED] 05:40AM BLOOD PEP-NO M-SPIKE FreeKap-27.9* FreeLam-15.5 Fr K/L-1.8* IgG-1014 IgA-296 IgM-198 IFE-FAINT FREE [MASKED] 08:07AM BLOOD PEP-M-SPIKE NO FreeKap-25.9* FreeLam-14.8 Fr K/L-1.8* IgG-1076 IgA-288 IgM-214 IFE-VERY FAINT ============== DISCHARGE LABS ============== Not obtained ======= IMAGING ======= CXR - [MASKED] No acute radiographic cardiopulmonary process. CT ABDOMEN WITH CONTRAST - [MASKED] 1. Endplate irregularity of L4/5 is similar to the most recent examination but MRI of the lumbar spine must be performed to exclude osteomyelitis. 2. Similar severe scoliosis of the lumbar spine secondary to L3-L4 and L4-L5 lateral subluxation. 3. Similar severe lower lumbar spine degenerative disc disease and facet arthropathy. ====== MICRO ====== Blood Culture, Routine (Final [MASKED]: VIRIDANS STREPTOCOCCI. Isolated from only one set in the previous five days. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Blood Culture, Routine (Final [MASKED]: NO GROWTH. URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 3:30 pm TISSUE Source: surgical - vertebral/intervertebral biopsy. GRAM STAIN (Final [MASKED]: 3+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Brief Hospital Course: ASSESSMENT & PLAN: ===================== [MASKED] year old lady with complex medical history including chronic pain/rheumatoid arthritis on prednisone, leukocytoclastic vasculitis, uterine cancer s/p hysterectomy, recent CVA in [MASKED], recently admitted for abdominal pain concerning for pyelonephritis, who represented with worsening of her periumbilical abdominal pain and back pain. She was found to have an abnormal lucency on L4/L5 on CT scan with c/f chronic osteomyelitis/discitis vs severe degenerative joint disease. She underwent [MASKED] spine biopsy of the lesion, with cultures negative to date. ACUTE/ACTIVE PROBLEMS: ====================== # Back pain # L4/L5 lesion Due to complaints of back pain and abdominal pain (as below), patient underwent CT A/P that noted a lucency on L4/L5 c/f chronic discitis/osteomyelitis vs severe DJD. This was in the setting of one positive blood culture with strep viridans. MRI was recommended for further evaluation; however, patient refused. Repeat blood cultures were all negative; it is possible strep viridans could have represented contaminant. However, repeat CRP obtained this admission elevated at 90 (WNL at presentation, and also normalized later this admission without intervention). ID was consulted and recommended intervertebral disc biopsy and cultures. We deferred MRI based on ID and radiology recommendations that a negative MRI would not definitively rule out osteomyelitis (would also show inflammation even if it were DJD). We proceeded with [MASKED] spine biopsy on [MASKED] with both the patient and the patient's HCP agreeing with the procedure; the patient did not require chemical sedation prior to the procedure. Gram stain demonstrated 3+ polymorphonuclear cells. Cultures are negative, though acid fast culture and fungal culture are still preliminary results. Patient was discharged afebrile and clinically stable to a rehabilitation facility with plan to follow up on final culture results. ID (attending Dr. [MASKED] [MASKED] was aware of discharge plan and in agreement; ID has low suspicion for infection at this point and recommend no antibiotics. Plan is for ongoing monitoring of her symptoms and clinical status at rehab/as an outpatient; if there is any recurrent concern for infection (fevers, worsening symptoms, persistently elevated CRP, etc), she should be referred to see Dr. [MASKED] (ID fellow) as an outpatient. # Hypothyroidism: Patient exhibited symptoms of depression and withdrawal in the setting of hypothyroidism ([MASKED]: 98). Of note, the patient is known to have hypothyroidism non-compliant on levothyroxine. Last hospital admission ([MASKED]), TSH: 43, fT4: 0.7. On this hospital admission, TSH was initially found to be 98. She was continued on 150 mcg daily. IV levothyroxine was considered; however, patient was unwilling to undergo pIV placement and HCP was not established at that time. [MASKED] on [MASKED] was 33 and patient was continued on PO regimen at 137 mcg daily, with endocrinology input. She will need to follow up with endocrinology [MASKED] weeks after discharge for repeat TFTs at that time. # Abdominal pain Patient complained of diffuse abdominal pain that increased with food intake and decreased when applying heat. Patient underwent CT A/P in ED due to abdominal pain. Imaging noted possible lucency on L4/L5 c/f discitis/osteomyelitis (see back pain/GPC bacteremia above). The patient refused MRI and IV medications. Bowel regimen was initiated with patient demonstrating relief from abdominal pain after bowel movements. Abdominal pain was possibly related to constipation. She did not have abdominal pain by discharge. # Health care proxy (HCP) # Patient refusal of care The patient declined IV therapy during the majority of her hospitalization. She also refused most blood tests. The patient has one biological child: [MASKED], and two step children: [MASKED] and [MASKED]. In [MASKED], [MASKED] was the health care proxy but was changed one month later to son [MASKED] was contacted but stated she did not wish to serve the role of HCP. Following meeting with [MASKED], we filed for HCP affirmation. [MASKED] was established as HCP on [MASKED] and was kept informed of all medical decision making throughout the patient's hospitalization. # Weight loss Endorses unintentional weight loss. Per OMR sheets, her standard bed weight was 193 lbs on [MASKED] and down to 171 lbs on [MASKED]. Nutrition was consulted but it was felt that tube feeds would be unfeasible given patient's failure to comply with medical interventions and refusal to discuss nutritional intervention. We encouraged PO intake throughout the hospitalization, provided a multivitamin with minerals and initiated mirtazapine to stimulate the patient's appetite. She will need to follow up with her PCP outpatient regarding this weight loss. CHRONIC/STABLE PROBLEMS: ======================= # Prediabetes: HbA1c 6.1% on last admission. Patient's home metformin was held while inpatient and restarted for discharge. # Hyperlipidemia: # History of CVA: Patient was continued home atorvastatin and aspirin. # Rheumatoid arthritis: Patient was continued on home prednisone 5 mg daily, home tylenol, home methadone. # Depression and anxiety Patient was continued on home sertraline 200 mg daily TRANSITIONAL ISSUES: ================== [] Outpatient endocrinology follow up in [MASKED] weeks post discharge is being arranged with [MASKED] MD. [MASKED] will need repeat TFTs at that time. Endocrinology was notified of discharge and is working on an appointment. Please call [MASKED] endocrinology department if you do not hear back with an appointment time within the next 3 days. [] Needs ongoing monitoring of her back pain and vitals at rehab/as an outpatient; if there is any recurrent concern for infection (fevers, worsening symptoms, persistently elevated CRP, leukocytosis, etc.), she should be referred to see Dr. [MASKED] [MASKED] ID fellow) as an outpatient. [] Follow up on finalized spine biopsy cultures (fungal cultures and acid fast cultures were still preliminary negative at time of discharge) [MASKED] [] Needs [MASKED] at rehab to regain mobility/strength. [] After rehab discharge, should f/u with PCP regarding weight loss and consider referral to outpatient nutrition if patient amenable [] Recheck labs including CBC and CRP in [MASKED] weeks post discharge, to assess if any ongoing c/f infection. [] Upon discharge from rehab, please write HCP son [MASKED] work letter to allow him to time off to care for the patient. [] Please give [MASKED] son [MASKED] of the HCP affirmation form and also the discharge summary, which are being sent with the patient to rehab, as son requested this. Code status: DNR/DNI Contact: [MASKED] ([MASKED]): [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Methadone 10 mg PO TID:PRN moderate-severe pain 6. Omeprazole 20 mg PO DAILY 7. PredniSONE 5 mg PO DAILY 8. Senna 8.6 mg PO BID 9. Sertraline 200 mg PO DAILY 10. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 11. Docusate Sodium 100 mg PO BID 12. Polyethylene Glycol 17 g PO DAILY 13. Simethicone 80 mg PO QID dyspepsia, gas 14. MetFORMIN (Glucophage) 500 mg PO DAILY 15. Bisacodyl AILY:PRN Constipation - First Line 16. Methadone 10 mg PO DAILY Discharge Medications: 1. Mirtazapine 15 mg PO DAILY 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Mupirocin Ointment 2% 1 Appl TP TID 4. Levothyroxine Sodium 137 mcg PO DAILY 5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 6. amLODIPine 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Bisacodyl AILY:PRN Constipation - First Line 10. Docusate Sodium 100 mg PO BID 11. MetFORMIN (Glucophage) 500 mg PO DAILY 12. Methadone 10 mg PO TID:PRN moderate-severe pain 13. Methadone 10 mg PO DAILY Consider prescribing naloxone at discharge 14. Omeprazole 20 mg PO DAILY 15. Polyethylene Glycol 17 g PO DAILY 16. PredniSONE 5 mg PO DAILY 17. Senna 8.6 mg PO BID 18. Sertraline 200 mg PO DAILY 19. Simethicone 80 mg PO QID dyspepsia, gas Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: ================= PRIMARY DIAGNOSIS ================= Degenerative joint disease - severe Back pain =================== SECONDARY DIAGNOSIS =================== Hypothyroidism Rheumatoid arthritis Depression 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 [MASKED], It was a pleasure to care for you at the [MASKED] [MASKED]. Why did you come to the hospital? - You came to the hospital because you experienced belly and back pains. You also complained of poor appetite and weight loss. What did you receive in the hospital? - You underwent CT imaging for your abdomen and back. You were found to have a lesion in your lower spine - You underwent a bone biopsy of the spine lesion. - Biopsy showed no evidence of infection in the bone; however, we are awaiting final results and will inform you when they are available. - You were also found to have low levels of thyroid hormones. You were seen by a specialized doctor in thyroid diseases (endocrinologist). The dose of thyroid hormone was set at 137 mcg. What should you do once you leave the hospital? - Please work at rehab to regain your strength. - Please take all your medication as advised. - Please follow-up with your doctors [MASKED] below) We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "D696", "D649", "Z66", "K5900", "F419", "F329", "E039", "E785", "F17210", "Z8673" ]
[ "M47816: Spondylosis without myelopathy or radiculopathy, lumbar region", "G9340: Encephalopathy, unspecified", "L97919: Non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity", "D696: Thrombocytopenia, unspecified", "I83009: Varicose veins of unspecified lower extremity with ulcer of unspecified site", "M069: Rheumatoid arthritis, unspecified", "D649: Anemia, unspecified", "R109: Unspecified abdominal pain", "L739: Follicular disorder, unspecified", "Z66: Do not resuscitate", "Z5329: Procedure and treatment not carried out because of patient's decision for other reasons", "R7303: Prediabetes", "K5900: Constipation, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z9114: Patient's other noncompliance with medication regimen", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z8542: Personal history of malignant neoplasm of other parts of uterus" ]
10,034,049
24,278,210
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with history of rheumatoid arthritis on daily prednisone, HTN, HLD, hypothyroidism, DM2, asthma, depression, anxiety who presents with AMS. The patient's son is not present, but the patient tells me that he brought her to the ED. She says "he's an ex ___, he thinks he knows everything but knows nothing. I think he jumped the gun bringing me here, overreading into things". She was noted to be reportedly lethargic in the ED. The patient is oriented to ___, ___, and can recite the days of the weeks backwards. She says she has had 2 days of malaise and feeling overall unwell. No myalgias, subjective fever, nausea, vomiting, dysuria, hematuria. However she does have suprapubic discomfort the past 2 days. She denies flank or back pain. No dyspnea or chest pain. Of note she was admitted/discharged ___ for AMS due to UTI and found to have enterococcus. ___ as outpatient she had urine culture for urinary urgency/dysuria by PCP and that showed GBS. She completed a 5 day course of Macrobid for that. ED: ___. Got IV Tylenol, IV vanc, IV CTX for presumed UTI. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy ___ ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: ___ Family History: Patient states her family had "medical conditions" but she cannot describe more specifically. Physical Exam: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: sitting up in chair EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, mildly TTP across upper abdomen. Bowel sounds present. MSK: Neck supple, moves all extremities NEUROLOGIC: Oriented to person, place, and situation Pertinent Results: ___ 05:06AM BLOOD TSH-20* CT ABD 1. Bladder appears mildly inflamed, correlate for cystitis. No signs of pyelonephritis. 2. Marked degenerated disease at L4-5, similar to prior, better assessed on prior CT and MRI. Please correlate clinically. 3. Renal hypodensities, possibly cysts, several too small to characterize. ___ 7:00 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Ms. ___ is a ___ female with history of rheumatoid arthritis on daily prednisone, HTN, HLD, hypothyroidism, NIDDM2, asthma, depression, anxiety who presents with AMS and fever, found to have a UTI. #UTI #Metabolic encephalopathy: The patient presented with increased frequency of urination, foul-smelling urine, and disorientation. Pt's UCx grew Ecoli that was sensitive to CTX and cipro. Pt improved after IV ceftriaxone and was transitioned to PO cipro, to complete a 7d course (last day = ___ for complicated UTI. Pt was then discharged to ___ Rehab. When discussing a discharge plan with the patient, she reported that she would like to stay in the hospital a little longer. When asked why this was the case, she alluded to issues at home and with her son with whom she lives. She explained that her son is a former ___ and has anger management issues. She reported theft of her personal property and suggested verbal abuse. Before providing more details, however, the patient became very nervous and shut down, expressing regret that she said anything at all, fearful of suffering retaliation. Based on patient's reports in the morning, an online EPS report was filed. #Slow-transit constipation: Exacerbated by chronic opioid use. Employing docusate, senna, polyethylene glycol, and bisacodyl suppositories titrated to have daily bowel movements. #Rheumatoid arthritis: Pt's home 5mg pred was continued. Of note, on presentation due to concerns for sepsis, pt received one dose of stress dose steroids, 100mg hydrorcortisone IV x1, which were then discontinued when pt was stable upon arrival to the floor. #NIDDM2 - SSI while inpatient, held home oral agents. Resume at discharge #HTN - Continued home losartan, amlodipine, HCTZ-triamterene #HLD - Continued home statin #Anxiety - Continued home zoloft #Hypothyroidism - Continued home synthroid (takes weekly ___ mcg/kg x7)) to help with compliance. TSH was elevated at 20, and the patient's son reported she has not been taking at home. #TRANSITIONAL: [ ] On CT A/P: Marked degenerated disease at L4-5, similar to prior, better assessed on prior CT and MRI. Nothing on exam to suggest myelopathy at this time; for outpatient follow up. [ ] Complete ciprofloxacin 500 mg q12 hr on ___ Ms. ___ was seen and examined on the day of discharge is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care today was greater than 30 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Docusate Sodium 100 mg PO BID 6. Losartan Potassium 50 mg PO DAILY 7. Methadone 10 mg PO Q8H:PRN severe back pain 8. Nabumetone 500 mg PO BID 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 10. Omeprazole 20 mg PO DAILY 11. PredniSONE 5 mg PO DAILY 12. Senna 8.6 mg PO BID:PRN constipation 13. Sertraline 200 mg PO DAILY 14. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions 15. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 16. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 17. Gabapentin 600 mg PO QID 18. Levothyroxine Sodium 1000 mcg PO EVERY ___ 19. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 20. Multivitamins 1 TAB PO DAILY 21. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN 22. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS Discharge Medications: 1. Bisacodyl 10 mg PR ONCE Duration: 1 Dose 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Polyethylene Glycol 17 g PO BID 4. Ramelteon 8 mg PO QHS Should be given 30 minutes before bedtime 5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Docusate Sodium 100 mg PO BID 11. Gabapentin 600 mg PO QID 12. Levothyroxine Sodium 1000 mcg PO EVERY ___ 13. Losartan Potassium 50 mg PO DAILY 14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 15. Methadone 10 mg PO Q8H:PRN severe back pain 16. Multivitamins 1 TAB PO DAILY 17. Nabumetone 500 mg PO BID 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Omeprazole 20 mg PO DAILY 20. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN 21. PredniSONE 5 mg PO DAILY 22. Senna 8.6 mg PO BID:PRN constipation 23. Sertraline 200 mg PO DAILY 24. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS 25. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions 26. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, You were hospitalized for a very severe infection. Now that you are stable, you are able to leave and be discharged to ___ Rehab. Please be sure to follow-up with your appointments listed below. We wish you the best with your health. Warm regards, ___ Health Followup Instructions: ___
[ "N390", "G9341", "K5901", "M069", "I10", "B9620", "E876", "E8342", "E785", "J449", "E039", "E119", "F419", "F329", "T402X5A", "Y92009", "F17210" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: AMS Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female with history of rheumatoid arthritis on daily prednisone, HTN, HLD, hypothyroidism, DM2, asthma, depression, anxiety who presents with AMS. The patient's son is not present, but the patient tells me that he brought her to the ED. She says "he's an ex [MASKED], he thinks he knows everything but knows nothing. I think he jumped the gun bringing me here, overreading into things". She was noted to be reportedly lethargic in the ED. The patient is oriented to [MASKED], [MASKED], and can recite the days of the weeks backwards. She says she has had 2 days of malaise and feeling overall unwell. No myalgias, subjective fever, nausea, vomiting, dysuria, hematuria. However she does have suprapubic discomfort the past 2 days. She denies flank or back pain. No dyspnea or chest pain. Of note she was admitted/discharged [MASKED] for AMS due to UTI and found to have enterococcus. [MASKED] as outpatient she had urine culture for urinary urgency/dysuria by PCP and that showed GBS. She completed a 5 day course of Macrobid for that. ED: [MASKED]. Got IV Tylenol, IV vanc, IV CTX for presumed UTI. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy [MASKED] ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: [MASKED] Family History: Patient states her family had "medical conditions" but she cannot describe more specifically. Physical Exam: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: sitting up in chair EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. CV: Heart regular, no murmur RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, mildly TTP across upper abdomen. Bowel sounds present. MSK: Neck supple, moves all extremities NEUROLOGIC: Oriented to person, place, and situation Pertinent Results: [MASKED] 05:06AM BLOOD TSH-20* CT ABD 1. Bladder appears mildly inflamed, correlate for cystitis. No signs of pyelonephritis. 2. Marked degenerated disease at L4-5, similar to prior, better assessed on prior CT and MRI. Please correlate clinically. 3. Renal hypodensities, possibly cysts, several too small to characterize. [MASKED] 7:00 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Ms. [MASKED] is a [MASKED] female with history of rheumatoid arthritis on daily prednisone, HTN, HLD, hypothyroidism, NIDDM2, asthma, depression, anxiety who presents with AMS and fever, found to have a UTI. #UTI #Metabolic encephalopathy: The patient presented with increased frequency of urination, foul-smelling urine, and disorientation. Pt's UCx grew Ecoli that was sensitive to CTX and cipro. Pt improved after IV ceftriaxone and was transitioned to PO cipro, to complete a 7d course (last day = [MASKED] for complicated UTI. Pt was then discharged to [MASKED] Rehab. When discussing a discharge plan with the patient, she reported that she would like to stay in the hospital a little longer. When asked why this was the case, she alluded to issues at home and with her son with whom she lives. She explained that her son is a former [MASKED] and has anger management issues. She reported theft of her personal property and suggested verbal abuse. Before providing more details, however, the patient became very nervous and shut down, expressing regret that she said anything at all, fearful of suffering retaliation. Based on patient's reports in the morning, an online EPS report was filed. #Slow-transit constipation: Exacerbated by chronic opioid use. Employing docusate, senna, polyethylene glycol, and bisacodyl suppositories titrated to have daily bowel movements. #Rheumatoid arthritis: Pt's home 5mg pred was continued. Of note, on presentation due to concerns for sepsis, pt received one dose of stress dose steroids, 100mg hydrorcortisone IV x1, which were then discontinued when pt was stable upon arrival to the floor. #NIDDM2 - SSI while inpatient, held home oral agents. Resume at discharge #HTN - Continued home losartan, amlodipine, HCTZ-triamterene #HLD - Continued home statin #Anxiety - Continued home zoloft #Hypothyroidism - Continued home synthroid (takes weekly [MASKED] mcg/kg x7)) to help with compliance. TSH was elevated at 20, and the patient's son reported she has not been taking at home. #TRANSITIONAL: [ ] On CT A/P: Marked degenerated disease at L4-5, similar to prior, better assessed on prior CT and MRI. Nothing on exam to suggest myelopathy at this time; for outpatient follow up. [ ] Complete ciprofloxacin 500 mg q12 hr on [MASKED] Ms. [MASKED] was seen and examined on the day of discharge is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care today was greater than 30 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Docusate Sodium 100 mg PO BID 6. Losartan Potassium 50 mg PO DAILY 7. Methadone 10 mg PO Q8H:PRN severe back pain 8. Nabumetone 500 mg PO BID 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 10. Omeprazole 20 mg PO DAILY 11. PredniSONE 5 mg PO DAILY 12. Senna 8.6 mg PO BID:PRN constipation 13. Sertraline 200 mg PO DAILY 14. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions 15. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 16. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 17. Gabapentin 600 mg PO QID 18. Levothyroxine Sodium 1000 mcg PO EVERY [MASKED] 19. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 20. Multivitamins 1 TAB PO DAILY 21. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN 22. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS Discharge Medications: 1. Bisacodyl 10 mg PR ONCE Duration: 1 Dose 2. Ciprofloxacin HCl 500 mg PO Q12H 3. Polyethylene Glycol 17 g PO BID 4. Ramelteon 8 mg PO QHS Should be given 30 minutes before bedtime 5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Docusate Sodium 100 mg PO BID 11. Gabapentin 600 mg PO QID 12. Levothyroxine Sodium 1000 mcg PO EVERY [MASKED] 13. Losartan Potassium 50 mg PO DAILY 14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 15. Methadone 10 mg PO Q8H:PRN severe back pain 16. Multivitamins 1 TAB PO DAILY 17. Nabumetone 500 mg PO BID 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Omeprazole 20 mg PO DAILY 20. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN 21. PredniSONE 5 mg PO DAILY 22. Senna 8.6 mg PO BID:PRN constipation 23. Sertraline 200 mg PO DAILY 24. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS 25. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions 26. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], You were hospitalized for a very severe infection. Now that you are stable, you are able to leave and be discharged to [MASKED] Rehab. Please be sure to follow-up with your appointments listed below. We wish you the best with your health. Warm regards, [MASKED] Health Followup Instructions: [MASKED]
[]
[ "N390", "I10", "E785", "J449", "E039", "E119", "F419", "F329", "F17210" ]
[ "N390: Urinary tract infection, site not specified", "G9341: Metabolic encephalopathy", "K5901: Slow transit constipation", "M069: Rheumatoid arthritis, unspecified", "I10: Essential (primary) hypertension", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E876: Hypokalemia", "E8342: Hypomagnesemia", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "E039: Hypothyroidism, unspecified", "E119: Type 2 diabetes mellitus without complications", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,034,049
28,052,811
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Leg lesions Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH chronic low back pain (on narcotics agreement) who presents with CC of bilateral lower extremity pain after a fall one week ago. Per ED, the patient states she slipped and fell in her hallway and went to the hospital 1 week ago. She doesn't remember which hospital but thinks it might have been BWH. She does not recall if she hit her head or if she had any imaging of her head or back done. She is endorsing low back pain that is worse than her chronic low back pain. She denies any fecal incontinence or saddle anesthesia. She says that when she feels the urge to urinate she doesn't always feel like she empties her bladder completely, but this has been going on since before her fall. She reports that when she fell she also scraped her legs. Even before this both of her legs were very itchy and she was prescribed some topical cream by her outpatient provider which was helping somewhat. She thinks however that this has all gotten worse since the fall. She thinks she has been scratching her legs in her sleep and is worried about the abrasions on her legs. She says that normally her legs are a little red below the knee but that the current redness and skin breakdown are worse than is typical for her. She denies any fevers, chills, N/V/D, lightheadedness. On ED exam. they noted that the patient was alert but confused at times, with bony tenderness along lumbar spine, strength ___ bilateral lower extremities. They noted her bilateral lower extremities were erythematous with 2+ pitting edema to the knee. Several areas of superficial abrasions and skin break down. Excoriations present. ED covered for cellulitis and UTI, noted concern re: delirium. Of note, the patient was pulling out IVs and confused in ED. ___ - ___ ___ reviewed VS, labs, orders, images, old records, meds. VS Tmax 99.3 ___ 04:35PM BLOOD Hgb: 9.6* ___ 04:55PM BLOOD Hgb: 12.6 ___ 04:35PM BLOOD MCV: 84 ___ 07:12AM BLOOD Hgb: 9.2* ___ 04:35PM BLOOD Creat: 0.7 ___ 07:11PM URINE Blood: NEG Nitrite: NEG Protein: 30* Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: 2* pH: 6.0 Leuks: MOD* ___ 07:11PM URINE RBC: 4* WBC: 10* Bacteri: FEW* Yeast: NONE Epi: 3 TransE: 1 ___ 7:11 pm URINE URINE CULTURE (Pending): ___ 5:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 5:35 pm BLOOD CULTURE Blood Culture, Routine (Pending): Patient is s/p ___ 17:54 IV CefTRIAXone ___ Started ___ 18:58 IV Vancomycin (1000 mg ordered) ___ ___ Started ___ 19:02 IV CefTRIAXone 1 g ___ Stopped (1h ___ ___ 20:00 PO Doxycycline Hyclate ___ Not Given ___ 20:00 PO/NG Atorvastatin ___ Not Given Imaging bilateral ___ duplex IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. Limited evaluation of the peroneal veins. 2. Enlarged bilateral inguinal lymph nodes measuring 4.3 x 2.0 cm on the right and 4.0 x 1.4 cm on the left, slightly enlarged compared to ___, and nonspecific. CT L spine w/o contrast chronic degenerative changes with acute fracture or new malignment CTH w/o contrast . No acute hemorrhage. No notable change compared to prior. 2. Diffuse hypodensities in the white matter are again seen, similar in extent to ___. These findings could be related to prior therapy or due to extensive small vessel disease. If clinically indicated, nonemergent MRI with gadolinium could be helpful for further assessment of these findings as MRI is more sensitive for intracranial metastases and post treatment changes. I interviewed patient. She was fairly lucid, very mildly confused. Was able to tell jokes. She notes that she fell and hurt her back a week ago, and was worked up for this fall at another hospital, which may have been ___. She notes that her legs over the past few days have become more painful, and while she can walk, it is more difficult. She denies fever, chills, SOB, nausea, vomiting, diarrhea. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy ___ ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: ___ Family History: Patient states her family had "medical conditions" but she cannot describe more specifically. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: bilateral lower extremity +2 edema and multiple scabbed lesions 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, mildly confused DISCHARGE PHYSICAL EXAM ======================= VITALS: 98.2PO 157/80 75 18 95 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: bilateral lower extremity +2 edema and multiple scabbed lesions, noted erythema in legs bilaterally 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 ============== ___ 04:35PM BLOOD WBC-5.1 RBC-3.50* Hgb-9.6* Hct-29.3* MCV-84 MCH-27.4 MCHC-32.8 RDW-13.6 RDWSD-40.6 Plt ___ ___ 05:49AM BLOOD ___ PTT-30.6 ___ ___ 04:35PM BLOOD Glucose-153* UreaN-7 Creat-0.7 Na-142 K-3.4 Cl-98 HCO3-32 AnGap-12 ___ 05:49AM BLOOD ALT-10 TotBili-0.3 ___ 05:49AM BLOOD Albumin-3.3* Calcium-8.8 Phos-3.5 Mg-1.6 ___ 07:11PM URINE Color-Yellow Appear-Clear Sp ___ ___ 07:11PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-MOD* ___ 07:11PM URINE RBC-4* WBC-10* Bacteri-FEW* Yeast-NONE Epi-3 TransE-1 ___ 07:11PM URINE CastHy-7* MICROBIOLOGY ============ ___ 7:11 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S ___ BLOOD CULTURES x 2: pending, NGTD IMAGING ======= ___ BILATERAL ___ DOPPLER ULTRASOUND IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. Limited evaluation of the peroneal veins. 2. Enlarged bilateral inguinal lymph nodes measuring 4.3 x 2.0 cm on the right and 4.0 x 1.4 cm on the left, slightly enlarged compared to ___, and nonspecific. ___ CT C spine w/o contrast 1. The mild anterolisthesis of C2 on C3, which is likely degenerative in nature, given overall degenerative change of cervical spine and lack of overlying prevertebral soft tissue swelling. No priors are available for comparison to assess for chronicity of this finding. 2. Moderate to severe degenerative changes throughout the remaining cervical spine, most severe at C3-4 causing at least moderate spinal canal narrowing. 3. No acute fracture of the cervical spine. ___ CT L spine w/o contrast Chronic degenerative changes with acute fracture or new malignment ___ CTH w/o contrast 1. No acute hemorrhage. No notable change compared to prior. 2. Diffuse hypodensities in the white matter are again seen, similar in extent to ___. These findings could be related to prior therapy or due to extensive small vessel disease. If clinically indicated, nonemergent MRI with gadolinium could be helpful for further assessment of these findings as MRI is more sensitive for intracranial metastases and post treatment changes. DISCHARGE LABS ============== ___ 06:13AM BLOOD WBC-5.8 RBC-3.83* Hgb-10.5* Hct-31.8* MCV-83 MCH-27.4 MCHC-33.0 RDW-13.6 RDWSD-40.7 Plt ___ ___ 06:13AM BLOOD Glucose-130* UreaN-7 Creat-0.7 Na-140 K-3.4 Cl-93* HCO3-34* AnGap-13 ___ 06:13AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.___ year old woman with history notable for chronic low back pain (on narcotics agreement, methadone & nabumetone), rheumatoid arthritis, chronic venous stasis and ulceration, who presented with lower extremity pain after a fall one week ago, and found to have delirium, positive urinalysis, and concern for bilateral lower extremity cellulitis. ACTIVE ISSUES ============= # Urinary tract infection # Encephalopathy Suspect secondary to infection. Concern for cellulitis, as below, though UA positive growing Enterococcus. Started on ceftriaxone (d1 = ___, received three days of treatment. # Bilateral lower extremity pain # Chronic venous insufficiency Initially concerned for bilateral lower extremity cellulitis, though wounds on the bilateral legs did not appear infected. They were not warm, and had superficial ulceration with serous discharge only; she had no fever, leukocytosis or other systemic signs of infection. Treated initially with vancomycin and levofloxacin, though discontinued due to low concern for cellulitis. ___ RN evaluated patient and left wound care instructions. CHRONIC ISSUES ============== # Chronic anemia: hemoglobin fluctuates ___ generally, normocytic. Hemoglobin remained stable during her admission. # Chronic low back pain (on narcotics agreement): ___ reviewed by admitting MD. ___ methadone and oxycodone and nabumetone. # Hypertensino: continued ___ amlodipine # Hyperlipidemia: continued ___ statin # Diabetes: ___ metformin was held. Sliding scale insulin was administered during admission. # Asthma: continued ___ albuterol PRN # Rheumatoid arthritis: continued prednisone 5mg per day, patient does not appear to be in flare, would recommend she follow up outpatient regarding tapering chronic steroids # Hypothyroidism: continued ___ levothyroxine # Depression and anxiety: continued ___ sertraline # COPD: continued albuterol PRN TRANSITIONAL ISSUES =================== # Follow-up: patient will be going to rehab. On CT head, she was found to have diffuse hypodensities in the white matter are again seen, similar in extent to ___. These findings could be related to prior therapy or due to extensive small vessel disease. If clinically indicated, nonemergent MRI with gadolinium could be helpful for further assessment of these findings as MRI is more sensitive for intracranial metastases and post treatment changes. # Code status: full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 600 mg PO QID 7. Levothyroxine Sodium 1000 mcg PO EVERY ___ 8. Losartan Potassium 50 mg PO DAILY 9. Methadone 10 mg PO Q8H:PRN severe back pain 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN 13. PredniSONE 5 mg PO DAILY 14. Senna 8.6 mg PO BID:PRN constipation 15. Sertraline 200 mg PO DAILY 16. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 17. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 18. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 19. Methotrexate 10 mg PO QSUN 20. Nabumetone 500 mg PO BID 21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 22. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS 23. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Gabapentin 600 mg PO QID 8. Levothyroxine Sodium 1000 mcg PO EVERY ___ 9. Losartan Potassium 50 mg PO DAILY 10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 11. Methadone 10 mg PO Q8H:PRN severe back pain RX *methadone 10 mg 1 tab by mouth every eight (8) hours Disp #*5 Tablet Refills:*0 12. Methotrexate 10 mg PO QSUN 13. Multivitamins 1 TAB PO DAILY 14. Nabumetone 500 mg PO BID 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Omeprazole 20 mg PO DAILY 17. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN RX *oxycodone 5 mg 1 capsule(s) by mouth every eight (8) hours Disp #*5 Capsule Refills:*0 18. PredniSONE 5 mg PO DAILY 19. Senna 8.6 mg PO BID:PRN constipation 20. Sertraline 200 mg PO DAILY 21. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS 22. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions 23. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Urinary tract infection 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 ___, You were admitted to the hospital with pain in your legs due to swelling and ulcers, from chronic venous insufficiency, but no cellulitis. You were also found to be rather confused. This was due to a urinary tract infection. We treated you with antibiotics, and you improved. It is important that you continue to take your medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: ___
[ "N390", "G9341", "L97819", "D649", "J449", "B952", "E119", "E039", "L97829", "I872", "M545", "G8929", "I10", "E785", "J45909", "M069", "F329", "F419", "S80812A", "S80811A", "W010XXA", "Z9181", "Y92008", "F17210" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Leg lesions Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH chronic low back pain (on narcotics agreement) who presents with CC of bilateral lower extremity pain after a fall one week ago. Per ED, the patient states she slipped and fell in her hallway and went to the hospital 1 week ago. She doesn't remember which hospital but thinks it might have been BWH. She does not recall if she hit her head or if she had any imaging of her head or back done. She is endorsing low back pain that is worse than her chronic low back pain. She denies any fecal incontinence or saddle anesthesia. She says that when she feels the urge to urinate she doesn't always feel like she empties her bladder completely, but this has been going on since before her fall. She reports that when she fell she also scraped her legs. Even before this both of her legs were very itchy and she was prescribed some topical cream by her outpatient provider which was helping somewhat. She thinks however that this has all gotten worse since the fall. She thinks she has been scratching her legs in her sleep and is worried about the abrasions on her legs. She says that normally her legs are a little red below the knee but that the current redness and skin breakdown are worse than is typical for her. She denies any fevers, chills, N/V/D, lightheadedness. On ED exam. they noted that the patient was alert but confused at times, with bony tenderness along lumbar spine, strength [MASKED] bilateral lower extremities. They noted her bilateral lower extremities were erythematous with 2+ pitting edema to the knee. Several areas of superficial abrasions and skin break down. Excoriations present. ED covered for cellulitis and UTI, noted concern re: delirium. Of note, the patient was pulling out IVs and confused in ED. [MASKED] - [MASKED] [MASKED] reviewed VS, labs, orders, images, old records, meds. VS Tmax 99.3 [MASKED] 04:35PM BLOOD Hgb: 9.6* [MASKED] 04:55PM BLOOD Hgb: 12.6 [MASKED] 04:35PM BLOOD MCV: 84 [MASKED] 07:12AM BLOOD Hgb: 9.2* [MASKED] 04:35PM BLOOD Creat: 0.7 [MASKED] 07:11PM URINE Blood: NEG Nitrite: NEG Protein: 30* Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: 2* pH: 6.0 Leuks: MOD* [MASKED] 07:11PM URINE RBC: 4* WBC: 10* Bacteri: FEW* Yeast: NONE Epi: 3 TransE: 1 [MASKED] 7:11 pm URINE URINE CULTURE (Pending): [MASKED] 5:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] 5:35 pm BLOOD CULTURE Blood Culture, Routine (Pending): Patient is s/p [MASKED] 17:54 IV CefTRIAXone [MASKED] Started [MASKED] 18:58 IV Vancomycin (1000 mg ordered) [MASKED] [MASKED] Started [MASKED] 19:02 IV CefTRIAXone 1 g [MASKED] Stopped (1h [MASKED] [MASKED] 20:00 PO Doxycycline Hyclate [MASKED] Not Given [MASKED] 20:00 PO/NG Atorvastatin [MASKED] Not Given Imaging bilateral [MASKED] duplex IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. Limited evaluation of the peroneal veins. 2. Enlarged bilateral inguinal lymph nodes measuring 4.3 x 2.0 cm on the right and 4.0 x 1.4 cm on the left, slightly enlarged compared to [MASKED], and nonspecific. CT L spine w/o contrast chronic degenerative changes with acute fracture or new malignment CTH w/o contrast . No acute hemorrhage. No notable change compared to prior. 2. Diffuse hypodensities in the white matter are again seen, similar in extent to [MASKED]. These findings could be related to prior therapy or due to extensive small vessel disease. If clinically indicated, nonemergent MRI with gadolinium could be helpful for further assessment of these findings as MRI is more sensitive for intracranial metastases and post treatment changes. I interviewed patient. She was fairly lucid, very mildly confused. Was able to tell jokes. She notes that she fell and hurt her back a week ago, and was worked up for this fall at another hospital, which may have been [MASKED]. She notes that her legs over the past few days have become more painful, and while she can walk, it is more difficult. She denies fever, chills, SOB, nausea, vomiting, diarrhea. Past Medical History: Chronic pain 30+ years back, hands Rheumatic fever Rheumatoid arthritis HTN HLD Type 2 DM Asthma ?cervical CA s/p hysterectomy [MASKED] ?uterine CA Hypothyroidism Venous stasis Depression Anxiety HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: [MASKED] Family History: Patient states her family had "medical conditions" but she cannot describe more specifically. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: bilateral lower extremity +2 edema and multiple scabbed lesions 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, mildly confused DISCHARGE PHYSICAL EXAM ======================= VITALS: 98.2PO 157/80 75 18 95 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: bilateral lower extremity +2 edema and multiple scabbed lesions, noted erythema in legs bilaterally 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] 04:35PM BLOOD WBC-5.1 RBC-3.50* Hgb-9.6* Hct-29.3* MCV-84 MCH-27.4 MCHC-32.8 RDW-13.6 RDWSD-40.6 Plt [MASKED] [MASKED] 05:49AM BLOOD [MASKED] PTT-30.6 [MASKED] [MASKED] 04:35PM BLOOD Glucose-153* UreaN-7 Creat-0.7 Na-142 K-3.4 Cl-98 HCO3-32 AnGap-12 [MASKED] 05:49AM BLOOD ALT-10 TotBili-0.3 [MASKED] 05:49AM BLOOD Albumin-3.3* Calcium-8.8 Phos-3.5 Mg-1.6 [MASKED] 07:11PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 07:11PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-MOD* [MASKED] 07:11PM URINE RBC-4* WBC-10* Bacteri-FEW* Yeast-NONE Epi-3 TransE-1 [MASKED] 07:11PM URINE CastHy-7* MICROBIOLOGY ============ [MASKED] 7:11 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S [MASKED] BLOOD CULTURES x 2: pending, NGTD IMAGING ======= [MASKED] BILATERAL [MASKED] DOPPLER ULTRASOUND IMPRESSION: 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. Limited evaluation of the peroneal veins. 2. Enlarged bilateral inguinal lymph nodes measuring 4.3 x 2.0 cm on the right and 4.0 x 1.4 cm on the left, slightly enlarged compared to [MASKED], and nonspecific. [MASKED] CT C spine w/o contrast 1. The mild anterolisthesis of C2 on C3, which is likely degenerative in nature, given overall degenerative change of cervical spine and lack of overlying prevertebral soft tissue swelling. No priors are available for comparison to assess for chronicity of this finding. 2. Moderate to severe degenerative changes throughout the remaining cervical spine, most severe at C3-4 causing at least moderate spinal canal narrowing. 3. No acute fracture of the cervical spine. [MASKED] CT L spine w/o contrast Chronic degenerative changes with acute fracture or new malignment [MASKED] CTH w/o contrast 1. No acute hemorrhage. No notable change compared to prior. 2. Diffuse hypodensities in the white matter are again seen, similar in extent to [MASKED]. These findings could be related to prior therapy or due to extensive small vessel disease. If clinically indicated, nonemergent MRI with gadolinium could be helpful for further assessment of these findings as MRI is more sensitive for intracranial metastases and post treatment changes. DISCHARGE LABS ============== [MASKED] 06:13AM BLOOD WBC-5.8 RBC-3.83* Hgb-10.5* Hct-31.8* MCV-83 MCH-27.4 MCHC-33.0 RDW-13.6 RDWSD-40.7 Plt [MASKED] [MASKED] 06:13AM BLOOD Glucose-130* UreaN-7 Creat-0.7 Na-140 K-3.4 Cl-93* HCO3-34* AnGap-13 [MASKED] 06:13AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.[MASKED] year old woman with history notable for chronic low back pain (on narcotics agreement, methadone & nabumetone), rheumatoid arthritis, chronic venous stasis and ulceration, who presented with lower extremity pain after a fall one week ago, and found to have delirium, positive urinalysis, and concern for bilateral lower extremity cellulitis. ACTIVE ISSUES ============= # Urinary tract infection # Encephalopathy Suspect secondary to infection. Concern for cellulitis, as below, though UA positive growing Enterococcus. Started on ceftriaxone (d1 = [MASKED], received three days of treatment. # Bilateral lower extremity pain # Chronic venous insufficiency Initially concerned for bilateral lower extremity cellulitis, though wounds on the bilateral legs did not appear infected. They were not warm, and had superficial ulceration with serous discharge only; she had no fever, leukocytosis or other systemic signs of infection. Treated initially with vancomycin and levofloxacin, though discontinued due to low concern for cellulitis. [MASKED] RN evaluated patient and left wound care instructions. CHRONIC ISSUES ============== # Chronic anemia: hemoglobin fluctuates [MASKED] generally, normocytic. Hemoglobin remained stable during her admission. # Chronic low back pain (on narcotics agreement): [MASKED] reviewed by admitting MD. [MASKED] methadone and oxycodone and nabumetone. # Hypertensino: continued [MASKED] amlodipine # Hyperlipidemia: continued [MASKED] statin # Diabetes: [MASKED] metformin was held. Sliding scale insulin was administered during admission. # Asthma: continued [MASKED] albuterol PRN # Rheumatoid arthritis: continued prednisone 5mg per day, patient does not appear to be in flare, would recommend she follow up outpatient regarding tapering chronic steroids # Hypothyroidism: continued [MASKED] levothyroxine # Depression and anxiety: continued [MASKED] sertraline # COPD: continued albuterol PRN TRANSITIONAL ISSUES =================== # Follow-up: patient will be going to rehab. On CT head, she was found to have diffuse hypodensities in the white matter are again seen, similar in extent to [MASKED]. These findings could be related to prior therapy or due to extensive small vessel disease. If clinically indicated, nonemergent MRI with gadolinium could be helpful for further assessment of these findings as MRI is more sensitive for intracranial metastases and post treatment changes. # Code status: full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 600 mg PO QID 7. Levothyroxine Sodium 1000 mcg PO EVERY [MASKED] 8. Losartan Potassium 50 mg PO DAILY 9. Methadone 10 mg PO Q8H:PRN severe back pain 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN 13. PredniSONE 5 mg PO DAILY 14. Senna 8.6 mg PO BID:PRN constipation 15. Sertraline 200 mg PO DAILY 16. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 17. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 18. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 19. Methotrexate 10 mg PO QSUN 20. Nabumetone 500 mg PO BID 21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 22. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS 23. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Gabapentin 600 mg PO QID 8. Levothyroxine Sodium 1000 mcg PO EVERY [MASKED] 9. Losartan Potassium 50 mg PO DAILY 10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 11. Methadone 10 mg PO Q8H:PRN severe back pain RX *methadone 10 mg 1 tab by mouth every eight (8) hours Disp #*5 Tablet Refills:*0 12. Methotrexate 10 mg PO QSUN 13. Multivitamins 1 TAB PO DAILY 14. Nabumetone 500 mg PO BID 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Omeprazole 20 mg PO DAILY 17. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN BREAKTHROUGH PAIN RX *oxycodone 5 mg 1 capsule(s) by mouth every eight (8) hours Disp #*5 Capsule Refills:*0 18. PredniSONE 5 mg PO DAILY 19. Senna 8.6 mg PO BID:PRN constipation 20. Sertraline 200 mg PO DAILY 21. Travatan Z (travoprost) 0.004 % ophthalmic (eye) QHS 22. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID lesions 23. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Urinary tract infection 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 [MASKED], You were admitted to the hospital with pain in your legs due to swelling and ulcers, from chronic venous insufficiency, but no cellulitis. You were also found to be rather confused. This was due to a urinary tract infection. We treated you with antibiotics, and you improved. It is important that you continue to take your medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: [MASKED]
[]
[ "N390", "D649", "J449", "E119", "E039", "G8929", "I10", "E785", "J45909", "F329", "F419", "F17210" ]
[ "N390: Urinary tract infection, site not specified", "G9341: Metabolic encephalopathy", "L97819: Non-pressure chronic ulcer of other part of right lower leg with unspecified severity", "D649: Anemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "B952: Enterococcus as the cause of diseases classified elsewhere", "E119: Type 2 diabetes mellitus without complications", "E039: Hypothyroidism, unspecified", "L97829: Non-pressure chronic ulcer of other part of left lower leg with unspecified severity", "I872: Venous insufficiency (chronic) (peripheral)", "M545: Low back pain", "G8929: Other chronic pain", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "M069: Rheumatoid arthritis, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "S80812A: Abrasion, left lower leg, initial encounter", "S80811A: Abrasion, right lower leg, initial encounter", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Z9181: History of falling", "Y92008: Other place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,034,049
28,952,773
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Bilateral leg pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a history of hypothyroidism, rheumatoid arthritis, chronic pain, DM II, hypertension who presents with 4 days of bilateral leg pain. She reports that she has had no inciting trauma or exposure, but that 4 days ago she began noticing increasing pain in her bilateral legs along with increased redness. She presented to the ___ ED on ___ but left before being evaluated by a physician. She now presents to ___ for further evaluation. In the ED, initial vitals: Pain 10 98.3 80 118/66 18 96% RA - Exam notable for: Alert patient, occasionally moaning in pain. Bilateral lower extremities with marked edema, well demarcated erythema, tender to palpation - Labs notable for: WBC 4.4 Hgb 10.8 Plt 199, Chemistry with K 3.3 and otherwise WNL. Lactate 1.5. - Imaging notable for: None obtained - Pt given: Methadone 10 mg x1, oxycodone 5 mg, Vancomycin 1g - Admission requested for management of cellulitis - Vitals prior to transfer: 98.8 81 168/93 18 96% RA On the floor, the patient is restless due to the foley that was placed in the ED. She persistently gets out of bed as she feels that standing will help "the urine come out." Review of systems: Denies fever, chills, weight change, headache, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation. She straight catheterizes at home due to incomplete bladder emptying but cannot quantify how often she straight caths. + urgency, no dysuria. Past Medical History: HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: ___ Family History: Patient states her family had "medical conditions" but she cannot describe more specifically. Physical Exam: Discharge Vitals T 98.4, BP 168/84, HR 87, RR22, O2Sat 92% RA HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, mid-abdominal tenderness to palpation, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Well demarcated venous stasis changes with 1+ lower extremity edema bilaterally. Right lower extremity with superficial ulceration on the ventral and dorsal aspect. No pain elicited with moderate pressure Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Oriented to self, ___, but not to date. Pertinent Results: On Admission: ___ 09:25PM BLOOD WBC-4.4 RBC-3.79* Hgb-10.8* Hct-31.8* MCV-84 MCH-28.5 MCHC-34.0 RDW-14.2 RDWSD-42.5 Plt ___ ___ 09:25PM BLOOD Neuts-68.7 ___ Monos-5.2 Eos-3.6 Baso-0.5 Im ___ AbsNeut-3.04 AbsLymp-0.95* AbsMono-0.23 AbsEos-0.16 AbsBaso-0.02 ___ 09:25PM BLOOD Glucose-160* UreaN-8 Creat-0.9 Na-139 K-3.3 Cl-97 HCO3-29 AnGap-16 ___ 09:30PM BLOOD Lactate-1.5 MICROBIOLOGY: ___: Urine culture pending ___: Blood culture pending On Discharge ___ 07:12AM BLOOD WBC-3.9* RBC-3.27* Hgb-9.2* Hct-28.0* MCV-86 MCH-28.1 MCHC-32.9 RDW-14.6 RDWSD-44.2 Plt ___ ___ 07:12AM BLOOD Glucose-170* UreaN-9 Creat-1.0 Na-139 K-3.6 Cl-99 HCO3-29 AnGap-15 ___ 07:12AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.6 ___ 09:30PM BLOOD Lactate-1.___SSESSMENT AND PLAN: Ms. ___ is a ___ year old woman with a history of chronic pain, rheumatoid arthritis, chronic venous stasis, hypertension, hyperlipidemia who presents with 4 days of worsening bilateral lower extremity pain, admitted given concern for cellulitis found to have chronic lymphedema . # Bilateral leg pain # Chronic venous stasis: Patient presents from home with worsening bilateral leg pain, admitted with concern for cellulitis. She is s/p a dose of vancomycin in the ED. Exam, however, is more consistent with severe bilateral venous stasis, with superficial skin tears noted on the right lower extremity. Patient afebrile and without white count to further raise suspicion for cellulitis. Additionally, patient without pain on exam with moderate pressure applied to her lower extremities. Consulted wound care who felt this was was lymphedema and wrapped her legs with improvement. We set her up with a ___ for wound care at home. She will need close follow up. # Concern for elder abuse: Review of last discharge summary reveals reported verbal abuse from her son with whom she lives. Patient did not want to move forward with a police filing or a restraining order. PCP is aware of the situation- patient has declined reporting in the past due to concerns about what such a report would do to her family. PCP reported that the patient has had capacity to make her own decisions. Social work was involved on the last admission and relayed the information to the open elder services case. Social work remains involved and she has ongoing support. # Hypothyroidism: TSH checked during last admission, noted to be abnormal though with normal free T4. - Will continue home levothyroxine # Chronic pain # Rheumatoid arthritis: - Continue home prednisone - Continue home methadone - Continue home oxycodone - Methotrexate ___ # HTN: Hypertensive on arrival, though patient cannot remember when she last took her medications. - Continue home losartan, amlodipine, triamterene-HCTZ # HLD: Continue home statin # Depression: Continue home sertraline # GERD: Continue home omeprazole # T2DM: Will hold home metformin and will treat with insulin sliding scale # Urinary retention: Patient straight catheterizes at home, though on admission patient cannot recall how often. Foley was placed in the ED. UA without evidence of UTI. Will plan to remove foley in AM and resume straight catheterization. >30 minutes was spent on this complicated discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Losartan Potassium 50 mg PO DAILY 7. Methadone 10 mg PO QHS 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO DAILY 10. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain - Severe 11. PredniSONE 5 mg PO DAILY 12. Sertraline 100 mg PO DAILY 13. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 14. Docusate Sodium 100 mg PO BID 15. Senna 8.6 mg PO BID:PRN constipation 16. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 17. Gabapentin 300 mg PO QID 18. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 19. Methotrexate 10 mg PO QSUN 20. Nabumetone 500 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Gabapentin 300 mg PO QID 8. Levothyroxine Sodium 150 mcg PO DAILY 9. Losartan Potassium 50 mg PO DAILY 10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 11. Methadone 10 mg PO QHS 12. Methotrexate 10 mg PO QSUN 13. Multivitamins 1 TAB PO DAILY 14. Nabumetone 500 mg PO BID 15. Omeprazole 20 mg PO DAILY 16. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain - Severe 17. PredniSONE 5 mg PO DAILY 18. Senna 8.6 mg PO BID:PRN constipation 19. Sertraline 100 mg PO DAILY 20. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Lymphedema Chronic Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, ___ were admitted when ___ had increased pain in your legs.Intially ___ were worried this was an infection. Your legs were examined and the redness and swelling were consistent with chronic lymphedema. Lymphedema is a progressive disorder of the lymphatic system that results in the accumulation of interstitial fluid and tissue. Your skin was not infected. ___ were seen by the wound nurse who recommended ___ ace wrap your legs. ___ will now have a visiting nurse to help manage your leg swelling and skin care. ___ will need to closely follow with your primary care doctor. It was a pleasure caring for ___, Your ___ doctors ___ Instructions: ___
[ "I890", "J449", "E119", "G8929", "I10", "E039", "M069", "Z87891", "J45909", "I872", "Z7952", "E785", "F329", "K219", "R339" ]
Allergies: Penicillins / Nutrasweet Aspartame / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Bilateral leg pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with a history of hypothyroidism, rheumatoid arthritis, chronic pain, DM II, hypertension who presents with 4 days of bilateral leg pain. She reports that she has had no inciting trauma or exposure, but that 4 days ago she began noticing increasing pain in her bilateral legs along with increased redness. She presented to the [MASKED] ED on [MASKED] but left before being evaluated by a physician. She now presents to [MASKED] for further evaluation. In the ED, initial vitals: Pain 10 98.3 80 118/66 18 96% RA - Exam notable for: Alert patient, occasionally moaning in pain. Bilateral lower extremities with marked edema, well demarcated erythema, tender to palpation - Labs notable for: WBC 4.4 Hgb 10.8 Plt 199, Chemistry with K 3.3 and otherwise WNL. Lactate 1.5. - Imaging notable for: None obtained - Pt given: Methadone 10 mg x1, oxycodone 5 mg, Vancomycin 1g - Admission requested for management of cellulitis - Vitals prior to transfer: 98.8 81 168/93 18 96% RA On the floor, the patient is restless due to the foley that was placed in the ED. She persistently gets out of bed as she feels that standing will help "the urine come out." Review of systems: Denies fever, chills, weight change, headache, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation. She straight catheterizes at home due to incomplete bladder emptying but cannot quantify how often she straight caths. + urgency, no dysuria. Past Medical History: HTN Hypothyroidism Chronic venous stasis ulcers Recurrent UTIs Chronic pain Back injury NOS Asthma COPD ?rheumatoid arthritis T2DM Social History: [MASKED] Family History: Patient states her family had "medical conditions" but she cannot describe more specifically. Physical Exam: Discharge Vitals T 98.4, BP 168/84, HR 87, RR22, O2Sat 92% RA HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, mid-abdominal tenderness to palpation, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Well demarcated venous stasis changes with 1+ lower extremity edema bilaterally. Right lower extremity with superficial ulceration on the ventral and dorsal aspect. No pain elicited with moderate pressure Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Oriented to self, [MASKED], but not to date. Pertinent Results: On Admission: [MASKED] 09:25PM BLOOD WBC-4.4 RBC-3.79* Hgb-10.8* Hct-31.8* MCV-84 MCH-28.5 MCHC-34.0 RDW-14.2 RDWSD-42.5 Plt [MASKED] [MASKED] 09:25PM BLOOD Neuts-68.7 [MASKED] Monos-5.2 Eos-3.6 Baso-0.5 Im [MASKED] AbsNeut-3.04 AbsLymp-0.95* AbsMono-0.23 AbsEos-0.16 AbsBaso-0.02 [MASKED] 09:25PM BLOOD Glucose-160* UreaN-8 Creat-0.9 Na-139 K-3.3 Cl-97 HCO3-29 AnGap-16 [MASKED] 09:30PM BLOOD Lactate-1.5 MICROBIOLOGY: [MASKED]: Urine culture pending [MASKED]: Blood culture pending On Discharge [MASKED] 07:12AM BLOOD WBC-3.9* RBC-3.27* Hgb-9.2* Hct-28.0* MCV-86 MCH-28.1 MCHC-32.9 RDW-14.6 RDWSD-44.2 Plt [MASKED] [MASKED] 07:12AM BLOOD Glucose-170* UreaN-9 Creat-1.0 Na-139 K-3.6 Cl-99 HCO3-29 AnGap-15 [MASKED] 07:12AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.6 [MASKED] 09:30PM BLOOD Lactate-1. SSESSMENT AND PLAN: Ms. [MASKED] is a [MASKED] year old woman with a history of chronic pain, rheumatoid arthritis, chronic venous stasis, hypertension, hyperlipidemia who presents with 4 days of worsening bilateral lower extremity pain, admitted given concern for cellulitis found to have chronic lymphedema . # Bilateral leg pain # Chronic venous stasis: Patient presents from home with worsening bilateral leg pain, admitted with concern for cellulitis. She is s/p a dose of vancomycin in the ED. Exam, however, is more consistent with severe bilateral venous stasis, with superficial skin tears noted on the right lower extremity. Patient afebrile and without white count to further raise suspicion for cellulitis. Additionally, patient without pain on exam with moderate pressure applied to her lower extremities. Consulted wound care who felt this was was lymphedema and wrapped her legs with improvement. We set her up with a [MASKED] for wound care at home. She will need close follow up. # Concern for elder abuse: Review of last discharge summary reveals reported verbal abuse from her son with whom she lives. Patient did not want to move forward with a police filing or a restraining order. PCP is aware of the situation- patient has declined reporting in the past due to concerns about what such a report would do to her family. PCP reported that the patient has had capacity to make her own decisions. Social work was involved on the last admission and relayed the information to the open elder services case. Social work remains involved and she has ongoing support. # Hypothyroidism: TSH checked during last admission, noted to be abnormal though with normal free T4. - Will continue home levothyroxine # Chronic pain # Rheumatoid arthritis: - Continue home prednisone - Continue home methadone - Continue home oxycodone - Methotrexate [MASKED] # HTN: Hypertensive on arrival, though patient cannot remember when she last took her medications. - Continue home losartan, amlodipine, triamterene-HCTZ # HLD: Continue home statin # Depression: Continue home sertraline # GERD: Continue home omeprazole # T2DM: Will hold home metformin and will treat with insulin sliding scale # Urinary retention: Patient straight catheterizes at home, though on admission patient cannot recall how often. Foley was placed in the ED. UA without evidence of UTI. Will plan to remove foley in AM and resume straight catheterization. >30 minutes was spent on this complicated discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Losartan Potassium 50 mg PO DAILY 7. Methadone 10 mg PO QHS 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 20 mg PO DAILY 10. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain - Severe 11. PredniSONE 5 mg PO DAILY 12. Sertraline 100 mg PO DAILY 13. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 14. Docusate Sodium 100 mg PO BID 15. Senna 8.6 mg PO BID:PRN constipation 16. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 17. Gabapentin 300 mg PO QID 18. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 19. Methotrexate 10 mg PO QSUN 20. Nabumetone 500 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Gabapentin 300 mg PO QID 8. Levothyroxine Sodium 150 mcg PO DAILY 9. Losartan Potassium 50 mg PO DAILY 10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 11. Methadone 10 mg PO QHS 12. Methotrexate 10 mg PO QSUN 13. Multivitamins 1 TAB PO DAILY 14. Nabumetone 500 mg PO BID 15. Omeprazole 20 mg PO DAILY 16. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain - Severe 17. PredniSONE 5 mg PO DAILY 18. Senna 8.6 mg PO BID:PRN constipation 19. Sertraline 100 mg PO DAILY 20. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Lymphedema Chronic Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], [MASKED] were admitted when [MASKED] had increased pain in your legs.Intially [MASKED] were worried this was an infection. Your legs were examined and the redness and swelling were consistent with chronic lymphedema. Lymphedema is a progressive disorder of the lymphatic system that results in the accumulation of interstitial fluid and tissue. Your skin was not infected. [MASKED] were seen by the wound nurse who recommended [MASKED] ace wrap your legs. [MASKED] will now have a visiting nurse to help manage your leg swelling and skin care. [MASKED] will need to closely follow with your primary care doctor. It was a pleasure caring for [MASKED], Your [MASKED] doctors [MASKED] Instructions: [MASKED]
[]
[ "J449", "E119", "G8929", "I10", "E039", "Z87891", "J45909", "E785", "F329", "K219" ]
[ "I890: Lymphedema, not elsewhere classified", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "G8929: Other chronic pain", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "M069: Rheumatoid arthritis, unspecified", "Z87891: Personal history of nicotine dependence", "J45909: Unspecified asthma, uncomplicated", "I872: Venous insufficiency (chronic) (peripheral)", "Z7952: Long term (current) use of systemic steroids", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R339: Retention of urine, unspecified" ]
10,034,317
20,827,960
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: morphine / hydrochlorothiazide / amiodarone Attending: ___. Chief Complaint: HCV, HCC Major Surgical or Invasive Procedure: ___ 1. Exploratory laparotomy and resection of Liver segment VIII 2. Intraoperative ultrasound. History of Present Illness: ___ man with HCC and fibrosis related to chronic HCV infection. This lesion is in segment VIII and was measured at 6 cm on preoperative imaging. He now presents for resection Past Medical History: MHx: CAD, afib, Coumadin (tia when Coumadin held) HTN, HLD, hep C ITP GERD SHx: ___ Family History: Relative Status Age Problem Onset Comments Father EMPHYSEMA Physical Exam: Discharge PE: Wt: 91.4kg on ___ A&O, NAD SR incision w staples with scant erythema at stable line. JP removed and site sutured. Pertinent Results: ___ 11:35AM BLOOD WBC-12.6* RBC-3.07* Hgb-9.3* Hct-29.6* MCV-96 MCH-30.3 MCHC-31.4* RDW-13.5 RDWSD-47.5* Plt ___ ___ 01:10PM BLOOD WBC-34.3* RBC-3.69* Hgb-11.3* Hct-34.9* MCV-95 MCH-30.6 MCHC-32.4 RDW-13.7 RDWSD-47.1* Plt ___ ___ 06:14AM BLOOD WBC-24.3* RBC-3.77* Hgb-11.4* Hct-34.3* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.9 RDWSD-48.9* Plt ___ ___ 01:20PM BLOOD WBC-17.1* RBC-3.01* Hgb-9.2* Hct-27.6* MCV-92 MCH-30.6 MCHC-33.3 RDW-14.7 RDWSD-48.8* Plt ___ ___ 07:41AM BLOOD WBC-23.4* RBC-3.43* Hgb-10.3* Hct-31.1* MCV-91 MCH-30.0 MCHC-33.1 RDW-15.4 RDWSD-50.4* Plt ___ ___ 02:22AM BLOOD WBC-14.4* RBC-3.16* Hgb-9.4* Hct-29.2* MCV-92 MCH-29.7 MCHC-32.2 RDW-14.6 RDWSD-48.8* Plt ___ ___ 05:17AM BLOOD WBC-14.8* RBC-3.54* Hgb-10.3* Hct-32.6* MCV-92 MCH-29.1 MCHC-31.6* RDW-14.2 RDWSD-48.1* Plt ___ ___ 05:31AM BLOOD ___ ___ 04:10AM BLOOD ___ PTT-36.4 ___ ___ 04:26AM BLOOD ___ ___ 05:17AM BLOOD ___ ___ 01:10PM BLOOD Glucose-186* UreaN-18 Creat-1.1 Na-146 K-5.3 Cl-111* HCO3-19* AnGap-16 ___ 07:10PM BLOOD Glucose-264* UreaN-22* Creat-1.4* Na-143 K-6.0* Cl-108 HCO3-17* AnGap-18 ___ 06:14AM BLOOD Glucose-193* UreaN-29* Creat-1.6* Na-145 K-5.2 Cl-110* HCO3-19* AnGap-16 ___ 05:17AM BLOOD Glucose-129* UreaN-17 Creat-0.9 Na-138 K-4.5 Cl-101 HCO3-24 AnGap-13 ___ 05:31AM BLOOD ALT-49* AST-26 AlkPhos-92 TotBili-0.8 ___ 04:10AM BLOOD ALT-41* AST-23 AlkPhos-88 TotBili-0.7 ___ 04:26AM BLOOD ALT-36 AST-26 AlkPhos-89 TotBili-0.6 ___ 05:17AM BLOOD ALT-34 AST-30 AlkPhos-96 TotBili-0.5 ___ 05:17AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.___ with h/o CAD, Afib on Coumadin, HCV, ITP, s/p segement 8 resection for HCC on ___. Surgeon was Dr. ___. He was quite oozy and Pringle maneuver was used on the whole hilum to facilitate the dissection. He became more oozy and SBP decreased to the ___. There was some bleeding from small veins that were branches of the right hepatic vein. SBP dropped to 40 and sutures were placed to control the bleeding. He remained hypotensive for about 10 to 15 minutes dropping as low as 30 prior to normalizing. Three units of blood and pressor support were given before pressure normalized. An intraoperative TEE was performed and showed normal cardiac function. Hemostasis was obtained using sutures, Argon beam and Bioglue on the cut surface. A 19 ___ ___ drain was place in the right abdomen alongside the cut surface of the liver. Please refer to operative note for complete details. Postop, he was hypotensive and went to the SICU as he required neo and PRBC for hematocrit decrease. He went into Afib w RVR that was treated with IV diltiazem 10mg x2 and Amiodarone load with conversion. Amiodarone was weaned off when he converted to sinus. Lasix was given as he was volume up. Home Diltiazem and Digoxin were resumed and he transferred out of the SICU. A Heparin drip was started. LFTs decreased. Liver duplex demonstrated normal vasculature although the right hepatic vein was not well-visualized. He was advanced to a regular diet by pod 4. He did develop diarrhea and bowel regimen was discontinued. Stool was negative for C.diff. Coumadin was resumed with lovenox bridge. Lasix was given for fluid retention, then afib w RVR recurred on ___ with rates up to 170s that was unresponsive to IV Metoprolol x2 and IV Diltiazem x 1 requiring transfer back to TSICU for Amiodarone load oon ___. He converted back to sinus. Metoprolol was added for rate control. Digoxin was discontinued. Cardiology recommendations were to continue Diltiazem, Metroprolol XL and Amiodarone (taper amiodarone 400mg twice daily for 2 weeks (until ___ then 200mg daily for 4 weeks then off. TSH and PFTs were recommended in 6 weeks if Amiodarone continued for more than 6 weeks. Of note, TSH was 7.1 on ___. Anticoagulation was resumed. However, INR became supra therapeutic at 4.1 that required holding Coumadin for 3 days. This was resumed on ___ when INR was 2.5. INR ranged between 2.1-2.3. Discharge dose was 5mg and he was instructed to have an INR on ___. ___ will do the INR and call his PCP for dosing until he is well enough to go for labs at ___ anticoagulation. The foley was removed on ___ and he voided. He did have urinary retention requiring Flomax with resolution. However, Flomax may have contributed to orthostatis that he experienced on several days. JP drain output was non-bilious and decreased allowing removal on ___. JP output was 165ml the day prior to removal. ___ assessed him and recommended rehab, however, he refused rehab and worked with ___ and nursing with plan to go home. He was using a cane for support. He was discharged to home in stable condition tolerating a regular diet. Oxycodone and Tylenol was used for pain control. The day prior to discharge, he used 40mg of Oxycodone. He was instructed to decrease Oxycodone and Tylenol use. Scripts were faxed to ___ in ___ in ___ (fax ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Digoxin 0.125 mg PO DAILY 2. Diltiazem Extended-Release 360 mg PO DAILY 3. Enoxaparin Sodium 80 mg SC PRN: BID bridge for coumadin Start: Today - ___, First Dose: Next Routine Administration Time 4. Warfarin 5 mg PO 4X/WEEK (___) afib 5. Warfarin 7.5 mg PO 2X/WEEK (___) afib 6. Insulin SC Sliding Scale Insulin SC Sliding Scale using novolog Insulin 7. Lisinopril 40 mg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Pravastatin 20 mg PO QPM Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild do not take more than 2000mg per day (that is 4 tablets) 2. Amiodarone 400 mg PO BID RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*68 Tablet Refills:*0 3. Famotidine 20 mg PO Q12H RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 4. Metoprolol Succinate XL 50 mg PO QHS hold for heart rate less than 60 or SBP less than 110 RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*5 5. Multivitamins W/minerals 1 TAB PO DAILY 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 7. Senna 8.6 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 8. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*14 Capsule Refills:*0 9. Diltiazem Extended-Release 180 mg PO DAILY hold for HR <60 or SBP <110 10. Humalog 12 Units Breakfast Humalog 12 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Warfarin 5 mg PO DAILY please have INR drawn on ___ and check with your ___ clinic for dosing 12. Enoxaparin Sodium 80 mg SC PRN: BID bridge for coumadin Start: ___, First Dose: Next Routine Administration Time take when instructed by the ___ clinic 13. Lisinopril 40 mg PO DAILY 14. MetFORMIN (Glucophage) 1000 mg PO BID 15. Pravastatin 20 mg PO QPM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: HCV HCC Afib DM 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: ___ Care Network to follow you at home Tel# ___, fax# ___ Please call Dr. ___ office at ___ for fever of 101 or greater, 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 has redness, drainage or bleeding, or any other concerning symptoms. You may shower. Allow water to run over the incision. Do not apply lotion or powder to the incision. Leave incision open to the air. No lifting more than 10 pounds No driving if taking narcotic pain medication Please have your INR lab drawn at ___ clinic on ___ Followup Instructions: ___
[ "C220", "R571", "D693", "D62", "N179", "J90", "B182", "I2510", "I252", "I480", "Z7901", "Z87891", "Z8673", "E119", "Z794", "M47896", "G4733", "G8918", "E875", "K219" ]
Allergies: morphine / hydrochlorothiazide / amiodarone Chief Complaint: HCV, HCC Major Surgical or Invasive Procedure: [MASKED] 1. Exploratory laparotomy and resection of Liver segment VIII 2. Intraoperative ultrasound. History of Present Illness: [MASKED] man with HCC and fibrosis related to chronic HCV infection. This lesion is in segment VIII and was measured at 6 cm on preoperative imaging. He now presents for resection Past Medical History: MHx: CAD, afib, Coumadin (tia when Coumadin held) HTN, HLD, hep C ITP GERD SHx: [MASKED] Family History: Relative Status Age Problem Onset Comments Father EMPHYSEMA Physical Exam: Discharge PE: Wt: 91.4kg on [MASKED] A&O, NAD SR incision w staples with scant erythema at stable line. JP removed and site sutured. Pertinent Results: [MASKED] 11:35AM BLOOD WBC-12.6* RBC-3.07* Hgb-9.3* Hct-29.6* MCV-96 MCH-30.3 MCHC-31.4* RDW-13.5 RDWSD-47.5* Plt [MASKED] [MASKED] 01:10PM BLOOD WBC-34.3* RBC-3.69* Hgb-11.3* Hct-34.9* MCV-95 MCH-30.6 MCHC-32.4 RDW-13.7 RDWSD-47.1* Plt [MASKED] [MASKED] 06:14AM BLOOD WBC-24.3* RBC-3.77* Hgb-11.4* Hct-34.3* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.9 RDWSD-48.9* Plt [MASKED] [MASKED] 01:20PM BLOOD WBC-17.1* RBC-3.01* Hgb-9.2* Hct-27.6* MCV-92 MCH-30.6 MCHC-33.3 RDW-14.7 RDWSD-48.8* Plt [MASKED] [MASKED] 07:41AM BLOOD WBC-23.4* RBC-3.43* Hgb-10.3* Hct-31.1* MCV-91 MCH-30.0 MCHC-33.1 RDW-15.4 RDWSD-50.4* Plt [MASKED] [MASKED] 02:22AM BLOOD WBC-14.4* RBC-3.16* Hgb-9.4* Hct-29.2* MCV-92 MCH-29.7 MCHC-32.2 RDW-14.6 RDWSD-48.8* Plt [MASKED] [MASKED] 05:17AM BLOOD WBC-14.8* RBC-3.54* Hgb-10.3* Hct-32.6* MCV-92 MCH-29.1 MCHC-31.6* RDW-14.2 RDWSD-48.1* Plt [MASKED] [MASKED] 05:31AM BLOOD [MASKED] [MASKED] 04:10AM BLOOD [MASKED] PTT-36.4 [MASKED] [MASKED] 04:26AM BLOOD [MASKED] [MASKED] 05:17AM BLOOD [MASKED] [MASKED] 01:10PM BLOOD Glucose-186* UreaN-18 Creat-1.1 Na-146 K-5.3 Cl-111* HCO3-19* AnGap-16 [MASKED] 07:10PM BLOOD Glucose-264* UreaN-22* Creat-1.4* Na-143 K-6.0* Cl-108 HCO3-17* AnGap-18 [MASKED] 06:14AM BLOOD Glucose-193* UreaN-29* Creat-1.6* Na-145 K-5.2 Cl-110* HCO3-19* AnGap-16 [MASKED] 05:17AM BLOOD Glucose-129* UreaN-17 Creat-0.9 Na-138 K-4.5 Cl-101 HCO3-24 AnGap-13 [MASKED] 05:31AM BLOOD ALT-49* AST-26 AlkPhos-92 TotBili-0.8 [MASKED] 04:10AM BLOOD ALT-41* AST-23 AlkPhos-88 TotBili-0.7 [MASKED] 04:26AM BLOOD ALT-36 AST-26 AlkPhos-89 TotBili-0.6 [MASKED] 05:17AM BLOOD ALT-34 AST-30 AlkPhos-96 TotBili-0.5 [MASKED] 05:17AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.[MASKED] with h/o CAD, Afib on Coumadin, HCV, ITP, s/p segement 8 resection for HCC on [MASKED]. Surgeon was Dr. [MASKED]. He was quite oozy and Pringle maneuver was used on the whole hilum to facilitate the dissection. He became more oozy and SBP decreased to the [MASKED]. There was some bleeding from small veins that were branches of the right hepatic vein. SBP dropped to 40 and sutures were placed to control the bleeding. He remained hypotensive for about 10 to 15 minutes dropping as low as 30 prior to normalizing. Three units of blood and pressor support were given before pressure normalized. An intraoperative TEE was performed and showed normal cardiac function. Hemostasis was obtained using sutures, Argon beam and Bioglue on the cut surface. A 19 [MASKED] [MASKED] drain was place in the right abdomen alongside the cut surface of the liver. Please refer to operative note for complete details. Postop, he was hypotensive and went to the SICU as he required neo and PRBC for hematocrit decrease. He went into Afib w RVR that was treated with IV diltiazem 10mg x2 and Amiodarone load with conversion. Amiodarone was weaned off when he converted to sinus. Lasix was given as he was volume up. Home Diltiazem and Digoxin were resumed and he transferred out of the SICU. A Heparin drip was started. LFTs decreased. Liver duplex demonstrated normal vasculature although the right hepatic vein was not well-visualized. He was advanced to a regular diet by pod 4. He did develop diarrhea and bowel regimen was discontinued. Stool was negative for C.diff. Coumadin was resumed with lovenox bridge. Lasix was given for fluid retention, then afib w RVR recurred on [MASKED] with rates up to 170s that was unresponsive to IV Metoprolol x2 and IV Diltiazem x 1 requiring transfer back to TSICU for Amiodarone load oon [MASKED]. He converted back to sinus. Metoprolol was added for rate control. Digoxin was discontinued. Cardiology recommendations were to continue Diltiazem, Metroprolol XL and Amiodarone (taper amiodarone 400mg twice daily for 2 weeks (until [MASKED] then 200mg daily for 4 weeks then off. TSH and PFTs were recommended in 6 weeks if Amiodarone continued for more than 6 weeks. Of note, TSH was 7.1 on [MASKED]. Anticoagulation was resumed. However, INR became supra therapeutic at 4.1 that required holding Coumadin for 3 days. This was resumed on [MASKED] when INR was 2.5. INR ranged between 2.1-2.3. Discharge dose was 5mg and he was instructed to have an INR on [MASKED]. [MASKED] will do the INR and call his PCP for dosing until he is well enough to go for labs at [MASKED] anticoagulation. The foley was removed on [MASKED] and he voided. He did have urinary retention requiring Flomax with resolution. However, Flomax may have contributed to orthostatis that he experienced on several days. JP drain output was non-bilious and decreased allowing removal on [MASKED]. JP output was 165ml the day prior to removal. [MASKED] assessed him and recommended rehab, however, he refused rehab and worked with [MASKED] and nursing with plan to go home. He was using a cane for support. He was discharged to home in stable condition tolerating a regular diet. Oxycodone and Tylenol was used for pain control. The day prior to discharge, he used 40mg of Oxycodone. He was instructed to decrease Oxycodone and Tylenol use. Scripts were faxed to [MASKED] in [MASKED] in [MASKED] (fax [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Digoxin 0.125 mg PO DAILY 2. Diltiazem Extended-Release 360 mg PO DAILY 3. Enoxaparin Sodium 80 mg SC PRN: BID bridge for coumadin Start: Today - [MASKED], First Dose: Next Routine Administration Time 4. Warfarin 5 mg PO 4X/WEEK ([MASKED]) afib 5. Warfarin 7.5 mg PO 2X/WEEK ([MASKED]) afib 6. Insulin SC Sliding Scale Insulin SC Sliding Scale using novolog Insulin 7. Lisinopril 40 mg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Pravastatin 20 mg PO QPM Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild do not take more than 2000mg per day (that is 4 tablets) 2. Amiodarone 400 mg PO BID RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*68 Tablet Refills:*0 3. Famotidine 20 mg PO Q12H RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 4. Metoprolol Succinate XL 50 mg PO QHS hold for heart rate less than 60 or SBP less than 110 RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*5 5. Multivitamins W/minerals 1 TAB PO DAILY 6. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 7. Senna 8.6 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 8. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*14 Capsule Refills:*0 9. Diltiazem Extended-Release 180 mg PO DAILY hold for HR <60 or SBP <110 10. Humalog 12 Units Breakfast Humalog 12 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Warfarin 5 mg PO DAILY please have INR drawn on [MASKED] and check with your [MASKED] clinic for dosing 12. Enoxaparin Sodium 80 mg SC PRN: BID bridge for coumadin Start: [MASKED], First Dose: Next Routine Administration Time take when instructed by the [MASKED] clinic 13. Lisinopril 40 mg PO DAILY 14. MetFORMIN (Glucophage) 1000 mg PO BID 15. Pravastatin 20 mg PO QPM Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: HCV HCC Afib DM 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: [MASKED] Care Network to follow you at home Tel# [MASKED], fax# [MASKED] Please call Dr. [MASKED] office at [MASKED] for fever of 101 or greater, 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 has redness, drainage or bleeding, or any other concerning symptoms. You may shower. Allow water to run over the incision. Do not apply lotion or powder to the incision. Leave incision open to the air. No lifting more than 10 pounds No driving if taking narcotic pain medication Please have your INR lab drawn at [MASKED] clinic on [MASKED] Followup Instructions: [MASKED]
[]
[ "D62", "N179", "I2510", "I252", "I480", "Z7901", "Z87891", "Z8673", "E119", "Z794", "G4733", "K219" ]
[ "C220: Liver cell carcinoma", "R571: Hypovolemic shock", "D693: Immune thrombocytopenic purpura", "D62: Acute posthemorrhagic anemia", "N179: Acute kidney failure, unspecified", "J90: Pleural effusion, not elsewhere classified", "B182: Chronic viral hepatitis C", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "M47896: Other spondylosis, lumbar region", "G4733: Obstructive sleep apnea (adult) (pediatric)", "G8918: Other acute postprocedural pain", "E875: Hyperkalemia", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,034,742
26,829,411
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: quinine Attending: ___ Chief Complaint: Lumbar stenosis Major Surgical or Invasive Procedure: ___: L2-3 laminectomy History of Present Illness: Ms. ___ is a ___ female who has a longstanding history of back pain. The back pain is ___. She is taking pain medication for the back pain. She applies ice, tried physical therapy and injection. The back pain is constant, sitting for more than 45 minutes is difficult for her. Her back pain has no mechanical qualities. She complains of severe leg pain. The pain is ___. This has a spasm-like quality, it is difficult for her to walk and it is worse with activity. The pain is consistent with neurogenic claudication. The patient denies any bowel or bladder symptoms. The patient had extensive conservative therapy including medication and ice packs, activity modification, physical therapy and injections. She is now s/p L2-3 laminectomy Past Medical History: chronic back pain s/p multiple lumar surgeries Urinary incontinence Radicular BLE pain hypothyroidism Social History: ___ Family History: non contributory Physical Exam: General: Awake and alert in no apparent distress Cardiac: Regular rate and rhythm Pulm: Breathing comfortably on room air GI: Soft, non-tender, non-distended Neuro: ___ strength in bilateral upper and lower extremities. Sensation intact to light touch throughout Pertinent Results: ___ 05:37AM BLOOD WBC-9.3# RBC-3.88* Hgb-10.2* Hct-31.3* MCV-81* MCH-26.3 MCHC-32.6 RDW-14.1 RDWSD-40.3 Plt ___ ___ 05:37AM BLOOD Glucose-153* UreaN-9 Creat-0.6 Na-140 K-4.2 Cl-100 HCO3-29 AnGap-15 Brief Hospital Course: The patient was admitted to the neurosurgery service on ___ and had a L2-3 laminectomy. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient received oral pain medications with IV pain medications for breakthrough pain. The patient's post-op strength was maintained from prior to the operation and the patient denied any numbness or paresthesias after surgery. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin for three post-op doses. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin 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 with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain 2. Bisacodyl 10 mg PO/PR DAILY constipation RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily Disp #*50 Tablet Refills:*0 3. Diclofenac Sodium ___ 75 mg PO BID 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 5. Diazepam 2 mg PO Q8H:PRN muscle spasm 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily Disp #*50 Capsule Refills:*0 7. Imipramine 25 mg PO QHS 8. Levothyroxine Sodium 112 mcg PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD DAILY PRN pain 10. metaxalone 800 mg oral Q8H 11. Multivitamins 1 TAB PO DAILY 12. Oxybutynin 5 mg PO TID 13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours Disp #*50 Tablet Refills:*0 14. Polyethylene Glycol 17 g PO DAILY:PRN comstopation 15. Pregabalin 100 mg PO BID 16. Pregabalin 200 mg PO HS 17. Senna 17.2 mg PO QHS RX *sennosides [senna] 8.6 mg 2 capsules by mouth At night Disp #*50 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Lumbar stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery · Your dressing may come off on the second day after surgery. · *** Your incision is closed with staples or sutures. You will need suture/staple removal. Please keep your incision dry until suture/staple removal. · *** Your incision is closed with dissolvable sutures underneath the skin and steri strips. You do not need suture removal. Do not remove your steri strips, let them fall off. Please keep your incision dry for 72 hours after surgery. · Do not apply any lotions or creams to the site. · Please avoid swimming for two weeks after suture/staple removal. · Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. · No driving while taking any narcotic or sedating medication. · No contact sports until cleared by your neurosurgeon. Medications · ***Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. · *** You may take Ibuprofen/ Motrin for pain. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. · It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · New weakness or changes in sensation in your arms or legs. Followup Instructions: ___
[ "M4806", "G8929", "M549", "E039", "J45909", "E669", "Z6834", "Z85828" ]
Allergies: quinine Chief Complaint: Lumbar stenosis Major Surgical or Invasive Procedure: [MASKED]: L2-3 laminectomy History of Present Illness: Ms. [MASKED] is a [MASKED] female who has a longstanding history of back pain. The back pain is [MASKED]. She is taking pain medication for the back pain. She applies ice, tried physical therapy and injection. The back pain is constant, sitting for more than 45 minutes is difficult for her. Her back pain has no mechanical qualities. She complains of severe leg pain. The pain is [MASKED]. This has a spasm-like quality, it is difficult for her to walk and it is worse with activity. The pain is consistent with neurogenic claudication. The patient denies any bowel or bladder symptoms. The patient had extensive conservative therapy including medication and ice packs, activity modification, physical therapy and injections. She is now s/p L2-3 laminectomy Past Medical History: chronic back pain s/p multiple lumar surgeries Urinary incontinence Radicular BLE pain hypothyroidism Social History: [MASKED] Family History: non contributory Physical Exam: General: Awake and alert in no apparent distress Cardiac: Regular rate and rhythm Pulm: Breathing comfortably on room air GI: Soft, non-tender, non-distended Neuro: [MASKED] strength in bilateral upper and lower extremities. Sensation intact to light touch throughout Pertinent Results: [MASKED] 05:37AM BLOOD WBC-9.3# RBC-3.88* Hgb-10.2* Hct-31.3* MCV-81* MCH-26.3 MCHC-32.6 RDW-14.1 RDWSD-40.3 Plt [MASKED] [MASKED] 05:37AM BLOOD Glucose-153* UreaN-9 Creat-0.6 Na-140 K-4.2 Cl-100 HCO3-29 AnGap-15 Brief Hospital Course: The patient was admitted to the neurosurgery service on [MASKED] and had a L2-3 laminectomy. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient received oral pain medications with IV pain medications for breakthrough pain. The patient's post-op strength was maintained from prior to the operation and the patient denied any numbness or paresthesias after surgery. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin for three post-op doses. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin 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 with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain 2. Bisacodyl 10 mg PO/PR DAILY constipation RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily Disp #*50 Tablet Refills:*0 3. Diclofenac Sodium [MASKED] 75 mg PO BID 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 5. Diazepam 2 mg PO Q8H:PRN muscle spasm 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice daily Disp #*50 Capsule Refills:*0 7. Imipramine 25 mg PO QHS 8. Levothyroxine Sodium 112 mcg PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD DAILY PRN pain 10. metaxalone 800 mg oral Q8H 11. Multivitamins 1 TAB PO DAILY 12. Oxybutynin 5 mg PO TID 13. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth Every 4 hours Disp #*50 Tablet Refills:*0 14. Polyethylene Glycol 17 g PO DAILY:PRN comstopation 15. Pregabalin 100 mg PO BID 16. Pregabalin 200 mg PO HS 17. Senna 17.2 mg PO QHS RX *sennosides [senna] 8.6 mg 2 capsules by mouth At night Disp #*50 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Lumbar stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery · Your dressing may come off on the second day after surgery. · *** Your incision is closed with staples or sutures. You will need suture/staple removal. Please keep your incision dry until suture/staple removal. · *** Your incision is closed with dissolvable sutures underneath the skin and steri strips. You do not need suture removal. Do not remove your steri strips, let them fall off. Please keep your incision dry for 72 hours after surgery. · Do not apply any lotions or creams to the site. · Please avoid swimming for two weeks after suture/staple removal. · Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace. [MASKED] try to do too much all at once. · No driving while taking any narcotic or sedating medication. · No contact sports until cleared by your neurosurgeon. Medications · ***Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. · *** You may take Ibuprofen/ Motrin for pain. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. · It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at [MASKED] for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · New weakness or changes in sensation in your arms or legs. Followup Instructions: [MASKED]
[]
[ "G8929", "E039", "J45909", "E669" ]
[ "M4806: Spinal stenosis, lumbar region", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "E039: Hypothyroidism, unspecified", "J45909: Unspecified asthma, uncomplicated", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "Z85828: Personal history of other malignant neoplasm of skin" ]
10,034,933
28,591,708
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fatigue, New Effusion Major Surgical or Invasive Procedure: Bone marrow biopsy ___ History of Present Illness: ___ PMH Bipolar Disorder, HTN, Metastatic HCC (on nivolumab, s/p recent XRT to skull bony mets), CVA, MCA Aneurysm, presented to ED with fatigue and new pleural effusion As per call in, patient initially presented to OSH with increasing confusion, CTH with stable skull mets, but further workup revealed neutropenia, and CXR with new loculated pleural effusion. Accordingly, he was given vanc/cefepime, and was transferred to ___ for thoracic evaluation. Patient's wife is unavailable at time of admission to the oncology floor however patient was alert and oriented and able to provide adequate history. He noted that he was not confused but instead was fatigued for 2 days and that was the reason that his wife brought him to the outside hospital. He noted that he was without fever, chills, cough, sore throat, nausea, vomiting, diarrhea, abdominal pain, dysuria, rash, sick contacts. He noted that his oral intake has been less than optimal. He noted that he has been voiding/stooling without issue. He denied any respiratory issues, shortness of breath or labored breathing. In the ED, initial vitals: 98.0 78 148/78 16 100% RA. WBC 1.0, (8% PMN, 8% bands), Hgb 8.0, plt 58, INR 1.2, ALT 73 AST 118, TBili 3.5, AP 368, Alb 2.3, Phos 2.2, Na 129, Lactate 0.8, UA + Glc /Prot/Bili but no e/o infection. CT Chest revealed: 1. New, lobulated, right greater than left, small pleural effusions. 2. No evidence of new or growing pulmonary nodules. 3. Cirrhotic liver, with multiple hepatic masses measuring up to 8.1 cm, compatible with known multifocal hepatocellular carcinoma, not fully assessed on this study. 4. New, wedge-shaped hypodensity within the spleen, which could be due to contrast bolus timing, although a splenic infarct could have a similar appearance. 5. Stable bilateral adrenal metastases. 6. No significant change in osseous metastatic disease of the ribs and vertebral bodies. 7. Other findings, as described above. Thoracic surgery consulted, noted that they will followup CT results. Patient was given normal saline and admitted for further care. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: As per last clinic note by Dr ___: - ___: Presented with back pain thought to be due to epidural abscess, a complication of his recent spinal surgery, found to have multiple spinal mets. - ___: Imaging shows multiple liver lesions and enlarged abdominal lymph nodes, metastases of the spine, skull, L adrenal gland, C2/3 paraspinal mass with cord impingement. - ___: Radiation therapy to C1-5 and associated paraspinal mass (20 Gy in 5 fx). - ___: plan port placement - ___: C1D1 FOLFOX - ___: C2D1 FOLFOX ___ bolus d/c for mouth sores) - ___: C3D1 held for hypokalemia - ___: C3D1 FOLFOX ___ bolus d/c), Zometa - ___: C4D1 FOLFOX ___ bolus d/c). D15 ___ CI ___ 20% for mucositis. (Zometa held for hypoPhos) - ___: C5D1 FOLFOX ___ bolus d/c, ___ CI ___ 20% for mucositis) - ___: C5D15 FOLFOX held for thrombocytopenia - ___: C6D1 FOLFOX ___ bolus d/c, CI ___ 20%, oxali ___ 20% for thrombocytopenia) - ___: Zometa only (Phos improved) - ___: C1 nivolumab PAST MEDICAL HISTORY: Bipolar Disorder Hypertension Pre-diabetes GERD Patient-reported Hemochromatosis (s/p phlebotomy, last done ___ years ago) s/p L3-S1 lumbar decompression with duraplasty in ___ s/p right hip replacement in ___ Chronic neoplasm related pain MCA Aneurysm CVA Social History: ___ Family History: Aunt with hemochromatosis Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: ___ 0118 Temp: 98.3 PO BP: 125/58 HR: 77 RR: 18 O2 sat: 100% O2 delivery: Ra GENERAL: Chronically ill-appearing man, Laying in bed, appears comfortable, no acute distress, cachectic EYES: Pupils equally round and reactive to light, anicteric sclera HEENT: Oropharynx clear, dry mucous membranes NECK: Supple, normal range of motion LUNGS: Clear to auscultation bilaterally without any wheezes rales or rhonchi, no increased respiratory rate, speaks in full sentences CV: Regular rate and rhythm, normal distal perfusion, no edema ABD: Soft nontender nondistended, normoactive bowel sounds GENITOURINARY: No Foley or suprapubic tenderness EXT: Cachectic extremities, decreased muscle bulk, normal muscle tone SKIN: Warm dry, no rash NEURO: Alert and oriented x3, fluent speech, able to describe his medical history in detail ACCESS: Port in right chest, dressing clean/dry/intact DISCHARGE PHYSICAL EXAM: ___ 0815 Temp: 98.3 PO BP: 147/81 HR: 66 RR: 18 O2 sat: 94% O2 delivery: Ra GENERAL: Very pleasant but cachectic man sitting up in bedside chair in no distress. HEENT: Anicteric slcera, PERLL, OP clear, dry MM. Large 3cm circumscribed bony mass over left brow CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, crackles at bases bilaterally with good air movement. Speaking in full sentences. ABD: Soft, non-tender, moderately distended and dull to percussion, positive bowel sounds. EXT: Warm, well perfused, no lower extremity edema, decreased muscle bulk. NEURO: A&Ox3, good attention and linear thought. Strength full throughout. Sensation to light touch intact. No asterixis. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. Pertinent Results: ADMISSION LABS: =============== ___ 04:45PM BLOOD WBC-1.0* RBC-2.65* Hgb-8.0* Hct-23.7* MCV-89 MCH-30.2 MCHC-33.8 RDW-19.0* RDWSD-62.8* Plt Ct-58* ___ 04:45PM BLOOD Neuts-8* Bands-8* Lymphs-63* Monos-19* Eos-0* ___ Metas-2* AbsNeut-0.16* AbsLymp-0.63* AbsMono-0.19* AbsEos-0.00* AbsBaso-0.00* ___ 04:45PM BLOOD ___ PTT-34.1 ___ ___ 04:45PM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-129* K-4.0 Cl-101 HCO3-18* AnGap-10 ___ 04:45PM BLOOD ALT-73* AST-118* AlkPhos-368* TotBili-3.5* ___ 04:45PM BLOOD Albumin-2.3* Calcium-7.3* Phos-2.2* Mg-1.6 ___ 04:55PM BLOOD Lactate-0.8 DISCHARGE LABS: =============== ___ 05:12AM BLOOD WBC-6.6 RBC-2.92* Hgb-8.6* Hct-25.6* MCV-88 MCH-29.5 MCHC-33.6 RDW-18.5* RDWSD-57.7* Plt Ct-48* ___ 05:16AM BLOOD Neuts-66 Bands-18* Lymphs-14* Monos-2* Eos-0* Baso-0 AbsNeut-4.70 AbsLymp-0.78* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.00* ___ 05:12AM BLOOD Ret Aut-0.4 Abs Ret-0.01* ___ 05:12AM BLOOD Glucose-150* UreaN-15 Creat-0.6 Na-131* K-4.6 Cl-98 HCO3-27 AnGap-6* ___ 05:16AM BLOOD ALT-70* AST-92* LD(LDH)-175 AlkPhos-388* TotBili-2.3* ___ 05:12AM BLOOD Calcium-7.6* Phos-2.3* Mg-1.7 MICROBIOLOGY: ___ Blood Culture x 2 - Pending ___ Urine Culture - No Growth BONE MARROW BX ___: Core Biopsy - PND Flow Cytometry - PND Cytogenetics - PND IMAGING: ___HEST W/CONTRAST 1. New, lobulated, right greater than left, small pleural effusions. 2. No evidence of new or growing pulmonary nodules. 3. Cirrhotic liver, with multiple hepatic masses measuring up to 8.1 cm, compatible with known multifocal hepatocellular carcinoma, not fully assessed on this study. 4. New, wedge-shaped hypodensity within the spleen, which could be due to contrast bolus timing, although a splenic infarct could have a similar appearance. 5. Stable bilateral adrenal metastases. 6. No significant change in osseous metastatic disease of the ribs and vertebrae. ___ Imaging LIVER OR GALLBLADDER US 1. Cirrhotic liver with redemonstration of a large, heterogeneous left hepatic mass. Additional masses are better appreciated on prior CT. 2. Sequela of portal hypertension including mild splenomegaly and small to moderate volume ascites. 3. Persistent moderate intrahepatic biliary ductal dilatation, primarily in the left hepatic lobe, similar to prior. Noevidence of common bile duct dilatation. 4. Focal, wedge shaped area of hypoechogenicity along the lateral margin of the spleen may represent a splenic infarct. ___ Imaging MRCP (MR ABD ___ 1. Probable progression of multifocal HCC compared to ___ with increased number and size of multiple lesions, although comparison is suboptimal due to differences in modality. 2. Worsening tumor thrombus in left portal venous branches. 3. Mild/moderate intrahepatic biliary dilation in segments II/III, worse compared to ___. No evidence of cholangitis or hepatic microabscess. 4. Bilateral adrenal and multiple osseous metastases. 5. Small bilateral pleural effusions, appearing slightly loculated on the right. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: Mr. ___ is a ___ male with history of bipolar disorder, hypertension, CVA, MCA aneurysm, and metastatic HCC on nivolumab who presents with fatigue, falls, and new pleural effusion. # Neutropenia (resolved) # Pure red cell aplasia: # Thrombocytopenia: He was found to have a hypoproliferative pancytopenia/neutropenia for which he started neupogen on ___. Etiology was thought potentially immune mediated reaction to nivolumab, and he underwent BM biopsy on ___ with initiation of prednisone. His WBC count improved, but he continued to have a pure red cell aplasia (per prelim BM bx results) and his retic count remained low. He received two tranfusions of pRBC and we increased his steroids to 60mg bid. Should be monitored closely on follow up. With extended prednisone taper. We did start Bactrim for PJP ppx, but DC'd on discharge given possible marrow suppressive side effects. # Hyperbilirubinemia: Patient with stable AST/ALT but elevated TBili that rose on admission. RUQUS and MRCP showed stable persistent moderate intrahepatic biliary ductal dilatation and no obvious intervenable lesion. Now improved upon discharge. We discontinued his statin. # Fatigue: # Fall: # Ascites: Fatigue likely to dehydration/malnutrition, anemia, medication effect. No clear source of infection and neuro exam was normal. Generally improved and he was cleared for DC home with home ___. We stopped his lisinopril and lorazepam. # Pleural Effusion: New small lobulated right pleural effusion on imaging. Likely due to metastatic disease. Less likely infection given no symptoms. Per Thoracic surgery very small effusion and given asymptomatic do not recommended drainage, would need CT-guidance if wish to drain. We deferred. # Concern for Splenic Infarct # PVT : CT was suggestive of infarct, but could also have been ___ contrast timing. No role for A/C for now given thrombocytopenia. # Metastatic HCC: # Secondary Neoplasm of Adrenal: # Secondary Neoplasm of Bone: Rising AFP and new effusion concern for disease progression despite initial treatment with FOLFOX and single dose of nivolumab. Unfortunately unlikely he will be able to resume nivolumab. Will need to discuss further plans with his outpatient oncologist. # Hyponatremia: Stable. Likely secondary to poor PO intake at baseline as well as poor renal perfusion with ascites. # Cancer-Related Pain: Continued home oxycontin and oxycodone. I refilled his RX on discharge. Continued bowel regimen # Hypophosphatemia - Repleted prn with oral repletion # Moderate Protein-Calorie Malnutrition - Nutrition consulted - Sent supplements # History of CVA - Held ASA given thrombocytopenia - Held Lipitor given transaminitis - Cont home atenolol # Hypertension - Continue home atenolol - Held home lisinorpil and monitor BPs # Bipolar Disorder - Continued home lamictal # Hypothyroidism - Continued home levothyroxine # Billing: >30 minutes spent coordinating this discharge plan TRANSITIONAL ISSUES: - Started Prednisone 60mg bid - Consider non-marrow suppressive PJP ppx - Stopped atorvastatin, lisinopril, and lorazepam - Holding ASA due to thrombocytopenia - Please check CBC with reticu count on follow up - Consider outpatient paracentesis pending PLT/WBC stability - Will need prolonged steroid taper - ___ final bone marrow biopsy results Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H 2. Atenolol 100 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. LamoTRIgine 200 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Senna 8.6 mg PO BID 10. Aspirin 81 mg PO DAILY 11. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - Moderate 12. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath/wheezing 13. Levothyroxine Sodium 25 mcg PO DAILY 14. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia 15. Potassium Chloride 20 mEq PO BID 16. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 17. Calcium Carbonate 600 mg PO BID 18. Vitamin D ___ UNIT PO DAILY 19. Magnesium Oxide 280 mg PO DAILY 20. Lidocaine Viscous 2% 15 mL PO Q3H:PRN throat pain 21. Phosphorus 250 mg PO DAILY 22. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN mouth/throain pain 23. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 24. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. PredniSONE 60 mg PO BID RX *prednisone 20 mg 3 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath/wheezing 3. Atenolol 100 mg PO DAILY 4. Calcium Carbonate 600 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. LamoTRIgine 200 mg PO BID 7. Levothyroxine Sodium 25 mcg PO DAILY 8. Magnesium Oxide 280 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 12. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 20 mg 1 tablet(s) by mouth q4 hours Disp #*120 Tablet Refills:*0 13. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H RX *oxycodone 60 mg 2 tablet(s) by mouth q8 hours Disp #*180 Tablet Refills:*0 14. Phosphorus 250 mg PO DAILY 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Potassium Chloride 20 mEq PO BID 17. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 18. Senna 8.6 mg PO BID 19. Vitamin D ___ UNIT PO DAILY 20. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until your platelet counts are better Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Immune mediated pan-cytopenia # Hepatocellular cancer # Ascites # Pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for weakness. We found you had very low blood counts, along with increasing fluid in your abdomen and a small amount around your lungs. We believe you have had an immune reaction to your recent nivolumab immunotherapy, causing damage to your bone marrow. We gave you injections to help increase your white blood cell count, started you on steroids, and performed a bone marrow biopsy. You also received two blood tranfusions. We elected against interventions on the fluid in your belly or lung, as you began to feel better. You will need to follow up with Dr. ___ closely to evaluate for recovery in your bone marrow and future treatment planning for your liver cancer. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "C220", "D61810", "D609", "C7951", "C7970", "J90", "E440", "Z681", "E871", "T451X5A", "I671", "Z8673", "F319", "I10", "K219", "R7303", "Z96641", "F17210", "E806", "E860", "D6959", "G893", "E8339" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fatigue, New Effusion Major Surgical or Invasive Procedure: Bone marrow biopsy [MASKED] History of Present Illness: [MASKED] PMH Bipolar Disorder, HTN, Metastatic HCC (on nivolumab, s/p recent XRT to skull bony mets), CVA, MCA Aneurysm, presented to ED with fatigue and new pleural effusion As per call in, patient initially presented to OSH with increasing confusion, CTH with stable skull mets, but further workup revealed neutropenia, and CXR with new loculated pleural effusion. Accordingly, he was given vanc/cefepime, and was transferred to [MASKED] for thoracic evaluation. Patient's wife is unavailable at time of admission to the oncology floor however patient was alert and oriented and able to provide adequate history. He noted that he was not confused but instead was fatigued for 2 days and that was the reason that his wife brought him to the outside hospital. He noted that he was without fever, chills, cough, sore throat, nausea, vomiting, diarrhea, abdominal pain, dysuria, rash, sick contacts. He noted that his oral intake has been less than optimal. He noted that he has been voiding/stooling without issue. He denied any respiratory issues, shortness of breath or labored breathing. In the ED, initial vitals: 98.0 78 148/78 16 100% RA. WBC 1.0, (8% PMN, 8% bands), Hgb 8.0, plt 58, INR 1.2, ALT 73 AST 118, TBili 3.5, AP 368, Alb 2.3, Phos 2.2, Na 129, Lactate 0.8, UA + Glc /Prot/Bili but no e/o infection. CT Chest revealed: 1. New, lobulated, right greater than left, small pleural effusions. 2. No evidence of new or growing pulmonary nodules. 3. Cirrhotic liver, with multiple hepatic masses measuring up to 8.1 cm, compatible with known multifocal hepatocellular carcinoma, not fully assessed on this study. 4. New, wedge-shaped hypodensity within the spleen, which could be due to contrast bolus timing, although a splenic infarct could have a similar appearance. 5. Stable bilateral adrenal metastases. 6. No significant change in osseous metastatic disease of the ribs and vertebral bodies. 7. Other findings, as described above. Thoracic surgery consulted, noted that they will followup CT results. Patient was given normal saline and admitted for further care. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: As per last clinic note by Dr [MASKED]: - [MASKED]: Presented with back pain thought to be due to epidural abscess, a complication of his recent spinal surgery, found to have multiple spinal mets. - [MASKED]: Imaging shows multiple liver lesions and enlarged abdominal lymph nodes, metastases of the spine, skull, L adrenal gland, C2/3 paraspinal mass with cord impingement. - [MASKED]: Radiation therapy to C1-5 and associated paraspinal mass (20 Gy in 5 fx). - [MASKED]: plan port placement - [MASKED]: C1D1 FOLFOX - [MASKED]: C2D1 FOLFOX [MASKED] bolus d/c for mouth sores) - [MASKED]: C3D1 held for hypokalemia - [MASKED]: C3D1 FOLFOX [MASKED] bolus d/c), Zometa - [MASKED]: C4D1 FOLFOX [MASKED] bolus d/c). D15 [MASKED] CI [MASKED] 20% for mucositis. (Zometa held for hypoPhos) - [MASKED]: C5D1 FOLFOX [MASKED] bolus d/c, [MASKED] CI [MASKED] 20% for mucositis) - [MASKED]: C5D15 FOLFOX held for thrombocytopenia - [MASKED]: C6D1 FOLFOX [MASKED] bolus d/c, CI [MASKED] 20%, oxali [MASKED] 20% for thrombocytopenia) - [MASKED]: Zometa only (Phos improved) - [MASKED]: C1 nivolumab PAST MEDICAL HISTORY: Bipolar Disorder Hypertension Pre-diabetes GERD Patient-reported Hemochromatosis (s/p phlebotomy, last done [MASKED] years ago) s/p L3-S1 lumbar decompression with duraplasty in [MASKED] s/p right hip replacement in [MASKED] Chronic neoplasm related pain MCA Aneurysm CVA Social History: [MASKED] Family History: Aunt with hemochromatosis Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: [MASKED] 0118 Temp: 98.3 PO BP: 125/58 HR: 77 RR: 18 O2 sat: 100% O2 delivery: Ra GENERAL: Chronically ill-appearing man, Laying in bed, appears comfortable, no acute distress, cachectic EYES: Pupils equally round and reactive to light, anicteric sclera HEENT: Oropharynx clear, dry mucous membranes NECK: Supple, normal range of motion LUNGS: Clear to auscultation bilaterally without any wheezes rales or rhonchi, no increased respiratory rate, speaks in full sentences CV: Regular rate and rhythm, normal distal perfusion, no edema ABD: Soft nontender nondistended, normoactive bowel sounds GENITOURINARY: No Foley or suprapubic tenderness EXT: Cachectic extremities, decreased muscle bulk, normal muscle tone SKIN: Warm dry, no rash NEURO: Alert and oriented x3, fluent speech, able to describe his medical history in detail ACCESS: Port in right chest, dressing clean/dry/intact DISCHARGE PHYSICAL EXAM: [MASKED] 0815 Temp: 98.3 PO BP: 147/81 HR: 66 RR: 18 O2 sat: 94% O2 delivery: Ra GENERAL: Very pleasant but cachectic man sitting up in bedside chair in no distress. HEENT: Anicteric slcera, PERLL, OP clear, dry MM. Large 3cm circumscribed bony mass over left brow CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, crackles at bases bilaterally with good air movement. Speaking in full sentences. ABD: Soft, non-tender, moderately distended and dull to percussion, positive bowel sounds. EXT: Warm, well perfused, no lower extremity edema, decreased muscle bulk. NEURO: A&Ox3, good attention and linear thought. Strength full throughout. Sensation to light touch intact. No asterixis. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. Pertinent Results: ADMISSION LABS: =============== [MASKED] 04:45PM BLOOD WBC-1.0* RBC-2.65* Hgb-8.0* Hct-23.7* MCV-89 MCH-30.2 MCHC-33.8 RDW-19.0* RDWSD-62.8* Plt Ct-58* [MASKED] 04:45PM BLOOD Neuts-8* Bands-8* Lymphs-63* Monos-19* Eos-0* [MASKED] Metas-2* AbsNeut-0.16* AbsLymp-0.63* AbsMono-0.19* AbsEos-0.00* AbsBaso-0.00* [MASKED] 04:45PM BLOOD [MASKED] PTT-34.1 [MASKED] [MASKED] 04:45PM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-129* K-4.0 Cl-101 HCO3-18* AnGap-10 [MASKED] 04:45PM BLOOD ALT-73* AST-118* AlkPhos-368* TotBili-3.5* [MASKED] 04:45PM BLOOD Albumin-2.3* Calcium-7.3* Phos-2.2* Mg-1.6 [MASKED] 04:55PM BLOOD Lactate-0.8 DISCHARGE LABS: =============== [MASKED] 05:12AM BLOOD WBC-6.6 RBC-2.92* Hgb-8.6* Hct-25.6* MCV-88 MCH-29.5 MCHC-33.6 RDW-18.5* RDWSD-57.7* Plt Ct-48* [MASKED] 05:16AM BLOOD Neuts-66 Bands-18* Lymphs-14* Monos-2* Eos-0* Baso-0 AbsNeut-4.70 AbsLymp-0.78* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.00* [MASKED] 05:12AM BLOOD Ret Aut-0.4 Abs Ret-0.01* [MASKED] 05:12AM BLOOD Glucose-150* UreaN-15 Creat-0.6 Na-131* K-4.6 Cl-98 HCO3-27 AnGap-6* [MASKED] 05:16AM BLOOD ALT-70* AST-92* LD(LDH)-175 AlkPhos-388* TotBili-2.3* [MASKED] 05:12AM BLOOD Calcium-7.6* Phos-2.3* Mg-1.7 MICROBIOLOGY: [MASKED] Blood Culture x 2 - Pending [MASKED] Urine Culture - No Growth BONE MARROW BX [MASKED]: Core Biopsy - PND Flow Cytometry - PND Cytogenetics - PND IMAGING: HEST W/CONTRAST 1. New, lobulated, right greater than left, small pleural effusions. 2. No evidence of new or growing pulmonary nodules. 3. Cirrhotic liver, with multiple hepatic masses measuring up to 8.1 cm, compatible with known multifocal hepatocellular carcinoma, not fully assessed on this study. 4. New, wedge-shaped hypodensity within the spleen, which could be due to contrast bolus timing, although a splenic infarct could have a similar appearance. 5. Stable bilateral adrenal metastases. 6. No significant change in osseous metastatic disease of the ribs and vertebrae. [MASKED] Imaging LIVER OR GALLBLADDER US 1. Cirrhotic liver with redemonstration of a large, heterogeneous left hepatic mass. Additional masses are better appreciated on prior CT. 2. Sequela of portal hypertension including mild splenomegaly and small to moderate volume ascites. 3. Persistent moderate intrahepatic biliary ductal dilatation, primarily in the left hepatic lobe, similar to prior. Noevidence of common bile duct dilatation. 4. Focal, wedge shaped area of hypoechogenicity along the lateral margin of the spleen may represent a splenic infarct. [MASKED] Imaging MRCP (MR ABD [MASKED] 1. Probable progression of multifocal HCC compared to [MASKED] with increased number and size of multiple lesions, although comparison is suboptimal due to differences in modality. 2. Worsening tumor thrombus in left portal venous branches. 3. Mild/moderate intrahepatic biliary dilation in segments II/III, worse compared to [MASKED]. No evidence of cholangitis or hepatic microabscess. 4. Bilateral adrenal and multiple osseous metastases. 5. Small bilateral pleural effusions, appearing slightly loculated on the right. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: Mr. [MASKED] is a [MASKED] male with history of bipolar disorder, hypertension, CVA, MCA aneurysm, and metastatic HCC on nivolumab who presents with fatigue, falls, and new pleural effusion. # Neutropenia (resolved) # Pure red cell aplasia: # Thrombocytopenia: He was found to have a hypoproliferative pancytopenia/neutropenia for which he started neupogen on [MASKED]. Etiology was thought potentially immune mediated reaction to nivolumab, and he underwent BM biopsy on [MASKED] with initiation of prednisone. His WBC count improved, but he continued to have a pure red cell aplasia (per prelim BM bx results) and his retic count remained low. He received two tranfusions of pRBC and we increased his steroids to 60mg bid. Should be monitored closely on follow up. With extended prednisone taper. We did start Bactrim for PJP ppx, but DC'd on discharge given possible marrow suppressive side effects. # Hyperbilirubinemia: Patient with stable AST/ALT but elevated TBili that rose on admission. RUQUS and MRCP showed stable persistent moderate intrahepatic biliary ductal dilatation and no obvious intervenable lesion. Now improved upon discharge. We discontinued his statin. # Fatigue: # Fall: # Ascites: Fatigue likely to dehydration/malnutrition, anemia, medication effect. No clear source of infection and neuro exam was normal. Generally improved and he was cleared for DC home with home [MASKED]. We stopped his lisinopril and lorazepam. # Pleural Effusion: New small lobulated right pleural effusion on imaging. Likely due to metastatic disease. Less likely infection given no symptoms. Per Thoracic surgery very small effusion and given asymptomatic do not recommended drainage, would need CT-guidance if wish to drain. We deferred. # Concern for Splenic Infarct # PVT : CT was suggestive of infarct, but could also have been [MASKED] contrast timing. No role for A/C for now given thrombocytopenia. # Metastatic HCC: # Secondary Neoplasm of Adrenal: # Secondary Neoplasm of Bone: Rising AFP and new effusion concern for disease progression despite initial treatment with FOLFOX and single dose of nivolumab. Unfortunately unlikely he will be able to resume nivolumab. Will need to discuss further plans with his outpatient oncologist. # Hyponatremia: Stable. Likely secondary to poor PO intake at baseline as well as poor renal perfusion with ascites. # Cancer-Related Pain: Continued home oxycontin and oxycodone. I refilled his RX on discharge. Continued bowel regimen # Hypophosphatemia - Repleted prn with oral repletion # Moderate Protein-Calorie Malnutrition - Nutrition consulted - Sent supplements # History of CVA - Held ASA given thrombocytopenia - Held Lipitor given transaminitis - Cont home atenolol # Hypertension - Continue home atenolol - Held home lisinorpil and monitor BPs # Bipolar Disorder - Continued home lamictal # Hypothyroidism - Continued home levothyroxine # Billing: >30 minutes spent coordinating this discharge plan TRANSITIONAL ISSUES: - Started Prednisone 60mg bid - Consider non-marrow suppressive PJP ppx - Stopped atorvastatin, lisinopril, and lorazepam - Holding ASA due to thrombocytopenia - Please check CBC with reticu count on follow up - Consider outpatient paracentesis pending PLT/WBC stability - Will need prolonged steroid taper - [MASKED] final bone marrow biopsy results Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H 2. Atenolol 100 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. LamoTRIgine 200 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Senna 8.6 mg PO BID 10. Aspirin 81 mg PO DAILY 11. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - Moderate 12. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath/wheezing 13. Levothyroxine Sodium 25 mcg PO DAILY 14. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia 15. Potassium Chloride 20 mEq PO BID 16. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 17. Calcium Carbonate 600 mg PO BID 18. Vitamin D [MASKED] UNIT PO DAILY 19. Magnesium Oxide 280 mg PO DAILY 20. Lidocaine Viscous 2% 15 mL PO Q3H:PRN throat pain 21. Phosphorus 250 mg PO DAILY 22. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN mouth/throain pain 23. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 24. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. PredniSONE 60 mg PO BID RX *prednisone 20 mg 3 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath/wheezing 3. Atenolol 100 mg PO DAILY 4. Calcium Carbonate 600 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. LamoTRIgine 200 mg PO BID 7. Levothyroxine Sodium 25 mcg PO DAILY 8. Magnesium Oxide 280 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 12. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 20 mg 1 tablet(s) by mouth q4 hours Disp #*120 Tablet Refills:*0 13. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H RX *oxycodone 60 mg 2 tablet(s) by mouth q8 hours Disp #*180 Tablet Refills:*0 14. Phosphorus 250 mg PO DAILY 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Potassium Chloride 20 mEq PO BID 17. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 18. Senna 8.6 mg PO BID 19. Vitamin D [MASKED] UNIT PO DAILY 20. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until your platelet counts are better Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: # Immune mediated pan-cytopenia # Hepatocellular cancer # Ascites # Pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. You were admitted for weakness. We found you had very low blood counts, along with increasing fluid in your abdomen and a small amount around your lungs. We believe you have had an immune reaction to your recent nivolumab immunotherapy, causing damage to your bone marrow. We gave you injections to help increase your white blood cell count, started you on steroids, and performed a bone marrow biopsy. You also received two blood tranfusions. We elected against interventions on the fluid in your belly or lung, as you began to feel better. You will need to follow up with Dr. [MASKED] closely to evaluate for recovery in your bone marrow and future treatment planning for your liver cancer. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "E871", "Z8673", "I10", "K219", "F17210" ]
[ "C220: Liver cell carcinoma", "D61810: Antineoplastic chemotherapy induced pancytopenia", "D609: Acquired pure red cell aplasia, unspecified", "C7951: Secondary malignant neoplasm of bone", "C7970: Secondary malignant neoplasm of unspecified adrenal gland", "J90: Pleural effusion, not elsewhere classified", "E440: Moderate protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "E871: Hypo-osmolality and hyponatremia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "I671: Cerebral aneurysm, nonruptured", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F319: Bipolar disorder, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "R7303: Prediabetes", "Z96641: Presence of right artificial hip joint", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E806: Other disorders of bilirubin metabolism", "E860: Dehydration", "D6959: Other secondary thrombocytopenia", "G893: Neoplasm related pain (acute) (chronic)", "E8339: Other disorders of phosphorus metabolism" ]
10,034,933
29,594,531
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: RTx treatment plan to deliver 20 Gy in 5 fractions total, D1 = ___, completed ___ History of Present Illness: Mr. ___ is a ___ man s/p L3-S1 lumbar decompression with duraplasty in ___ and right hip replacement with epidural 1 month ago who presents from ___ with epidural abscess and osteomyelitis seen on MRI, transferred to ___ for spine consult, admitted to medicine for epidural abscess drainage with ___ and treatment of osteomyelitis. Mr. ___ says he has had lower back and left hip pain since before his surgery, but it has been getting worse since his R hip replacement 1 month ago at ___, which was performed with an epidural. Since then, he has had worsening left sided hip and shooting leg pain over the last two weeks. He has had poor PO intake during this time due to pain, but denies fever and chills. He initially presented to ___ one week ago, where they did x-rays and discharged him home. Over the weekend, he had dark vomit and diarrhea. Today, he presented to ___ course: Vitals: Temp 98.4 HR 84 BP 164/62 RR 18 O2 sat 98% RA Exam was notable for normal sensation and motor function bilaterally, though limited by pain. MRI Spine Lumbar W/WO Cont was most consistent with an epidural abscess and osteomyelitis: destructive changes involving the L4 vertebral body and epidural collection, abnormal enhancement pattern in the superior portion of the L5 vertebral body, an abnormal enhancement in the paraspinal soft tissues epicentered at L4 extending superiorly to L3 on the left. Furthermore, there are abnormal destructive areas in L1-L2 vertebral bodies and sacrum. IV vanco(1g)/ceftriaxone(2g) were given at ___. He was transferred here for spine consult. In the ___ ED, initial vitals were: Temp 98.4 HR 90 BP 167/89 RR 18 O2 sat 98% RA -Exam was notable for sensation and motor function intact bilaterally in the lower extremities. Strength was limited due to pain. Rectal tone was normal, and no saddle anesthesia noted. -Labs notable for: WBC 12.5 Hgb 10.2 Hct 29.5 Na 127 Cl 84 BUN 22 K 3.4 Lactate 1.3 -Imaging was notable for: -Patient was given: 1L NS, 500ml 40meqK in NS, 1mg IV hydromorphone Spine was consulted and recommended inpatient ___ guided biopsy. Upon arrival to the floor, patient reports ___ pain at rest which increases to ___ with any movement. He has been very limited with mobility due to pain and has not been ambulating due to pain, currently using wheelchair to get around. He also reports a 53lb weight loss over the last 3 months. He describes an "esophageal burning" that he contributes to not eating and vomiting. He also reported that he has been using adult diapers due to one stool accident, which he says was due to pain and being confined to the wheelchair so that he couldn't make it to the bathroom. He is able to feel the need to move his bowels and is not generally incontinent. The patient denies numbness, paresthesias, and fevers. Occasional chills at night for many years, but no recently increased chills. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative. Past Medical History: Bipolar Disorder Hypertension Pre-diabetes GERD Patient-reported Hemochromatosis (s/p phlebotomy, last done ___ years ago) Social History: ___ Family History: Aunt with hemochromatosis Physical Exam: ADMISSION VITAL SIGNS: 99.1 144 / 61 86 18 96 Ra GENERAL: Alert and interactive. In no acute distress. HEENT: Has 2 x 5 cm round skin-colored bumps on forehead c/w epidermal cyst. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes. Oropharynx is clear. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Mild wheezes heard in the anterior lung fields bilaterally. Exam limited by pain. ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No peripheral edema. SKIN: No rashes appreciated. NEUROLOGIC: CN2-12 intact. ___ strength in the upper extremities. Movement in lower extremities but exam limited by pain. AAOx2-3. DISCHARGE Vitals: Tm 98.3 BO 104/57 HR 66 RR 16 SpO2 96% on RA General: lying in bed in no acute distress HEENT: Two 3x3cm palpable nodules on the left forehead with no overlying skin changes. Nodules are soft but not fluctuant, non-tender to palpation, minimally mobile, no central pore. Lungs: clear to auscultation bilaterally CV: regular rate and rhythm with normal S1 and S2 GI: soft, non-distended, non-tender to palpation Extremities: warm and well perfused without edema NEURO: alert and interactive with strength ___ ___dduction and abduction and elbow flexion and extension. ___ strength in the lower extremities bilaterally. Pertinent Results: Admission Labs ___ 04:45PM WBC-12.5* RBC-3.89* HGB-10.2* HCT-29.5* MCV-76* MCH-26.2 MCHC-34.6 RDW-20.5* RDWSD-55.3* ___ 04:45PM NEUTS-68.8 LYMPHS-17.3* MONOS-9.9 EOS-0.2* BASOS-0.2 IM ___ AbsNeut-8.60* AbsLymp-2.16 AbsMono-1.24* AbsEos-0.02* AbsBaso-0.03 ___ 04:45PM GLUCOSE-110* UREA N-22* CREAT-0.6 SODIUM-127* POTASSIUM-4.3 CHLORIDE-84* TOTAL CO2-27 ANION GAP-16 ___ 04:45PM CALCIUM-8.7 PHOSPHATE-3.4 MAGNESIUM-1.8 ___ 04:45PM CRP-78.2* ___ 04:26PM LACTATE-1.3 K+-3.4 ___ 05:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 05:21PM URINE RBC-3* WBC-3 BACTERIA-FEW* YEAST-NONE EPI-0 RENAL EPI-<1 IMAGING: Head ultrasound ___: Palpable masses in the left lateral forehead correspond to vascular soft tissue masses which appear to have eroded the cortex of the underlying frontal bone and are continuous with the medullary cavity. These are highly concerning for bone metastases. Alternative consideration includes multiple myeloma or lymphoma. Liver ultrasound ___: Diffuse heterogeneity of the left lobe of the liver with moderate intrahepatic biliary duct dilatation in the left lobe. A discrete mass in the left lobe measures 7 x 7.7 x 10 cm. Note is also made of an ill-defined hypoechoic lesion in periphery of segment 6 measuring up to 1.4 cm. These findings are concerning for either primary liver malignancy, specifically cholangiocarcinoma, or metastatic disease. CT Head ___: 1. Incidental note made of a 9 x 8 mm right distal M1 segment MCA aneurysm. 2. Subtle hypodensity in the right frontal white matter in the centrum semiovale. This is nonspecific, however given likely malignancy, MR head is recommended for further evaluation. 3. 2 lytic and soft tissue lesions centered in the left frontal calvarium extending into the overlying scalp soft tissues, with lytic involvement of the inner table. No definite intracranial extension. 4. Although evaluation is limited due to recent venous administration of IV contrast, no evidence of intracranial hemorrhage, acute infarction, or mass effect. CT Chest ___: 1. 3 left lung pulmonary nodules measure up to 5 mm. Follow-up as per clinical protocol is recommended. 2. Diffuse esophageal wall thickening as well as enteric contrast material within it, likely reflecting chronic reflux. 3. Small right pleural effusion. 4. Healing left posterolateral 8 through tenth rib fractures. CT Abdomen/Pelvis ___: 1. Enlargement of the caudate and left lobe with calcifications involving the anterior surface of the right lobe which appears smaller, has there been prior hepatic resection?, Alternatively this could represent cirrhosis. Multiple hepatic masses with large hypovascular lesion proximally in the left lobe showing delayed enhancement with associated left intrahepatic biliary dilatation is suspicious for a cholangiocarcinoma. Small arterially enhancing mass showing washout is suspicious for small HCC. Large heterogeneously enhancing mass in the left lobe is difficult to be characterized, tissue sampling is recommended. No evidence of portal vein thrombosis. 2. Large non-fat containing left adrenal mass is suspicious for a metastasis. Small subcentimeter arterially hyperenhancing lesion in the right adrenal gland is indeterminate in etiology. 3. Multiple prominent gastrohepatic, celiac, periportal and portacaval lymph nodes. 4. Large destructive mass involving L4 vertebral body with enhancing epidural component encroaching onto the spinal canal. ___ MRI/MRA BRAIN 1. Two left frontal calvarial lesions erode both the inner and outer table. No evidence of intracranial extension. Lesions could be due to bony metastatic disease unless proven otherwise. 2. No evidence of intracranial metastatic disease. 3. Approximately 1.5 cm right centrum semiovale acute or subacute infarct. 4. Bilateral, M1 segment MCA aneurysms measuring up to 12 x 8 mm on the right and 3 x 2 mm on the left. 5. Narrowing of the cervical spine at C3 level partially visualized on sagittal T1 images. This can be further evaluated with cervical spine MRI. ___ CTA HEAD 1. Lobulated right MCA bifurcation aneurysm with 2 dominant components, which overall measures 10 x 9 x 12 mm. 2. 3 x 2 mm posteriorly projecting right ICA terminus aneurysm. 3. 3 x 2 mm laterally projecting left MCA bifurcation aneurysm. 4. Calcified plaque mildly narrows the proximal V4 segment of the right vertebral artery. Calcified plaque mildly narrows the petrous segment of the right internal carotid artery. 5. Again seen are two left frontal coronal vary ___ expansile, erosive masses with soft tissue component extending into the scalp, suggesting metastases. 6. Partially visualized expansile, erosive mass centered in the right lateral mass and right vertebral body of C2, extending into the prevertebral space, and also extending into the spinal canal with mild to moderate narrowing of the thecal sac. The mass extends into the right C2-C3 neural foramen and into the right C2 transverse foramen, encasing the distal right vertebral artery without evidence for narrowing. ___ DYNAMIC LSPINE XR Unchanged appearances of the known fracture at L4. No evidence of dynamic instability. ___ MR ___ SPINE W/WO CONTRAST 1. Enhancing large soft tissue mass centered about right lateral and posterior elements C2 on C3 with vertebral body involvement at both levels. Epidural tumor extension at C2, C3 levels. Additional lesion at T 2. Findings consistent with metastases or lymphoma. 2. Severe central canal narrowing at C3 level, with cord flattening, equivocal cord edema. 3. Degenerative changes remainder of the cervical spine, as above. 4. Multilevel severe foraminal narrowing. 5. Severe compression C3 vertebral body. ___ TTE Good image quality. Small PFO by saline contrast injection with maneuvers. Normal biventricular wall thicknesses, cavity sizes, and regional/global systolic function. Bilateral Lower Extremity Ultrasound ___: IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. PATHOLOGY ___ PATHOLOGIC DIAGNOSIS: Skull lesion, biopsy: Metastatic hepatocellular carcinoma, see note. Note: The tumor cells stain positively for glypican 3, glutamine synthetase 6, canalicular pattern positivity for polyclonal CEA and CD10, and negative for CK20 and CK7. A reticulin stain highlights expansion of the cell plate. The case was reviewed with Dr. ___ ___. DISCHARGE LABS ___ 04:45PM BLOOD WBC-12.5* RBC-3.89* Hgb-10.2* Hct-29.5* MCV-76* MCH-26.2 MCHC-34.6 RDW-20.5* RDWSD-55.3* Plt ___ ___ 04:45PM BLOOD Neuts-68.8 Lymphs-17.3* Monos-9.9 Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.60* AbsLymp-2.16 AbsMono-1.24* AbsEos-0.02* AbsBaso-0.03 ___ 06:48AM BLOOD ___ PTT-25.6 ___ ___ 04:45PM BLOOD Glucose-110* UreaN-22* Creat-0.6 Na-127* K-4.3 Cl-84* HCO3-27 AnGap-16 ___ 04:45PM BLOOD Calcium-8.7 Phos-3.4 Mg-1.8 ___ 04:45PM BLOOD CRP-78.2* ___ 04:45PM BLOOD CRP-78.2* ___ 05:21PM URINE HOURS-RANDOM ___ 05:21PM URINE UHOLD-HOLD ___ 05:21PM URINE UHOLD-HOLD ___ 06:50AM BLOOD WBC-5.6 RBC-3.36* Hgb-8.9* Hct-27.3* MCV-81* MCH-26.5 MCHC-32.6 RDW-20.1* RDWSD-59.7* Plt ___ ___ 06:50AM BLOOD WBC-5.6 RBC-3.36* Hgb-8.9* Hct-27.3* MCV-81* MCH-26.5 MCHC-32.6 RDW-20.1* RDWSD-59.7* Plt ___ ___ 06:50AM BLOOD WBC-5.6 RBC-3.36* Hgb-8.9* Hct-27.3* MCV-81* MCH-26.5 MCHC-32.6 RDW-20.1* RDWSD-59.7* Plt ___ ___ 05:21PM URINE HOURS-RANDOM ___ 05:21PM URINE UHOLD-HOLD ___ 05:21PM URINE UHOLD-HOLD ___ 05:21PM URINE HYALINE-3* ___ 05:21PM URINE MUCOUS-RARE* ___ 04:45PM CRP-78.2* Brief Hospital Course: ___ with recent 53 pound weight loss, increased GERD symptoms, and severe back pain was transferred from ___ with initial concern for epidural abscess, found to have metastatic HCC with multiple metastasis including spinal and skull metastasis, subacute CVA, bilateral MCA aneurysms and C2/3 mass with cord impingement. Started course of palliative radiation treatment to C2/C3 mass. He will continue these as outpatient. Med Oncology scheduled an outpatient appointment for follow up to discuss prognosis and treatment options. #Metastatic Hepatocellular carcinoma Given his recent weight loss, rapid growth of forehead lesions, worsening GERD symptoms, and unexplained transaminase elevation, he received ultrasound of his forehead nodules and liver. The subcutaneous nodules invaded bone and were concerning for metastasis. Liver ultrasound and subsequent staging CT have found both a small and a large mass. CT abdomen/pelvis also found an adrenal mass. CT chest showed 3 small lung nodules. His back pain and lumbar MRI findings are likely due to bone metastasis rather than osteomyelitis, and he has continued to remain clinically stable and afebrile off antibiotics. Biopsy of his forehead mass was consistent with Hepatocellular Carcinoma. Oncology was consulted, and recommended outpatient follow up. He will follow up with Dr. ___ on ___. Pain was controlled with 80mg Oxycotin BID, Acetaminophen 1g PO q8hr, oxy 15mg PO PRN q4hrs, Gabapentin 600mg TID. #Spinal Metastasis #C2/3 mass with cord impingement Initial presentation of back pain and initial MRI findings are likely due to bone metastasis rather than osteomyelitis. CTA on ___ noted ___ mass in C2 that could be concerning for spinal cord compression. Follow up C spine MRI notable for enhancing large soft tissue mass centered about right lateral and posterior elements C2 on C3 with vertebral body involvement at both levels. Epidural tumor extension at C2, C3 levels. Additional lesion at T 2. Findings consistent with metastases or lymphoma. Severe central canal narrowing at C3 level, with cord flattening, equivocal cord edema. Radiation Oncology was consulted, and patient completed 5 fractions of radiation therapy to prevent further spinal cord compression on ___. #MCA Aneurysm MRA head on ___ notable for bilateral, M1 segment MCA aneurysms measuring up to 12 x 8 mm on the right and 3 x 2 mm on the left. CTA notable for bilateral M1 segment aneurysms measuring up to 1.1 cm on the right and 0.3 cm on the left. Neurosurgery consulted, and recommended blood pressure control and smoking cessation. Decision on intervention pending prognosis. Plan to follow up as an outpatient. #Acute/subacute Neural Infarct MRI brain notable for approximately 1.5 cm right centrum semiovale acute or subacute infarct. Noted to have R arm weakness compared to L arm, now improving, no other focal neurologic deficits. Neurology workup for possible etiology including HgA1c, TSH and tele monitoring for afib were all normal. TTE revealed a small PFO. LENIs were negative. Started on aspirin 81 mg daily. Fasting lipids notable for LDL 80; atorvastatin increased to 80mg per neurology recommendations. Will follow up with Neurology as outpatient. #Dyspepsia/GERD His change in GERD symptoms and anorexia may be due to liver malignancy. Nutrition was consulted, he was continued on home Omeprazole 20mg, and he will follow up with GI as outpatient for EGD if within goals of care. His symptoms were controlled on home omeprazole at time of discharge. #Hip Pain: Patient reported pain in his L hip (which is s/p replacement ___ at ___, worse with motion. On exam, he has tenderness with movement and log rolling of his left leg. Hip and femur x-ray showed no effusion or erosions, making septic arthritis or osteomyelitis less likely. Orthopedic surgery was consulted, and they had low suspicion of septic joint. ___ revealed no DVT. Attributed to malignancy and pain was controlled with multimodal medications as in ___ plan. #Anemia: Microcytic anemia, new from baseline 13 in ___. Most likely mixed picture of chronic disease and iron deficiency given iron studies showing low-normal iron, normal ferritin, and low transferrin and TIBC. It is likely related to his malignancy. CHRONIC ISSUES: =============== # HTN: Hypertensive at ___ and ___. He was continued on home amlodipine, atenolol, and Lisinopril. Amlodipine was held on discharge for low normal BP at rest and asymptomatic hypotension to SBP ___. He will follow with PCP to consider further titration. # HLD: Home atorvastatin dose was increased to 80mg. # Pre-diabetes: self-dc'ed metformin. HbA1c 5.9. Insulin sliding scale while in hospital # Bipolar disorder. Mood stable on home lamotrigine. TRANSITIONAL ISSUES: ==================== - follow up with ___ Oncology on ___ - consider GI follow up and EGD as an outpatient if within goals of care - Neurosurgery follow-up for MCA aneurysm (Dr. ___ - Neurology follow up for stroke - Neurosurgery follow-up for consideration of surgical management of spinal metastases (Dr. ___ - Smoking cessation counseling - Hep B non-immune ___ is clinically stable for discharge today. On the day of discharge, greater than 30 minutes were spent on the planning, coordination, and communication of the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. LamoTRIgine 200 mg PO BID 3. Atenolol 100 mg PO DAILY 4. amLODIPine 5 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Hydrochlorothiazide 50 mg PO DAILY 9. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Moderate 10. Fish Oil (Omega 3) 1000 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 600 mg PO TID 5. OxyCODONE SR (OxyconTIN) 80 mg PO Q12H RX *oxycodone [OxyContin] 80 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*22 Tablet Refills:*0 6. Senna 8.6 mg PO BID 7. Atorvastatin 80 mg PO QPM 8. amLODIPine 5 mg PO DAILY 9. Atenolol 100 mg PO DAILY 10. Fish Oil (Omega 3) 1000 mg PO BID 11. Hydrochlorothiazide 50 mg PO DAILY 12. LamoTRIgine 200 mg PO BID 13. Lisinopril 40 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 20 mg PO DAILY 16. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Moderate 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*180 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Gabapentin 600 mg PO TID RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 5. OxyCODONE SR (OxyconTIN) 80 mg PO Q12H RX *oxycodone [OxyContin] 80 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*25 Tablet Refills:*0 6. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 7. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 8. Atenolol 100 mg PO DAILY 9. Fish Oil (Omega 3) 1000 mg PO BID 10. Hydrochlorothiazide 50 mg PO DAILY 11. LamoTRIgine 200 mg PO BID 12. Lisinopril 40 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 20 mg PO DAILY 15. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 15 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 16. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do not restart amLODIPine until your primary care doctor restarts it Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Metastatic Hepatocellular Carcinoma # Spinal Metastasis # MCA Aneurysms # Subacute Stroke # C2/3 mass with cord impingement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, It was a pleasure caring for you at ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital for back pain WHAT HAPPENED TO ME IN THE HOSPITAL? - Initially, we thought your back pain was due to an infection in your back, so you were treated with IV antibiotics. - You were found to have a new anemia (low red blood cell count), abnormal liver enzymes, and nodules below the skin on your forehead. We evaluated your liver and head, and found lesions we were concerned were cancer that had spread from your liver. -We took images of your head and torso with a CT scanner, and confirmed that the lesions likely represented cancer. We also found another mass in your left adrenal gland and some lymph nodes in that area. - We then evaluated you with an MRI of your brain, which showed aneurysms (outpouchings of your vessels. You were seen by neurosurgery, who did not recommend any urgent intervention but asked you to make an appointment in clinic when you leave the hospital. - A CT scan of your head also showed a mass on your spine, that was concerning for compression of your spinal cord so the Radidiation Oncology team saw you, and began radiation on those spinal masses to shrink them - You were seen by the Oncology team, who made an appointment for you to see them when you leave the hospital to discuss prognosis and treatment options. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "C7951", "G9519", "I639", "C228", "C792", "E871", "R29702", "E876", "I671", "G8321", "K219", "D509", "E039", "F17200", "Z96643", "F319", "E83110", "E785", "D638", "E861" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Back Pain Major Surgical or Invasive Procedure: RTx treatment plan to deliver 20 Gy in 5 fractions total, D1 = [MASKED], completed [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] man s/p L3-S1 lumbar decompression with duraplasty in [MASKED] and right hip replacement with epidural 1 month ago who presents from [MASKED] with epidural abscess and osteomyelitis seen on MRI, transferred to [MASKED] for spine consult, admitted to medicine for epidural abscess drainage with [MASKED] and treatment of osteomyelitis. Mr. [MASKED] says he has had lower back and left hip pain since before his surgery, but it has been getting worse since his R hip replacement 1 month ago at [MASKED], which was performed with an epidural. Since then, he has had worsening left sided hip and shooting leg pain over the last two weeks. He has had poor PO intake during this time due to pain, but denies fever and chills. He initially presented to [MASKED] one week ago, where they did x-rays and discharged him home. Over the weekend, he had dark vomit and diarrhea. Today, he presented to [MASKED] course: Vitals: Temp 98.4 HR 84 BP 164/62 RR 18 O2 sat 98% RA Exam was notable for normal sensation and motor function bilaterally, though limited by pain. MRI Spine Lumbar W/WO Cont was most consistent with an epidural abscess and osteomyelitis: destructive changes involving the L4 vertebral body and epidural collection, abnormal enhancement pattern in the superior portion of the L5 vertebral body, an abnormal enhancement in the paraspinal soft tissues epicentered at L4 extending superiorly to L3 on the left. Furthermore, there are abnormal destructive areas in L1-L2 vertebral bodies and sacrum. IV vanco(1g)/ceftriaxone(2g) were given at [MASKED]. He was transferred here for spine consult. In the [MASKED] ED, initial vitals were: Temp 98.4 HR 90 BP 167/89 RR 18 O2 sat 98% RA -Exam was notable for sensation and motor function intact bilaterally in the lower extremities. Strength was limited due to pain. Rectal tone was normal, and no saddle anesthesia noted. -Labs notable for: WBC 12.5 Hgb 10.2 Hct 29.5 Na 127 Cl 84 BUN 22 K 3.4 Lactate 1.3 -Imaging was notable for: -Patient was given: 1L NS, 500ml 40meqK in NS, 1mg IV hydromorphone Spine was consulted and recommended inpatient [MASKED] guided biopsy. Upon arrival to the floor, patient reports [MASKED] pain at rest which increases to [MASKED] with any movement. He has been very limited with mobility due to pain and has not been ambulating due to pain, currently using wheelchair to get around. He also reports a 53lb weight loss over the last 3 months. He describes an "esophageal burning" that he contributes to not eating and vomiting. He also reported that he has been using adult diapers due to one stool accident, which he says was due to pain and being confined to the wheelchair so that he couldn't make it to the bathroom. He is able to feel the need to move his bowels and is not generally incontinent. The patient denies numbness, paresthesias, and fevers. Occasional chills at night for many years, but no recently increased chills. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative. Past Medical History: Bipolar Disorder Hypertension Pre-diabetes GERD Patient-reported Hemochromatosis (s/p phlebotomy, last done [MASKED] years ago) Social History: [MASKED] Family History: Aunt with hemochromatosis Physical Exam: ADMISSION VITAL SIGNS: 99.1 144 / 61 86 18 96 Ra GENERAL: Alert and interactive. In no acute distress. HEENT: Has 2 x 5 cm round skin-colored bumps on forehead c/w epidermal cyst. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes. Oropharynx is clear. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Mild wheezes heard in the anterior lung fields bilaterally. Exam limited by pain. ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No peripheral edema. SKIN: No rashes appreciated. NEUROLOGIC: CN2-12 intact. [MASKED] strength in the upper extremities. Movement in lower extremities but exam limited by pain. AAOx2-3. DISCHARGE Vitals: Tm 98.3 BO 104/57 HR 66 RR 16 SpO2 96% on RA General: lying in bed in no acute distress HEENT: Two 3x3cm palpable nodules on the left forehead with no overlying skin changes. Nodules are soft but not fluctuant, non-tender to palpation, minimally mobile, no central pore. Lungs: clear to auscultation bilaterally CV: regular rate and rhythm with normal S1 and S2 GI: soft, non-distended, non-tender to palpation Extremities: warm and well perfused without edema NEURO: alert and interactive with strength [MASKED] dduction and abduction and elbow flexion and extension. [MASKED] strength in the lower extremities bilaterally. Pertinent Results: Admission Labs [MASKED] 04:45PM WBC-12.5* RBC-3.89* HGB-10.2* HCT-29.5* MCV-76* MCH-26.2 MCHC-34.6 RDW-20.5* RDWSD-55.3* [MASKED] 04:45PM NEUTS-68.8 LYMPHS-17.3* MONOS-9.9 EOS-0.2* BASOS-0.2 IM [MASKED] AbsNeut-8.60* AbsLymp-2.16 AbsMono-1.24* AbsEos-0.02* AbsBaso-0.03 [MASKED] 04:45PM GLUCOSE-110* UREA N-22* CREAT-0.6 SODIUM-127* POTASSIUM-4.3 CHLORIDE-84* TOTAL CO2-27 ANION GAP-16 [MASKED] 04:45PM CALCIUM-8.7 PHOSPHATE-3.4 MAGNESIUM-1.8 [MASKED] 04:45PM CRP-78.2* [MASKED] 04:26PM LACTATE-1.3 K+-3.4 [MASKED] 05:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 05:21PM URINE RBC-3* WBC-3 BACTERIA-FEW* YEAST-NONE EPI-0 RENAL EPI-<1 IMAGING: Head ultrasound [MASKED]: Palpable masses in the left lateral forehead correspond to vascular soft tissue masses which appear to have eroded the cortex of the underlying frontal bone and are continuous with the medullary cavity. These are highly concerning for bone metastases. Alternative consideration includes multiple myeloma or lymphoma. Liver ultrasound [MASKED]: Diffuse heterogeneity of the left lobe of the liver with moderate intrahepatic biliary duct dilatation in the left lobe. A discrete mass in the left lobe measures 7 x 7.7 x 10 cm. Note is also made of an ill-defined hypoechoic lesion in periphery of segment 6 measuring up to 1.4 cm. These findings are concerning for either primary liver malignancy, specifically cholangiocarcinoma, or metastatic disease. CT Head [MASKED]: 1. Incidental note made of a 9 x 8 mm right distal M1 segment MCA aneurysm. 2. Subtle hypodensity in the right frontal white matter in the centrum semiovale. This is nonspecific, however given likely malignancy, MR head is recommended for further evaluation. 3. 2 lytic and soft tissue lesions centered in the left frontal calvarium extending into the overlying scalp soft tissues, with lytic involvement of the inner table. No definite intracranial extension. 4. Although evaluation is limited due to recent venous administration of IV contrast, no evidence of intracranial hemorrhage, acute infarction, or mass effect. CT Chest [MASKED]: 1. 3 left lung pulmonary nodules measure up to 5 mm. Follow-up as per clinical protocol is recommended. 2. Diffuse esophageal wall thickening as well as enteric contrast material within it, likely reflecting chronic reflux. 3. Small right pleural effusion. 4. Healing left posterolateral 8 through tenth rib fractures. CT Abdomen/Pelvis [MASKED]: 1. Enlargement of the caudate and left lobe with calcifications involving the anterior surface of the right lobe which appears smaller, has there been prior hepatic resection?, Alternatively this could represent cirrhosis. Multiple hepatic masses with large hypovascular lesion proximally in the left lobe showing delayed enhancement with associated left intrahepatic biliary dilatation is suspicious for a cholangiocarcinoma. Small arterially enhancing mass showing washout is suspicious for small HCC. Large heterogeneously enhancing mass in the left lobe is difficult to be characterized, tissue sampling is recommended. No evidence of portal vein thrombosis. 2. Large non-fat containing left adrenal mass is suspicious for a metastasis. Small subcentimeter arterially hyperenhancing lesion in the right adrenal gland is indeterminate in etiology. 3. Multiple prominent gastrohepatic, celiac, periportal and portacaval lymph nodes. 4. Large destructive mass involving L4 vertebral body with enhancing epidural component encroaching onto the spinal canal. [MASKED] MRI/MRA BRAIN 1. Two left frontal calvarial lesions erode both the inner and outer table. No evidence of intracranial extension. Lesions could be due to bony metastatic disease unless proven otherwise. 2. No evidence of intracranial metastatic disease. 3. Approximately 1.5 cm right centrum semiovale acute or subacute infarct. 4. Bilateral, M1 segment MCA aneurysms measuring up to 12 x 8 mm on the right and 3 x 2 mm on the left. 5. Narrowing of the cervical spine at C3 level partially visualized on sagittal T1 images. This can be further evaluated with cervical spine MRI. [MASKED] CTA HEAD 1. Lobulated right MCA bifurcation aneurysm with 2 dominant components, which overall measures 10 x 9 x 12 mm. 2. 3 x 2 mm posteriorly projecting right ICA terminus aneurysm. 3. 3 x 2 mm laterally projecting left MCA bifurcation aneurysm. 4. Calcified plaque mildly narrows the proximal V4 segment of the right vertebral artery. Calcified plaque mildly narrows the petrous segment of the right internal carotid artery. 5. Again seen are two left frontal coronal vary [MASKED] expansile, erosive masses with soft tissue component extending into the scalp, suggesting metastases. 6. Partially visualized expansile, erosive mass centered in the right lateral mass and right vertebral body of C2, extending into the prevertebral space, and also extending into the spinal canal with mild to moderate narrowing of the thecal sac. The mass extends into the right C2-C3 neural foramen and into the right C2 transverse foramen, encasing the distal right vertebral artery without evidence for narrowing. [MASKED] DYNAMIC LSPINE XR Unchanged appearances of the known fracture at L4. No evidence of dynamic instability. [MASKED] MR [MASKED] SPINE W/WO CONTRAST 1. Enhancing large soft tissue mass centered about right lateral and posterior elements C2 on C3 with vertebral body involvement at both levels. Epidural tumor extension at C2, C3 levels. Additional lesion at T 2. Findings consistent with metastases or lymphoma. 2. Severe central canal narrowing at C3 level, with cord flattening, equivocal cord edema. 3. Degenerative changes remainder of the cervical spine, as above. 4. Multilevel severe foraminal narrowing. 5. Severe compression C3 vertebral body. [MASKED] TTE Good image quality. Small PFO by saline contrast injection with maneuvers. Normal biventricular wall thicknesses, cavity sizes, and regional/global systolic function. Bilateral Lower Extremity Ultrasound [MASKED]: IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. PATHOLOGY [MASKED] PATHOLOGIC DIAGNOSIS: Skull lesion, biopsy: Metastatic hepatocellular carcinoma, see note. Note: The tumor cells stain positively for glypican 3, glutamine synthetase 6, canalicular pattern positivity for polyclonal CEA and CD10, and negative for CK20 and CK7. A reticulin stain highlights expansion of the cell plate. The case was reviewed with Dr. [MASKED] [MASKED]. DISCHARGE LABS [MASKED] 04:45PM BLOOD WBC-12.5* RBC-3.89* Hgb-10.2* Hct-29.5* MCV-76* MCH-26.2 MCHC-34.6 RDW-20.5* RDWSD-55.3* Plt [MASKED] [MASKED] 04:45PM BLOOD Neuts-68.8 Lymphs-17.3* Monos-9.9 Eos-0.2* Baso-0.2 Im [MASKED] AbsNeut-8.60* AbsLymp-2.16 AbsMono-1.24* AbsEos-0.02* AbsBaso-0.03 [MASKED] 06:48AM BLOOD [MASKED] PTT-25.6 [MASKED] [MASKED] 04:45PM BLOOD Glucose-110* UreaN-22* Creat-0.6 Na-127* K-4.3 Cl-84* HCO3-27 AnGap-16 [MASKED] 04:45PM BLOOD Calcium-8.7 Phos-3.4 Mg-1.8 [MASKED] 04:45PM BLOOD CRP-78.2* [MASKED] 04:45PM BLOOD CRP-78.2* [MASKED] 05:21PM URINE HOURS-RANDOM [MASKED] 05:21PM URINE UHOLD-HOLD [MASKED] 05:21PM URINE UHOLD-HOLD [MASKED] 06:50AM BLOOD WBC-5.6 RBC-3.36* Hgb-8.9* Hct-27.3* MCV-81* MCH-26.5 MCHC-32.6 RDW-20.1* RDWSD-59.7* Plt [MASKED] [MASKED] 06:50AM BLOOD WBC-5.6 RBC-3.36* Hgb-8.9* Hct-27.3* MCV-81* MCH-26.5 MCHC-32.6 RDW-20.1* RDWSD-59.7* Plt [MASKED] [MASKED] 06:50AM BLOOD WBC-5.6 RBC-3.36* Hgb-8.9* Hct-27.3* MCV-81* MCH-26.5 MCHC-32.6 RDW-20.1* RDWSD-59.7* Plt [MASKED] [MASKED] 05:21PM URINE HOURS-RANDOM [MASKED] 05:21PM URINE UHOLD-HOLD [MASKED] 05:21PM URINE UHOLD-HOLD [MASKED] 05:21PM URINE HYALINE-3* [MASKED] 05:21PM URINE MUCOUS-RARE* [MASKED] 04:45PM CRP-78.2* Brief Hospital Course: [MASKED] with recent 53 pound weight loss, increased GERD symptoms, and severe back pain was transferred from [MASKED] with initial concern for epidural abscess, found to have metastatic HCC with multiple metastasis including spinal and skull metastasis, subacute CVA, bilateral MCA aneurysms and C2/3 mass with cord impingement. Started course of palliative radiation treatment to C2/C3 mass. He will continue these as outpatient. Med Oncology scheduled an outpatient appointment for follow up to discuss prognosis and treatment options. #Metastatic Hepatocellular carcinoma Given his recent weight loss, rapid growth of forehead lesions, worsening GERD symptoms, and unexplained transaminase elevation, he received ultrasound of his forehead nodules and liver. The subcutaneous nodules invaded bone and were concerning for metastasis. Liver ultrasound and subsequent staging CT have found both a small and a large mass. CT abdomen/pelvis also found an adrenal mass. CT chest showed 3 small lung nodules. His back pain and lumbar MRI findings are likely due to bone metastasis rather than osteomyelitis, and he has continued to remain clinically stable and afebrile off antibiotics. Biopsy of his forehead mass was consistent with Hepatocellular Carcinoma. Oncology was consulted, and recommended outpatient follow up. He will follow up with Dr. [MASKED] on [MASKED]. Pain was controlled with 80mg Oxycotin BID, Acetaminophen 1g PO q8hr, oxy 15mg PO PRN q4hrs, Gabapentin 600mg TID. #Spinal Metastasis #C2/3 mass with cord impingement Initial presentation of back pain and initial MRI findings are likely due to bone metastasis rather than osteomyelitis. CTA on [MASKED] noted [MASKED] mass in C2 that could be concerning for spinal cord compression. Follow up C spine MRI notable for enhancing large soft tissue mass centered about right lateral and posterior elements C2 on C3 with vertebral body involvement at both levels. Epidural tumor extension at C2, C3 levels. Additional lesion at T 2. Findings consistent with metastases or lymphoma. Severe central canal narrowing at C3 level, with cord flattening, equivocal cord edema. Radiation Oncology was consulted, and patient completed 5 fractions of radiation therapy to prevent further spinal cord compression on [MASKED]. #MCA Aneurysm MRA head on [MASKED] notable for bilateral, M1 segment MCA aneurysms measuring up to 12 x 8 mm on the right and 3 x 2 mm on the left. CTA notable for bilateral M1 segment aneurysms measuring up to 1.1 cm on the right and 0.3 cm on the left. Neurosurgery consulted, and recommended blood pressure control and smoking cessation. Decision on intervention pending prognosis. Plan to follow up as an outpatient. #Acute/subacute Neural Infarct MRI brain notable for approximately 1.5 cm right centrum semiovale acute or subacute infarct. Noted to have R arm weakness compared to L arm, now improving, no other focal neurologic deficits. Neurology workup for possible etiology including HgA1c, TSH and tele monitoring for afib were all normal. TTE revealed a small PFO. LENIs were negative. Started on aspirin 81 mg daily. Fasting lipids notable for LDL 80; atorvastatin increased to 80mg per neurology recommendations. Will follow up with Neurology as outpatient. #Dyspepsia/GERD His change in GERD symptoms and anorexia may be due to liver malignancy. Nutrition was consulted, he was continued on home Omeprazole 20mg, and he will follow up with GI as outpatient for EGD if within goals of care. His symptoms were controlled on home omeprazole at time of discharge. #Hip Pain: Patient reported pain in his L hip (which is s/p replacement [MASKED] at [MASKED], worse with motion. On exam, he has tenderness with movement and log rolling of his left leg. Hip and femur x-ray showed no effusion or erosions, making septic arthritis or osteomyelitis less likely. Orthopedic surgery was consulted, and they had low suspicion of septic joint. [MASKED] revealed no DVT. Attributed to malignancy and pain was controlled with multimodal medications as in [MASKED] plan. #Anemia: Microcytic anemia, new from baseline 13 in [MASKED]. Most likely mixed picture of chronic disease and iron deficiency given iron studies showing low-normal iron, normal ferritin, and low transferrin and TIBC. It is likely related to his malignancy. CHRONIC ISSUES: =============== # HTN: Hypertensive at [MASKED] and [MASKED]. He was continued on home amlodipine, atenolol, and Lisinopril. Amlodipine was held on discharge for low normal BP at rest and asymptomatic hypotension to SBP [MASKED]. He will follow with PCP to consider further titration. # HLD: Home atorvastatin dose was increased to 80mg. # Pre-diabetes: self-dc'ed metformin. HbA1c 5.9. Insulin sliding scale while in hospital # Bipolar disorder. Mood stable on home lamotrigine. TRANSITIONAL ISSUES: ==================== - follow up with [MASKED] Oncology on [MASKED] - consider GI follow up and EGD as an outpatient if within goals of care - Neurosurgery follow-up for MCA aneurysm (Dr. [MASKED] - Neurology follow up for stroke - Neurosurgery follow-up for consideration of surgical management of spinal metastases (Dr. [MASKED] - Smoking cessation counseling - Hep B non-immune [MASKED] is clinically stable for discharge today. On the day of discharge, greater than 30 minutes were spent on the planning, coordination, and communication of the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. LamoTRIgine 200 mg PO BID 3. Atenolol 100 mg PO DAILY 4. amLODIPine 5 mg PO DAILY 5. Atorvastatin 20 mg PO QPM 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Hydrochlorothiazide 50 mg PO DAILY 9. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Moderate 10. Fish Oil (Omega 3) 1000 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 600 mg PO TID 5. OxyCODONE SR (OxyconTIN) 80 mg PO Q12H RX *oxycodone [OxyContin] 80 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*22 Tablet Refills:*0 6. Senna 8.6 mg PO BID 7. Atorvastatin 80 mg PO QPM 8. amLODIPine 5 mg PO DAILY 9. Atenolol 100 mg PO DAILY 10. Fish Oil (Omega 3) 1000 mg PO BID 11. Hydrochlorothiazide 50 mg PO DAILY 12. LamoTRIgine 200 mg PO BID 13. Lisinopril 40 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 20 mg PO DAILY 16. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Moderate 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*180 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Gabapentin 600 mg PO TID RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 5. OxyCODONE SR (OxyconTIN) 80 mg PO Q12H RX *oxycodone [OxyContin] 80 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*25 Tablet Refills:*0 6. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 7. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 8. Atenolol 100 mg PO DAILY 9. Fish Oil (Omega 3) 1000 mg PO BID 10. Hydrochlorothiazide 50 mg PO DAILY 11. LamoTRIgine 200 mg PO BID 12. Lisinopril 40 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 20 mg PO DAILY 15. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 15 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 16. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do not restart amLODIPine until your primary care doctor restarts it Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: # Metastatic Hepatocellular Carcinoma # Spinal Metastasis # MCA Aneurysms # Subacute Stroke # C2/3 mass with cord impingement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], It was a pleasure caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You came to the hospital for back pain WHAT HAPPENED TO ME IN THE HOSPITAL? - Initially, we thought your back pain was due to an infection in your back, so you were treated with IV antibiotics. - You were found to have a new anemia (low red blood cell count), abnormal liver enzymes, and nodules below the skin on your forehead. We evaluated your liver and head, and found lesions we were concerned were cancer that had spread from your liver. -We took images of your head and torso with a CT scanner, and confirmed that the lesions likely represented cancer. We also found another mass in your left adrenal gland and some lymph nodes in that area. - We then evaluated you with an MRI of your brain, which showed aneurysms (outpouchings of your vessels. You were seen by neurosurgery, who did not recommend any urgent intervention but asked you to make an appointment in clinic when you leave the hospital. - A CT scan of your head also showed a mass on your spine, that was concerning for compression of your spinal cord so the Radidiation Oncology team saw you, and began radiation on those spinal masses to shrink them - You were seen by the Oncology team, who made an appointment for you to see them when you leave the hospital to discuss prognosis and treatment options. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "E871", "K219", "D509", "E039", "E785" ]
[ "C7951: Secondary malignant neoplasm of bone", "G9519: Other vascular myelopathies", "I639: Cerebral infarction, unspecified", "C228: Malignant neoplasm of liver, primary, unspecified as to type", "C792: Secondary malignant neoplasm of skin", "E871: Hypo-osmolality and hyponatremia", "R29702: NIHSS score 2", "E876: Hypokalemia", "I671: Cerebral aneurysm, nonruptured", "G8321: Monoplegia of upper limb affecting right dominant side", "K219: Gastro-esophageal reflux disease without esophagitis", "D509: Iron deficiency anemia, unspecified", "E039: Hypothyroidism, unspecified", "F17200: Nicotine dependence, unspecified, uncomplicated", "Z96643: Presence of artificial hip joint, bilateral", "F319: Bipolar disorder, unspecified", "E83110: Hereditary hemochromatosis", "E785: Hyperlipidemia, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "E861: Hypovolemia" ]
10,035,301
23,974,616
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Endoscopic Ultrasound with Biopsy ___ History of Present Illness: CC: abdominal pain, nausea, vomiting, anorexia, pancreatic mass. HISTORY OF PRESENT ILLNESS: Ms ___ is a ___ year old woman with a history of hypertension who presented to ___ with abdominal pain, nausea, vomiting, anorexia, found to have gastric outlet obstruction and pancreatic mass, transferred to ___ for further management. She states that 2 weeks ago she was doing well in her usual state of health. Approximately ___ days ago, she developed abdominal pain, as well as nausea and vomiting. Vomiting multiple times (___) per day, bilious/mucus, without blood. She has been unable to keep down any food or fluids in the 48 hours prior to presentation, and has multiple episodes of bilious emesis per day. Her last bowel movement was 3 days ago, and she does not think she has passed gas for 3 days either. She noted abdominal distention ___ days ago, which gradually resolved with reduced food intake and has fully resolved now that NG tube is in place. ROS is negative for fevers, chills, BRBPR, melena, chest pain, dyspnea, cough, dizziness, headache, lower extremity edema, skin changes. History of hysterectomy for endometriosis. She presented to ___ ___, where CT abdomen/pelvis demonstrated a dilated stomach and proximal duodenum with gastric outlet obstruction, likely caused by a 5x6cm pancreatic mass in the pancreatic head and duodenal sweep. Labs at ___ showed bicarb 37, creat 1.6, An NG tube was placed prior to transfer, which resulted in decreased distention and abdominal discomfort. In the ___ ED, initial vitals were: T 99.1, HR 85, BP 125/77, RR 18, SPO2 99%RA Exam notable for mild abdominal tenderness Labs notable for --WBC 16.1 (83% PMNs), Hgb 14.3, Plt 268 --Amylase 163, lipase 72, normal LFTs, bilirubin, albumin --Na 139, K 3.6, HCO3 35, Creat 1.4, glucose 126, BUN 40, anion gap 16 --UA with 30 protein, trace ketones, few bacteria -- normal coags Imaging notable for: CXR negative for acute cardiopulmonary process. Patient was given: -morphine 4mg IV, Zofran 4mg IV, lactate ringer gtt at 125cc/hr Patient was seen by surgery who recommended admission to medicine for diagnostic work-up of pancreatic mass. On the floor, patient feels well without acute complaint Review of systems: as above. Past Medical History: PAST MEDICAL HISTORY: -Hypertension -Hyperlipidemia -Iron deficiency aneima -Depression -Hysterectomy -Sciatica, history of back surgery x 2 Social History: ___ Family History: FAMILY HISTORY: father died of pancreatitis, otherwise no significant family history Physical Exam: ADMISSION PHYSICAL EXAM: ========================== Vitals: 98.3 PO 143 / 67 83 18 100 2L. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. NG tube in right nostril Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: warm and dry no rashes. No jaundice. Neuro: fully oriented and alert. Strength and sensation intact. No tremor or dysmetria. No astrexis. Discharge Exam ================ Vitals: T98.4, BP 123/62, HR 118, RR 18, O2 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Neck: supple Lungs: Clear to auscultation bilaterally. no wheezes, rales, CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops Abdomen: soft, NT, ND, NABS Ext: WWP, no edema Skin: warm and dry no rashes. No jaundice. Neuro: moving all extremities spontaneously Pertinent Results: Admission Labs ============= ___ 10:00PM BLOOD WBC-16.1* RBC-4.98 Hgb-14.3 Hct-44.1 MCV-89 MCH-28.7 MCHC-32.4 RDW-17.5* RDWSD-57.4* Plt ___ ___ 10:00PM BLOOD Neuts-83.1* Lymphs-9.1* Monos-7.1 Eos-0.1* Baso-0.2 Im ___ AbsNeut-13.40* AbsLymp-1.46 AbsMono-1.15* AbsEos-0.01* AbsBaso-0.03 ___ 10:00PM BLOOD ___ PTT-27.8 ___ ___ 10:00PM BLOOD Plt ___ ___ 10:00PM BLOOD Glucose-126* UreaN-40* Creat-1.4* Na-139 K-3.6 Cl-89* HCO3-35* AnGap-19 ___ 10:00PM BLOOD ALT-24 AST-19 AlkPhos-93 Amylase-163* TotBili-0.5 ___ 08:55AM BLOOD LD(LDH)-268* ___ 10:00PM BLOOD Lipase-72* ___ 10:00PM BLOOD Albumin-4.6 ___ 08:55AM BLOOD Calcium-9.8 Phos-2.8 Mg-2.0 Imaging ========== ___ Endoscopic ultrasound IMPRESSIONS ___ D Esophagitis EUS : The parenchyma in the uncinate, head, body and tail of the pancreas was homogenous, with a normal “salt and pepper” appearance. Normal main pancreatic duct The bile duct and pancreatic duct were imaged and appeared normal. Mass: An ill defined, 4 cm X 6 cm irregular, hypoechoeic and heterogenous in echotexture was found arising from the duodenal wall. The lesion involved the mucosa, submucosa and the muscularis. Few ''pseudopodia'' were noted along the outer border of the muscularis propria - these were suspicious for tumor extension beyond the muscularis layer. FNA was performed Cold forceps biopsies were performed for histology. ___ CTA abd/pelvis 1. Circumferential wall thickening of the third portion of the duodenum with an enhancing soft tissue mass, most likely duodenal in origin. There is no fat plane with the otherwise normal appearing pancreas. Small retroperitoneal lymph nodes do not meet size criteria for pathologic enlargement. No other evidence of lymphadenopathy or local invasion. 2. Diverticulosis. 3. Please see the separately submitted report of the same day CT Chest forfindings above the diaphragm. ___ CT Chest with contrast 1. A 1.5 cm low-density pulmonary lesion in the right lower lobe is suspicious for Bronchocele distal to a strictured or atretic bronchus or a small endobronchial mass. Any prior imaging of the chest, including remote chest radiographs should be consulted to determine its chronicity and the need for further imaging. 2. Other multiple pulmonary nodules are 5 mm or less. Some of the lower lobe nodules included on prior CT abdomen and pelvis from ___ are larger since then. 3. New mild pulmonary edema as evidenced by ground-glass opacities and interlobular septal thickening. 4. Anterior mediastinal soft tissue lesion may be thymoma or thymic hyperplasia. If clinically indicated, consider MRI for better evaluation. 5. Moderate emphysema. Pathology ============ Biopsy -preliminary showed plasma cells Discharge labs ==================== ___ 06:40AM BLOOD WBC-5.4 RBC-4.09 Hgb-11.9 Hct-38.3 MCV-94 MCH-29.1 MCHC-31.1* RDW-15.6* RDWSD-48.4* Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 06:40AM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-139 K-5.0 Cl-107 HCO3-24 AnGap-13 ___ 06:40AM BLOOD ALT-18 AST-20 LD(LDH)-194 AlkPhos-80 TotBili-<0.2 ___ 06:40AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0 UricAcd-2.3* Iron-43 ___ 06:40AM BLOOD IgG-577* IgA-208 IgM-51 ___ 06:40AM BLOOD calTIBC-244* Ferritn-81 TRF-188* ___ 06:40AM BLOOD tTG-IgA-pending ___ 01:15PM BLOOD PEP-Pending FreeKap-pending FreeLam-PND b2micro-2.___ year old woman with a history of hypertension who presented to ___ with abdominal pain, nausea, vomiting, anorexia, found to have gastric outlet obstruction and abdominal mass, transferred to ___ for further management now s/p EUS and CT TORSO awaiting biopsy results. ACTIVE ISSUES: ========================== #Duodenal mass: Patient presents with upper GI obstructive symptoms, found on outside hospital CT imaging to have 5x6cm mass in region of pancreatic head. On ___ Endoscopic ultra sound and Duodena FNA were performed. CEA and ___ returned negative. Biopsy prelim path came back from duodenal FNA with plasma cells - which is concerning for plasmacytoma vs. GI lymphoma vs. other plasma cell dyscrasia. On ___ CTA c/a/p showed "Circumferential wall thickening of the third portion of the duodenum with an enhancing soft tissue mass, most likely duodenal in origin. There is no fat plane with the otherwise normal appearing pancreas. Small retroperitoneal lymph nodes do not meet size criteria for pathologic enlargement. No other evidence of lymphadenopathy or local invasion." She was offered close follow up in the ___ where original treatment plans could be formulated and suggested to her primary oncologist on ___. However she would prefer to receive all of her care on the ___ and is scheduling close follow up with her PCP who will then refer her to an oncologist. If she changes her mind she was provided the contact information for the ___ clinic. The ___ Hematology group has plans to help coordinate transfer of pending results from this hospital admission. #Gastric outlet obstruction: Although she has suffered Gastric outlet obstruction, she did not have obstructive jaundice or pancreatitis while admitted at ___. Caused by mass in duodenum discussed above. A Nasogastric tube was placed upon admission to relieve symptoms. This was removed by the patient night of ___ and was not reinserted as her symptoms had resolved and she was found to have non tender non-distended abdomen. Duodenal stent was not placed during Endoscopic ultrasound because she was not completely obstructed during procedure. It is likely the mass is causing transient obstruction. Her diet was advanced as tolerated through the hospital course and she was discharge on a liquid diet. Nutrition also recommended supplementing Thiamine and she received five day course of Thiamine 100 mg (last day ___ #hypophosphatemia - Phosphate 2.2 on ___. She received 250 mg PO. Basic metabolic panel was trended to monitor Phosphate and upon discharge it was 3. CHRONIC ISSUES: ========================== #Hyperlipidemia: Home pravastatin was held first night while she was NPO and restarted when her diet was advanced. #Depression: continued home sertraline Transitional issues ==================== - Please obtain basic metabolic panel to monitor electrolytes and replete as needed - Ensure obstructive symptoms have not returned. If they return advise her to return to the hospital for potential intervention to relieve obstruction - Patient given contact numbers for ___ clinic and hematologic malignancy clinic. Please consider treating Ms. ___ with their recommend plan. - Preliminary pathology of duodenal FNA showed plasma cells, patient will likely need follow up with outpatient oncology for further evaluation - Consider CT guided biopsy of RLL lung nodule to evaluate for metastatic disease as this will guide further management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 100 mg PO QHS:PRN insomnia 2. Sertraline 50 mg PO DAILY 3. Pravastatin 20 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Magnesium Oxide 200 mg PO DAILY 6. Ascorbic Acid ___ mg PO DAILY 7. Ferrous Sulfate Dose is Unknown PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO DAILY:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 3. Ondansetron 4 mg PO Q8H:PRN nausea only take once every 8 hours as needed RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*30 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 5. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 50 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 6. Ascorbic Acid ___ mg PO DAILY 7. Ferrous Sulfate 325 mg PO DAILY Do not take at the same time as any antacids 8. Magnesium Oxide 200 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Pravastatin 20 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. TraZODone 100 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary: Gastric Outlet Obstruction, Duodenal Mass Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure meeting you and taking care of you during your hospitalization at ___. You were transferred to ___ because a CAT scan at ___ found you have an abdominal mass concerning for cancer. You originally had a tube placed in your nose that went to your stomach to relieve nausea and vomiting which had been caused by the abdominal mass. When your symptoms resolved this tube was removed and you were slowly given more food to eat. If you experience vomiting and abdominal pain please return to the hospital. While you were in ___ you had a procedure where a endoscope was placed into your stomach and intestine to look at the mass. A biopsy of the mass was taken and the results are not complete at this time but preliminary results are concerning for a hematologic malignancy, potentially lymphoma. You also received a CAT scan of your torso. This scan showed the mass located in the first part of your intestines pressing up against your pancreas. It is unclear from the scan if the mass has entered the pancreas. We recommend that you follow-up in the hematologic malignancy clinic at ___. This will allow you to learn the final diagnosis and start planning for chemotherapy treatment. You decided that you want to follow-up with a oncologist near your home town. This will require URGENT action on your part, and requesting records and pathology results and samples to be sent to the oncologist of your choosing. We urge you to follow-up with your primary care doctor as soon as possible to coordinate this. Meanwhile, if you choose to follow-up at ___, please call ___ to schedule an appointment to be seen. Alternatively, call ___, which is number for the hematologic malignancy department. Your CAT scan also showed a small nodule in your lungs. You will need to have a biopsy of this nodule to determine whether it is related to the findings in your abdomen. You should follow-up with the interventional radiology team for this biopsy. We recommend that you adhere to a liquid diet to prevent recurrent obstruction. While you were in the hospital the nutritionist team recommended that you take Thiamine supplements for 5 days given that you had not been eating before coming to the hospital. You have be prescribed Thiamine for discharge. Please continue the ___y taking the Thiamine until ___ as directed. It has been a pleasure to care for you. We wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "C9030", "K311", "E46", "Z681", "D509", "E8339", "I10", "E785", "F329", "Z87891", "R918" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Endoscopic Ultrasound with Biopsy [MASKED] History of Present Illness: CC: abdominal pain, nausea, vomiting, anorexia, pancreatic mass. HISTORY OF PRESENT ILLNESS: Ms [MASKED] is a [MASKED] year old woman with a history of hypertension who presented to [MASKED] with abdominal pain, nausea, vomiting, anorexia, found to have gastric outlet obstruction and pancreatic mass, transferred to [MASKED] for further management. She states that 2 weeks ago she was doing well in her usual state of health. Approximately [MASKED] days ago, she developed abdominal pain, as well as nausea and vomiting. Vomiting multiple times ([MASKED]) per day, bilious/mucus, without blood. She has been unable to keep down any food or fluids in the 48 hours prior to presentation, and has multiple episodes of bilious emesis per day. Her last bowel movement was 3 days ago, and she does not think she has passed gas for 3 days either. She noted abdominal distention [MASKED] days ago, which gradually resolved with reduced food intake and has fully resolved now that NG tube is in place. ROS is negative for fevers, chills, BRBPR, melena, chest pain, dyspnea, cough, dizziness, headache, lower extremity edema, skin changes. History of hysterectomy for endometriosis. She presented to [MASKED] [MASKED], where CT abdomen/pelvis demonstrated a dilated stomach and proximal duodenum with gastric outlet obstruction, likely caused by a 5x6cm pancreatic mass in the pancreatic head and duodenal sweep. Labs at [MASKED] showed bicarb 37, creat 1.6, An NG tube was placed prior to transfer, which resulted in decreased distention and abdominal discomfort. In the [MASKED] ED, initial vitals were: T 99.1, HR 85, BP 125/77, RR 18, SPO2 99%RA Exam notable for mild abdominal tenderness Labs notable for --WBC 16.1 (83% PMNs), Hgb 14.3, Plt 268 --Amylase 163, lipase 72, normal LFTs, bilirubin, albumin --Na 139, K 3.6, HCO3 35, Creat 1.4, glucose 126, BUN 40, anion gap 16 --UA with 30 protein, trace ketones, few bacteria -- normal coags Imaging notable for: CXR negative for acute cardiopulmonary process. Patient was given: -morphine 4mg IV, Zofran 4mg IV, lactate ringer gtt at 125cc/hr Patient was seen by surgery who recommended admission to medicine for diagnostic work-up of pancreatic mass. On the floor, patient feels well without acute complaint Review of systems: as above. Past Medical History: PAST MEDICAL HISTORY: -Hypertension -Hyperlipidemia -Iron deficiency aneima -Depression -Hysterectomy -Sciatica, history of back surgery x 2 Social History: [MASKED] Family History: FAMILY HISTORY: father died of pancreatitis, otherwise no significant family history Physical Exam: ADMISSION PHYSICAL EXAM: ========================== Vitals: 98.3 PO 143 / 67 83 18 100 2L. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. NG tube in right nostril Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: warm and dry no rashes. No jaundice. Neuro: fully oriented and alert. Strength and sensation intact. No tremor or dysmetria. No astrexis. Discharge Exam ================ Vitals: T98.4, BP 123/62, HR 118, RR 18, O2 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Neck: supple Lungs: Clear to auscultation bilaterally. no wheezes, rales, CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops Abdomen: soft, NT, ND, NABS Ext: WWP, no edema Skin: warm and dry no rashes. No jaundice. Neuro: moving all extremities spontaneously Pertinent Results: Admission Labs ============= [MASKED] 10:00PM BLOOD WBC-16.1* RBC-4.98 Hgb-14.3 Hct-44.1 MCV-89 MCH-28.7 MCHC-32.4 RDW-17.5* RDWSD-57.4* Plt [MASKED] [MASKED] 10:00PM BLOOD Neuts-83.1* Lymphs-9.1* Monos-7.1 Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-13.40* AbsLymp-1.46 AbsMono-1.15* AbsEos-0.01* AbsBaso-0.03 [MASKED] 10:00PM BLOOD [MASKED] PTT-27.8 [MASKED] [MASKED] 10:00PM BLOOD Plt [MASKED] [MASKED] 10:00PM BLOOD Glucose-126* UreaN-40* Creat-1.4* Na-139 K-3.6 Cl-89* HCO3-35* AnGap-19 [MASKED] 10:00PM BLOOD ALT-24 AST-19 AlkPhos-93 Amylase-163* TotBili-0.5 [MASKED] 08:55AM BLOOD LD(LDH)-268* [MASKED] 10:00PM BLOOD Lipase-72* [MASKED] 10:00PM BLOOD Albumin-4.6 [MASKED] 08:55AM BLOOD Calcium-9.8 Phos-2.8 Mg-2.0 Imaging ========== [MASKED] Endoscopic ultrasound IMPRESSIONS [MASKED] D Esophagitis EUS : The parenchyma in the uncinate, head, body and tail of the pancreas was homogenous, with a normal “salt and pepper” appearance. Normal main pancreatic duct The bile duct and pancreatic duct were imaged and appeared normal. Mass: An ill defined, 4 cm X 6 cm irregular, hypoechoeic and heterogenous in echotexture was found arising from the duodenal wall. The lesion involved the mucosa, submucosa and the muscularis. Few ''pseudopodia'' were noted along the outer border of the muscularis propria - these were suspicious for tumor extension beyond the muscularis layer. FNA was performed Cold forceps biopsies were performed for histology. [MASKED] CTA abd/pelvis 1. Circumferential wall thickening of the third portion of the duodenum with an enhancing soft tissue mass, most likely duodenal in origin. There is no fat plane with the otherwise normal appearing pancreas. Small retroperitoneal lymph nodes do not meet size criteria for pathologic enlargement. No other evidence of lymphadenopathy or local invasion. 2. Diverticulosis. 3. Please see the separately submitted report of the same day CT Chest forfindings above the diaphragm. [MASKED] CT Chest with contrast 1. A 1.5 cm low-density pulmonary lesion in the right lower lobe is suspicious for Bronchocele distal to a strictured or atretic bronchus or a small endobronchial mass. Any prior imaging of the chest, including remote chest radiographs should be consulted to determine its chronicity and the need for further imaging. 2. Other multiple pulmonary nodules are 5 mm or less. Some of the lower lobe nodules included on prior CT abdomen and pelvis from [MASKED] are larger since then. 3. New mild pulmonary edema as evidenced by ground-glass opacities and interlobular septal thickening. 4. Anterior mediastinal soft tissue lesion may be thymoma or thymic hyperplasia. If clinically indicated, consider MRI for better evaluation. 5. Moderate emphysema. Pathology ============ Biopsy -preliminary showed plasma cells Discharge labs ==================== [MASKED] 06:40AM BLOOD WBC-5.4 RBC-4.09 Hgb-11.9 Hct-38.3 MCV-94 MCH-29.1 MCHC-31.1* RDW-15.6* RDWSD-48.4* Plt [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-139 K-5.0 Cl-107 HCO3-24 AnGap-13 [MASKED] 06:40AM BLOOD ALT-18 AST-20 LD(LDH)-194 AlkPhos-80 TotBili-<0.2 [MASKED] 06:40AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0 UricAcd-2.3* Iron-43 [MASKED] 06:40AM BLOOD IgG-577* IgA-208 IgM-51 [MASKED] 06:40AM BLOOD calTIBC-244* Ferritn-81 TRF-188* [MASKED] 06:40AM BLOOD tTG-IgA-pending [MASKED] 01:15PM BLOOD PEP-Pending FreeKap-pending FreeLam-PND b2micro-2.[MASKED] year old woman with a history of hypertension who presented to [MASKED] with abdominal pain, nausea, vomiting, anorexia, found to have gastric outlet obstruction and abdominal mass, transferred to [MASKED] for further management now s/p EUS and CT TORSO awaiting biopsy results. ACTIVE ISSUES: ========================== #Duodenal mass: Patient presents with upper GI obstructive symptoms, found on outside hospital CT imaging to have 5x6cm mass in region of pancreatic head. On [MASKED] Endoscopic ultra sound and Duodena FNA were performed. CEA and [MASKED] returned negative. Biopsy prelim path came back from duodenal FNA with plasma cells - which is concerning for plasmacytoma vs. GI lymphoma vs. other plasma cell dyscrasia. On [MASKED] CTA c/a/p showed "Circumferential wall thickening of the third portion of the duodenum with an enhancing soft tissue mass, most likely duodenal in origin. There is no fat plane with the otherwise normal appearing pancreas. Small retroperitoneal lymph nodes do not meet size criteria for pathologic enlargement. No other evidence of lymphadenopathy or local invasion." She was offered close follow up in the [MASKED] where original treatment plans could be formulated and suggested to her primary oncologist on [MASKED]. However she would prefer to receive all of her care on the [MASKED] and is scheduling close follow up with her PCP who will then refer her to an oncologist. If she changes her mind she was provided the contact information for the [MASKED] clinic. The [MASKED] Hematology group has plans to help coordinate transfer of pending results from this hospital admission. #Gastric outlet obstruction: Although she has suffered Gastric outlet obstruction, she did not have obstructive jaundice or pancreatitis while admitted at [MASKED]. Caused by mass in duodenum discussed above. A Nasogastric tube was placed upon admission to relieve symptoms. This was removed by the patient night of [MASKED] and was not reinserted as her symptoms had resolved and she was found to have non tender non-distended abdomen. Duodenal stent was not placed during Endoscopic ultrasound because she was not completely obstructed during procedure. It is likely the mass is causing transient obstruction. Her diet was advanced as tolerated through the hospital course and she was discharge on a liquid diet. Nutrition also recommended supplementing Thiamine and she received five day course of Thiamine 100 mg (last day [MASKED] #hypophosphatemia - Phosphate 2.2 on [MASKED]. She received 250 mg PO. Basic metabolic panel was trended to monitor Phosphate and upon discharge it was 3. CHRONIC ISSUES: ========================== #Hyperlipidemia: Home pravastatin was held first night while she was NPO and restarted when her diet was advanced. #Depression: continued home sertraline Transitional issues ==================== - Please obtain basic metabolic panel to monitor electrolytes and replete as needed - Ensure obstructive symptoms have not returned. If they return advise her to return to the hospital for potential intervention to relieve obstruction - Patient given contact numbers for [MASKED] clinic and hematologic malignancy clinic. Please consider treating Ms. [MASKED] with their recommend plan. - Preliminary pathology of duodenal FNA showed plasma cells, patient will likely need follow up with outpatient oncology for further evaluation - Consider CT guided biopsy of RLL lung nodule to evaluate for metastatic disease as this will guide further management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 100 mg PO QHS:PRN insomnia 2. Sertraline 50 mg PO DAILY 3. Pravastatin 20 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Magnesium Oxide 200 mg PO DAILY 6. Ascorbic Acid [MASKED] mg PO DAILY 7. Ferrous Sulfate Dose is Unknown PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO DAILY:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 3. Ondansetron 4 mg PO Q8H:PRN nausea only take once every 8 hours as needed RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*30 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 5. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 50 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 6. Ascorbic Acid [MASKED] mg PO DAILY 7. Ferrous Sulfate 325 mg PO DAILY Do not take at the same time as any antacids 8. Magnesium Oxide 200 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Pravastatin 20 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. TraZODone 100 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary: Gastric Outlet Obstruction, Duodenal Mass Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure meeting you and taking care of you during your hospitalization at [MASKED]. You were transferred to [MASKED] because a CAT scan at [MASKED] found you have an abdominal mass concerning for cancer. You originally had a tube placed in your nose that went to your stomach to relieve nausea and vomiting which had been caused by the abdominal mass. When your symptoms resolved this tube was removed and you were slowly given more food to eat. If you experience vomiting and abdominal pain please return to the hospital. While you were in [MASKED] you had a procedure where a endoscope was placed into your stomach and intestine to look at the mass. A biopsy of the mass was taken and the results are not complete at this time but preliminary results are concerning for a hematologic malignancy, potentially lymphoma. You also received a CAT scan of your torso. This scan showed the mass located in the first part of your intestines pressing up against your pancreas. It is unclear from the scan if the mass has entered the pancreas. We recommend that you follow-up in the hematologic malignancy clinic at [MASKED]. This will allow you to learn the final diagnosis and start planning for chemotherapy treatment. You decided that you want to follow-up with a oncologist near your home town. This will require URGENT action on your part, and requesting records and pathology results and samples to be sent to the oncologist of your choosing. We urge you to follow-up with your primary care doctor as soon as possible to coordinate this. Meanwhile, if you choose to follow-up at [MASKED], please call [MASKED] to schedule an appointment to be seen. Alternatively, call [MASKED], which is number for the hematologic malignancy department. Your CAT scan also showed a small nodule in your lungs. You will need to have a biopsy of this nodule to determine whether it is related to the findings in your abdomen. You should follow-up with the interventional radiology team for this biopsy. We recommend that you adhere to a liquid diet to prevent recurrent obstruction. While you were in the hospital the nutritionist team recommended that you take Thiamine supplements for 5 days given that you had not been eating before coming to the hospital. You have be prescribed Thiamine for discharge. Please continue the y taking the Thiamine until [MASKED] as directed. It has been a pleasure to care for you. We wish you the best. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "D509", "I10", "E785", "F329", "Z87891" ]
[ "C9030: Solitary plasmacytoma not having achieved remission", "K311: Adult hypertrophic pyloric stenosis", "E46: Unspecified protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "D509: Iron deficiency anemia, unspecified", "E8339: Other disorders of phosphorus metabolism", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z87891: Personal history of nicotine dependence", "R918: Other nonspecific abnormal finding of lung field" ]
10,035,631
21,476,294
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fevers, chills and fatigue; concern for acute leukemia Major Surgical or Invasive Procedure: ___ placement ___ Bone Marrow Biopsy ___ History of Present Illness: Mr. ___ is a ___ y/o male with a history of stage IIA breast cancer ___- s/p left mastectomy and currently on tamoxifen, also with a history of intermediate risk AML s/p reduced intensity allogeneic stem cell transplant ___, MRD sister) currently in remission who presented with myalgias, night sweats, fatigue and leukocytosis. Patient was in his usual stated of health until 4 days prior to admission when he received the influenza vaccine. Following vaccination he developed severe left arm pain. The patient subsequently developed upper body pain, back spasms, headaches, drenching night sweats and rigors. He also complained of severe fatigue and myalgias. He was afebrile. He has been taking ibuprofen 400 mg q3h for symptom control. Patient also reports having had a tick bite approximately ___ weeks ago. Denies bleeding, bruising, gingival hyperplasia, rashes, cough. Today the patient presented to ___ Urgent Care at which point a CBC showed a WBC 33, Hb 15, PLT 30. Patient was referred to ___ for further evaluation. Upon arrival to the ED, T 98.7, HR 100, BP 109/65, RR 18, 91% RA (rechecked and was 96% RA). Labs were notable for a white count of 32.7 (80% others, 7% neutrophils, 11% lymphocytes), Hb 14.6, Hct 41.4, platelet 24. K 4.1, Cr 1.1, lactate 2.9, Ca 9.2, Mg 2.0, Phos 2.4, LDH 682, UA 5.3, haptoglobin 143, INR 1.2. Upon arrival to the floor, the patient was complaining of back pain and headache. Review of Systems: A full 10 point review of systems was performed and negative unless stated above. Past Medical History: AML, Intermediate risk (normal cytogenetics, FLT3/NPM1 neg, diagnosed in ___. Enrolled in ECOG 2906, received indection with 7+3 with ___, consolidation with midAC x 1. MRD AlloSCT with reduced intensity flu/bu on ECOG 2906, d0 ___. Received 4.62 x 10^6 CD34+/kg cells. Male Breast Cancer s/p Mastectomy (___) Aspergillosis (___) Prostatitis (___) Seizure vs. Syncope (___) - Holter/MRI/MRA/EEG all negative Lyme Disease (___) Social History: ___ Family History: Mr. ___ has one brother with history of stroke. His father died of lung cancer at age ___. His mother died at age ___. Physical Exam: ADMISSION: ========== Vitals: Tc 98.2, BP 126/78, HR 85, RR 20, 96% RA Gen: A+Ox3, NAD, well nourished male HEENT: No conjunctival pallor. No icterus. MMM. OP clear. No petechiae. NECK: supple, no JVD LYMPH: No cervical, axillary, supraclav, inguinal LAD CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. No hepatosplenomegaly. EXT: WWP. No ___ edema. SKIN: No rashes/lesions, petechiae/purpura ecchymoses. NEURO: A&Ox3. LINES: right PIV DISCHARGE: ========== VS: ___ 97.6 PO 116 / 64 79 18 100 RA Weight: 78.2 kg (77.11 on ___ I/O ytd: ___ BMx1 soft Gen: A+Ox3, Sitting in bed in no acute distress HEENT: EOMI, PERRL. MMM. No petechiae NECK: supple, JVP not elevated LYMPH: No significant cervical or supraclavicular LAD CHEST: Non-tender to palpation CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. No w/r/r. ABD: Normoactive bowel sounds. No tenderness to palpation. EXT: WWP. No ___ edema. SKIN: TEDS off this AM. Petechiae on bilateral shins. NEURO: A&Ox3, CN II-XII grossly intact. Sensation and strength grossly intact. LINES: R PICC is c/d/i Pertinent Results: ADMISSION: ========== ___ 01:00PM BLOOD WBC-32.7*# RBC-4.25* Hgb-14.6 Hct-41.4 MCV-97 MCH-34.4* MCHC-35.3 RDW-13.0 RDWSD-45.8 Plt Ct-24*# ___ 01:00PM BLOOD Neuts-7* Bands-0 Lymphs-11* Monos-0 Eos-2 Baso-0 ___ Myelos-0 Blasts-80* Other-0 AbsNeut-2.29 AbsLymp-3.60 AbsMono-0.00* AbsEos-0.65* AbsBaso-0.00* ___ 01:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Spheroc-OCCASIONAL Tear Dr-OCCASIONAL ___ 01:00PM BLOOD ___ PTT-25.4 ___ ___ 01:00PM BLOOD Ret Aut-0.3* Abs Ret-0.01* ___ 01:00PM BLOOD Glucose-193* UreaN-16 Creat-1.1 Na-139 K-4.1 Cl-99 HCO3-25 AnGap-19 ___ 01:00PM BLOOD ALT-50* AST-35 LD(LDH)-682* AlkPhos-69 TotBili-0.3 ___ 01:00PM BLOOD Albumin-4.2 Calcium-9.2 Phos-2.4* Mg-2.0 UricAcd-5.3 ___ 01:00PM BLOOD Hapto-143 ___ 01:00PM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Negative ___ 01:00PM BLOOD HCV Ab-Negative ___ 01:06PM BLOOD Lactate-2.9* ___ 07:37PM BLOOD Lactate-1.8 ___ 07:26AM BLOOD Lactate-2.4* ___ 02:29AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 ___ 02:29AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 02:29AM URINE Color-Yellow Appear-Clear Sp ___ ___ 1:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:45 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. NADIR: ===== ___ 12:00AM BLOOD Neuts-17* Bands-3 ___ Monos-0 Eos-1 Baso-0 ___ Myelos-0 Blasts-57* AbsNeut-1.92 AbsLymp-2.11 AbsMono-0.00* AbsEos-0.10 AbsBaso-0.00* ___ 12:04AM BLOOD WBC-0.3* RBC-3.12* Hgb-10.4* Hct-29.8* MCV-96 MCH-33.3* MCHC-34.9 RDW-12.2 RDWSD-42.5 Plt Ct-9* ___ 12:00AM BLOOD WBC-0.4* RBC-3.09* Hgb-10.3* Hct-28.4* MCV-92 MCH-33.3* MCHC-36.3 RDW-11.9 RDWSD-39.8 Plt Ct-9* ___ 12:00AM BLOOD WBC-0.4* RBC-2.69* Hgb-8.9* Hct-25.2* MCV-94 MCH-33.1* MCHC-35.3 RDW-11.7 RDWSD-39.8 Plt Ct-33* ___ 12:00AM BLOOD Neuts-0 Bands-0 Lymphs-99* Monos-0 Eos-0 Baso-0 ___ Myelos-0 Blasts-1* AbsNeut-0.00* AbsLymp-0.40* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Neuts-1* Bands-0 Lymphs-98* Monos-1* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.00* AbsLymp-0.29* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 12:01AM BLOOD WBC-0.4* RBC-2.31* Hgb-7.7* Hct-21.3* MCV-92 MCH-33.3* MCHC-36.2 RDW-11.5 RDWSD-38.4 Plt Ct-15* MICRO: ====== ___ 2:29 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 1:30 pm Blood (LYME) **FINAL REPORT ___ Lyme IgG (Final ___: POSITIVE BY EIA. (Reference Range-Negative). EIA RESULT NOT CONFIRMED BY WESTERN BLOT. NEGATIVE BY WESTERN BLOT. Refer to outside lab system for complete Western Blot results. Lyme IgM (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). Negative results do not rule out B. burg___ infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. ___ 9:34 pm STOOL CONSISTENCY: WATERY **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). IMAGING: ======== ___ 8:13 ___ CT HEAD W/O CONTRAST IMPRESSION: No evidence of acute intracranial hemorrhage. ___ 10:___HEST W/CONTRAST IMPRESSION: 1. New ground-glass opacities with septal thickening and dependent small pleural effusions, most suggestive of hydrostatic edema. Differential agnosis includes atypical infection and less likely leukemic nfiltration. 2. Pre-existing lung nodules are difficult to compare to the prior CT due to technical limitations of today's exam. Consider a ___ month followup CT to allow more precise comparison of a potentially growing left upper lobe nodule in order to exclude the possibility of a slowly growing lesion within the lung adenocarcinoma spectrum. ___ 10:___BD & PELVIS WITH CONTRAST IMPRESSION: 1. No intra-abdominal infection or hemorrhage is identified. 2. Splenomegaly (similar to ___ CT) PATHOLOGY: ========== ___ FLOW CYTOMETRY REPORT Cell marker analysis demonstrates that a major subset of the cells isolated from this peripheral blood are in the CD45 dim/low side scatter “blast" region. They express CD38, immature antigens CD34, ___, nTdT (dim subset ~39%), myeloid associated antigens cytoplasmic MPO, CD117 and CD33. They co-express CD56. They lack B-cell associated antigens (CD19, cCD22, cCD79a), T cells (cCD3) associated antigens and are negative for CD13, CD14, CD64, CD11b. Blast cells comprise 88% of total analyzed events. INTERPRETATION Immunophenotypic findings consistent with involvement by acute myeloid leukemia. Correlation with clinical, morphologic (see separate pathology report ___ cytogenetic findings is recommended. ___ HEMATOPATHOLOGY REPORT - Final DIAGNOSIS: RELAPSED ACUTE MYELOID LEUKEMIA, SEE NOTE. NOTE: By flow cytometry, blasts comprise >90% of total analyzed events and have a myeloid immunophenotype expressing CD38, CD34, HLADR, nTdT (subset), CD117, CD33, cyMPO, along with CD56. Please correlate with cytogenetics (___-1550) findings. Findings discussed at interdepartmental ___ conference on ___. ASPIRATE SMEAR: The aspirate material is adequate for evaluation and consists of multiple cellular spicules. The cellularity is almost entirely comprised of blasts with cytomorphologic features similar to those described above. Residual hematopoiesis is extremely scant. DISCHARGE: ========== ___ 12:00AM BLOOD WBC-1.4* RBC-2.64* Hgb-8.2* Hct-24.3* MCV-92 MCH-31.1 MCHC-33.7 RDW-12.9 RDWSD-39.9 Plt Ct-88* ___ 12:00AM BLOOD Neuts-20.1* ___ Monos-28.1* Eos-0.0* Baso-0.0 NRBC-2.9* Im ___ AbsNeut-0.28* AbsLymp-0.71* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL ___ 12:00AM BLOOD ___ PTT-27.1 ___ ___ 12:00AM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-137 K-4.4 Cl-102 HCO3-27 AnGap-12 ___ 12:00AM BLOOD ALT-18 AST-17 LD(LDH)-180 AlkPhos-106 TotBili-0.2 ___ 12:00AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.1 Mg-2.3 Brief Hospital Course: Mr. ___ is a ___ y/o male with a history of stage IIA breast cancer ___- s/p left mastectomy and currently on tamoxifen, also with a history of intermediate risk AML s/p reduced intensity allogeneic stem cell transplant ___, MRD sister) currently in remission who presented with myalgias, night sweats, fatigue and leukocytosis concerning for acute leukemia. ACTIVE ISSUES: ============== # Relapsed acute leukemia: BM Bx ___ consistent with relapse. Treated w/ MEC (D1 = ___, no blasts on D23 sustained. Sluggish count recovery. Given low counts, repeat BM deferred to outpatient setting (f/u apt scheduled ___. # Abx: After completing tx for febrile neutropenia (cefepime, doxy), maintained on PPX with ciprofloxacin, acyclovir, voriconazole. # Dizziness/ Orthostatic symptoms: Differential includes autonomic neuropathy ___ chemo vs medication side effect (reported on voriconazole PI but incidence not included). Endocrine and cardiac sources less likely based on normal ___ stim (___), normal TSH (___), and normal LVEF (___). The role of anemia has also been considered, however, the Hgb has been stable for several days. Switched fludrocort -> midodrine ___. Midodrine titrated with good effect. Discharged on midodrine 7.5mg QAM and at noon, and 10mg QPM given symtoms occur o/n or in early AM CHRONIC ISSUES: =============== # Stage IIA breast cancer s/p mastectomy: Continued tamoxifen daily # Atypical chest pain: Had point tenderness above mastectomy scar and in R axilla, at different points during hospitalization. Most likely MSK or neuropathic and resolved prior to discharge. However, given h/o breast CA, there was concern for recurrent breast cancer. If symptoms worsen, would obtain chest imaging (CT v. MRI) to evaluate for masses. RESOLVED ISSUES: ================ # Pulmonary Edema/Borderline O2 sats: Acute pulmonary edema in setting of fluids with medications and as treatment for acute leukemia ___, improved O2 sats ___ and ___ after diuresis. Repeat TTE showed normal EF. Responded to Lasix 20mg IV PRN # Tick exposure: tick bite ___ wks prior to presentation. Treated w/ doxycycline x2 weeks. Serologies returned negative. # Pain: Severe multifocal pain on admission, worst site low back spasms; significantly improved. Improvement coincident with chemotherapy suggests cancer-related pain most likely; differential includes infection and electrolyte shifts. Negative lyme serologies argue against infection. Not requiring pain management today. # Loose stools: Loose stools for several days without abdominal pain or tenderness. Differential is medication side effect, infection or GVHD. Given benign abdomen and no history of chronic GHVD, most likely medication effect. C diff negative ___ and ___. Resolved w/ discontinuation of cefepime___. TRANSITIONAL: ============= - ORTHOSTATIC HYPOTENSION: If persistent orthostatic sx, refer to ___ clinic - CHEST PAIN: Had intermittent chest pain near mastectomy site. If progresses while patient immunosuppressed, please consider the need for imaging/ recurrence -------------- Discharge CBC: 1.4 > 8.2 / ___.3 < 88, ___ 280 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 2. Tamoxifen Citrate 20 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes Discharge Medications: 1. Acyclovir 400 mg PO TID RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 3. Midodrine 10 mg PO QPM RX *midodrine 10 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 4. Midodrine 7.5 mg PO QAM RX *midodrine 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Midodrine 7.5 mg PO NOON RX *midodrine 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Voriconazole 200 mg PO Q12H RX *voriconazole 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 7. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 9. Multivitamins 1 TAB PO DAILY 10. Tamoxifen Citrate 20 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================== Acute myelogenous leukemia, relapsed Orthostatic hypotension SECONDARY DIAGNOSES: ==================== Lyme disease prophylaxis Male breast cancer (ER+/PR+, HER2-) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to ___ because you had fevers, chills and pain. You were admitted because your blood counts were concerning for infection or leukemia. What was done while you were in the hospital? - You were diagnosed with relapsed leukemia - You were treated with medications for acute leukemia - You were received medications for pain and infections - You had lightheadedness, possibly as a side effect of these treatments. We treated this with a new medication called midodrine. - We monitored your blood counts daily What should you do now that you are leaving the hospital? - Attend your doctor appointments as scheduled - Take your medications as prescribed - If you develop fever, severe pain, or other concerning symptoms, go to an emergency room right away It was a pleasure participating in your care. Wishing you all the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "C92Z2", "J810", "Z9484", "D709", "K521", "D696", "E871", "I951", "R5081", "R0789", "G893", "Z853", "Z79810", "Z9012", "Z87891", "G44209", "R740", "T361X5A", "Y92230", "Z792", "Z20828", "R634", "Z6826", "M545" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fevers, chills and fatigue; concern for acute leukemia Major Surgical or Invasive Procedure: [MASKED] placement [MASKED] Bone Marrow Biopsy [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] y/o male with a history of stage IIA breast cancer [MASKED]- s/p left mastectomy and currently on tamoxifen, also with a history of intermediate risk AML s/p reduced intensity allogeneic stem cell transplant [MASKED], MRD sister) currently in remission who presented with myalgias, night sweats, fatigue and leukocytosis. Patient was in his usual stated of health until 4 days prior to admission when he received the influenza vaccine. Following vaccination he developed severe left arm pain. The patient subsequently developed upper body pain, back spasms, headaches, drenching night sweats and rigors. He also complained of severe fatigue and myalgias. He was afebrile. He has been taking ibuprofen 400 mg q3h for symptom control. Patient also reports having had a tick bite approximately [MASKED] weeks ago. Denies bleeding, bruising, gingival hyperplasia, rashes, cough. Today the patient presented to [MASKED] Urgent Care at which point a CBC showed a WBC 33, Hb 15, PLT 30. Patient was referred to [MASKED] for further evaluation. Upon arrival to the ED, T 98.7, HR 100, BP 109/65, RR 18, 91% RA (rechecked and was 96% RA). Labs were notable for a white count of 32.7 (80% others, 7% neutrophils, 11% lymphocytes), Hb 14.6, Hct 41.4, platelet 24. K 4.1, Cr 1.1, lactate 2.9, Ca 9.2, Mg 2.0, Phos 2.4, LDH 682, UA 5.3, haptoglobin 143, INR 1.2. Upon arrival to the floor, the patient was complaining of back pain and headache. Review of Systems: A full 10 point review of systems was performed and negative unless stated above. Past Medical History: AML, Intermediate risk (normal cytogenetics, FLT3/NPM1 neg, diagnosed in [MASKED]. Enrolled in ECOG 2906, received indection with 7+3 with [MASKED], consolidation with midAC x 1. MRD AlloSCT with reduced intensity flu/bu on ECOG 2906, d0 [MASKED]. Received 4.62 x 10^6 CD34+/kg cells. Male Breast Cancer s/p Mastectomy ([MASKED]) Aspergillosis ([MASKED]) Prostatitis ([MASKED]) Seizure vs. Syncope ([MASKED]) - Holter/MRI/MRA/EEG all negative Lyme Disease ([MASKED]) Social History: [MASKED] Family History: Mr. [MASKED] has one brother with history of stroke. His father died of lung cancer at age [MASKED]. His mother died at age [MASKED]. Physical Exam: ADMISSION: ========== Vitals: Tc 98.2, BP 126/78, HR 85, RR 20, 96% RA Gen: A+Ox3, NAD, well nourished male HEENT: No conjunctival pallor. No icterus. MMM. OP clear. No petechiae. NECK: supple, no JVD LYMPH: No cervical, axillary, supraclav, inguinal LAD CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. No hepatosplenomegaly. EXT: WWP. No [MASKED] edema. SKIN: No rashes/lesions, petechiae/purpura ecchymoses. NEURO: A&Ox3. LINES: right PIV DISCHARGE: ========== VS: [MASKED] 97.6 PO 116 / 64 79 18 100 RA Weight: 78.2 kg (77.11 on [MASKED] I/O ytd: [MASKED] BMx1 soft Gen: A+Ox3, Sitting in bed in no acute distress HEENT: EOMI, PERRL. MMM. No petechiae NECK: supple, JVP not elevated LYMPH: No significant cervical or supraclavicular LAD CHEST: Non-tender to palpation CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. No w/r/r. ABD: Normoactive bowel sounds. No tenderness to palpation. EXT: WWP. No [MASKED] edema. SKIN: TEDS off this AM. Petechiae on bilateral shins. NEURO: A&Ox3, CN II-XII grossly intact. Sensation and strength grossly intact. LINES: R PICC is c/d/i Pertinent Results: ADMISSION: ========== [MASKED] 01:00PM BLOOD WBC-32.7*# RBC-4.25* Hgb-14.6 Hct-41.4 MCV-97 MCH-34.4* MCHC-35.3 RDW-13.0 RDWSD-45.8 Plt Ct-24*# [MASKED] 01:00PM BLOOD Neuts-7* Bands-0 Lymphs-11* Monos-0 Eos-2 Baso-0 [MASKED] Myelos-0 Blasts-80* Other-0 AbsNeut-2.29 AbsLymp-3.60 AbsMono-0.00* AbsEos-0.65* AbsBaso-0.00* [MASKED] 01:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Spheroc-OCCASIONAL Tear Dr-OCCASIONAL [MASKED] 01:00PM BLOOD [MASKED] PTT-25.4 [MASKED] [MASKED] 01:00PM BLOOD Ret Aut-0.3* Abs Ret-0.01* [MASKED] 01:00PM BLOOD Glucose-193* UreaN-16 Creat-1.1 Na-139 K-4.1 Cl-99 HCO3-25 AnGap-19 [MASKED] 01:00PM BLOOD ALT-50* AST-35 LD(LDH)-682* AlkPhos-69 TotBili-0.3 [MASKED] 01:00PM BLOOD Albumin-4.2 Calcium-9.2 Phos-2.4* Mg-2.0 UricAcd-5.3 [MASKED] 01:00PM BLOOD Hapto-143 [MASKED] 01:00PM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Negative [MASKED] 01:00PM BLOOD HCV Ab-Negative [MASKED] 01:06PM BLOOD Lactate-2.9* [MASKED] 07:37PM BLOOD Lactate-1.8 [MASKED] 07:26AM BLOOD Lactate-2.4* [MASKED] 02:29AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 [MASKED] 02:29AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 02:29AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 1:00 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 12:45 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. NADIR: ===== [MASKED] 12:00AM BLOOD Neuts-17* Bands-3 [MASKED] Monos-0 Eos-1 Baso-0 [MASKED] Myelos-0 Blasts-57* AbsNeut-1.92 AbsLymp-2.11 AbsMono-0.00* AbsEos-0.10 AbsBaso-0.00* [MASKED] 12:04AM BLOOD WBC-0.3* RBC-3.12* Hgb-10.4* Hct-29.8* MCV-96 MCH-33.3* MCHC-34.9 RDW-12.2 RDWSD-42.5 Plt Ct-9* [MASKED] 12:00AM BLOOD WBC-0.4* RBC-3.09* Hgb-10.3* Hct-28.4* MCV-92 MCH-33.3* MCHC-36.3 RDW-11.9 RDWSD-39.8 Plt Ct-9* [MASKED] 12:00AM BLOOD WBC-0.4* RBC-2.69* Hgb-8.9* Hct-25.2* MCV-94 MCH-33.1* MCHC-35.3 RDW-11.7 RDWSD-39.8 Plt Ct-33* [MASKED] 12:00AM BLOOD Neuts-0 Bands-0 Lymphs-99* Monos-0 Eos-0 Baso-0 [MASKED] Myelos-0 Blasts-1* AbsNeut-0.00* AbsLymp-0.40* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD Neuts-1* Bands-0 Lymphs-98* Monos-1* Eos-0 Baso-0 [MASKED] Myelos-0 AbsNeut-0.00* AbsLymp-0.29* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:01AM BLOOD WBC-0.4* RBC-2.31* Hgb-7.7* Hct-21.3* MCV-92 MCH-33.3* MCHC-36.2 RDW-11.5 RDWSD-38.4 Plt Ct-15* MICRO: ====== [MASKED] 2:29 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 1:30 pm Blood (LYME) **FINAL REPORT [MASKED] Lyme IgG (Final [MASKED]: POSITIVE BY EIA. (Reference Range-Negative). EIA RESULT NOT CONFIRMED BY WESTERN BLOT. NEGATIVE BY WESTERN BLOT. Refer to outside lab system for complete Western Blot results. Lyme IgM (Final [MASKED]: NEGATIVE BY EIA. (Reference Range-Negative). Negative results do not rule out B. burg infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. [MASKED] 9:34 pm STOOL CONSISTENCY: WATERY **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). IMAGING: ======== [MASKED] 8:13 [MASKED] CT HEAD W/O CONTRAST IMPRESSION: No evidence of acute intracranial hemorrhage. [MASKED] 10: HEST W/CONTRAST IMPRESSION: 1. New ground-glass opacities with septal thickening and dependent small pleural effusions, most suggestive of hydrostatic edema. Differential agnosis includes atypical infection and less likely leukemic nfiltration. 2. Pre-existing lung nodules are difficult to compare to the prior CT due to technical limitations of today's exam. Consider a [MASKED] month followup CT to allow more precise comparison of a potentially growing left upper lobe nodule in order to exclude the possibility of a slowly growing lesion within the lung adenocarcinoma spectrum. [MASKED] 10: BD & PELVIS WITH CONTRAST IMPRESSION: 1. No intra-abdominal infection or hemorrhage is identified. 2. Splenomegaly (similar to [MASKED] CT) PATHOLOGY: ========== [MASKED] FLOW CYTOMETRY REPORT Cell marker analysis demonstrates that a major subset of the cells isolated from this peripheral blood are in the CD45 dim/low side scatter “blast" region. They express CD38, immature antigens CD34, [MASKED], nTdT (dim subset ~39%), myeloid associated antigens cytoplasmic MPO, CD117 and CD33. They co-express CD56. They lack B-cell associated antigens (CD19, cCD22, cCD79a), T cells (cCD3) associated antigens and are negative for CD13, CD14, CD64, CD11b. Blast cells comprise 88% of total analyzed events. INTERPRETATION Immunophenotypic findings consistent with involvement by acute myeloid leukemia. Correlation with clinical, morphologic (see separate pathology report [MASKED] cytogenetic findings is recommended. [MASKED] HEMATOPATHOLOGY REPORT - Final DIAGNOSIS: RELAPSED ACUTE MYELOID LEUKEMIA, SEE NOTE. NOTE: By flow cytometry, blasts comprise >90% of total analyzed events and have a myeloid immunophenotype expressing CD38, CD34, HLADR, nTdT (subset), CD117, CD33, cyMPO, along with CD56. Please correlate with cytogenetics ([MASKED]-1550) findings. Findings discussed at interdepartmental [MASKED] conference on [MASKED]. ASPIRATE SMEAR: The aspirate material is adequate for evaluation and consists of multiple cellular spicules. The cellularity is almost entirely comprised of blasts with cytomorphologic features similar to those described above. Residual hematopoiesis is extremely scant. DISCHARGE: ========== [MASKED] 12:00AM BLOOD WBC-1.4* RBC-2.64* Hgb-8.2* Hct-24.3* MCV-92 MCH-31.1 MCHC-33.7 RDW-12.9 RDWSD-39.9 Plt Ct-88* [MASKED] 12:00AM BLOOD Neuts-20.1* [MASKED] Monos-28.1* Eos-0.0* Baso-0.0 NRBC-2.9* Im [MASKED] AbsNeut-0.28* AbsLymp-0.71* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [MASKED] 12:00AM BLOOD [MASKED] PTT-27.1 [MASKED] [MASKED] 12:00AM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-137 K-4.4 Cl-102 HCO3-27 AnGap-12 [MASKED] 12:00AM BLOOD ALT-18 AST-17 LD(LDH)-180 AlkPhos-106 TotBili-0.2 [MASKED] 12:00AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.1 Mg-2.3 Brief Hospital Course: Mr. [MASKED] is a [MASKED] y/o male with a history of stage IIA breast cancer [MASKED]- s/p left mastectomy and currently on tamoxifen, also with a history of intermediate risk AML s/p reduced intensity allogeneic stem cell transplant [MASKED], MRD sister) currently in remission who presented with myalgias, night sweats, fatigue and leukocytosis concerning for acute leukemia. ACTIVE ISSUES: ============== # Relapsed acute leukemia: BM Bx [MASKED] consistent with relapse. Treated w/ MEC (D1 = [MASKED], no blasts on D23 sustained. Sluggish count recovery. Given low counts, repeat BM deferred to outpatient setting (f/u apt scheduled [MASKED]. # Abx: After completing tx for febrile neutropenia (cefepime, doxy), maintained on PPX with ciprofloxacin, acyclovir, voriconazole. # Dizziness/ Orthostatic symptoms: Differential includes autonomic neuropathy [MASKED] chemo vs medication side effect (reported on voriconazole PI but incidence not included). Endocrine and cardiac sources less likely based on normal [MASKED] stim ([MASKED]), normal TSH ([MASKED]), and normal LVEF ([MASKED]). The role of anemia has also been considered, however, the Hgb has been stable for several days. Switched fludrocort -> midodrine [MASKED]. Midodrine titrated with good effect. Discharged on midodrine 7.5mg QAM and at noon, and 10mg QPM given symtoms occur o/n or in early AM CHRONIC ISSUES: =============== # Stage IIA breast cancer s/p mastectomy: Continued tamoxifen daily # Atypical chest pain: Had point tenderness above mastectomy scar and in R axilla, at different points during hospitalization. Most likely MSK or neuropathic and resolved prior to discharge. However, given h/o breast CA, there was concern for recurrent breast cancer. If symptoms worsen, would obtain chest imaging (CT v. MRI) to evaluate for masses. RESOLVED ISSUES: ================ # Pulmonary Edema/Borderline O2 sats: Acute pulmonary edema in setting of fluids with medications and as treatment for acute leukemia [MASKED], improved O2 sats [MASKED] and [MASKED] after diuresis. Repeat TTE showed normal EF. Responded to Lasix 20mg IV PRN # Tick exposure: tick bite [MASKED] wks prior to presentation. Treated w/ doxycycline x2 weeks. Serologies returned negative. # Pain: Severe multifocal pain on admission, worst site low back spasms; significantly improved. Improvement coincident with chemotherapy suggests cancer-related pain most likely; differential includes infection and electrolyte shifts. Negative lyme serologies argue against infection. Not requiring pain management today. # Loose stools: Loose stools for several days without abdominal pain or tenderness. Differential is medication side effect, infection or GVHD. Given benign abdomen and no history of chronic GHVD, most likely medication effect. C diff negative [MASKED] and [MASKED]. Resolved w/ discontinuation of cefepime . TRANSITIONAL: ============= - ORTHOSTATIC HYPOTENSION: If persistent orthostatic sx, refer to [MASKED] clinic - CHEST PAIN: Had intermittent chest pain near mastectomy site. If progresses while patient immunosuppressed, please consider the need for imaging/ recurrence -------------- Discharge CBC: 1.4 > 8.2 / [MASKED].3 < 88, [MASKED] 280 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 2. Tamoxifen Citrate 20 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN dry eyes Discharge Medications: 1. Acyclovir 400 mg PO TID RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 3. Midodrine 10 mg PO QPM RX *midodrine 10 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 4. Midodrine 7.5 mg PO QAM RX *midodrine 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Midodrine 7.5 mg PO NOON RX *midodrine 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Voriconazole 200 mg PO Q12H RX *voriconazole 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 7. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN dry eyes 8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 9. Multivitamins 1 TAB PO DAILY 10. Tamoxifen Citrate 20 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================== Acute myelogenous leukemia, relapsed Orthostatic hypotension SECONDARY DIAGNOSES: ==================== Lyme disease prophylaxis Male breast cancer (ER+/PR+, HER2-) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You came to [MASKED] because you had fevers, chills and pain. You were admitted because your blood counts were concerning for infection or leukemia. What was done while you were in the hospital? - You were diagnosed with relapsed leukemia - You were treated with medications for acute leukemia - You were received medications for pain and infections - You had lightheadedness, possibly as a side effect of these treatments. We treated this with a new medication called midodrine. - We monitored your blood counts daily What should you do now that you are leaving the hospital? - Attend your doctor appointments as scheduled - Take your medications as prescribed - If you develop fever, severe pain, or other concerning symptoms, go to an emergency room right away It was a pleasure participating in your care. Wishing you all the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "D696", "E871", "Z87891", "Y92230" ]
[ "C92Z2: Other myeloid leukemia, in relapse", "J810: Acute pulmonary edema", "Z9484: Stem cells transplant status", "D709: Neutropenia, unspecified", "K521: Toxic gastroenteritis and colitis", "D696: Thrombocytopenia, unspecified", "E871: Hypo-osmolality and hyponatremia", "I951: Orthostatic hypotension", "R5081: Fever presenting with conditions classified elsewhere", "R0789: Other chest pain", "G893: Neoplasm related pain (acute) (chronic)", "Z853: Personal history of malignant neoplasm of breast", "Z79810: Long term (current) use of selective estrogen receptor modulators (SERMs)", "Z9012: Acquired absence of left breast and nipple", "Z87891: Personal history of nicotine dependence", "G44209: Tension-type headache, unspecified, not intractable", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "T361X5A: Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z792: Long term (current) use of antibiotics", "Z20828: Contact with and (suspected) exposure to other viral communicable diseases", "R634: Abnormal weight loss", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "M545: Low back pain" ]
10,035,631
21,599,196
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: admission for cycle 1 of dacogen Major Surgical or Invasive Procedure: ___ placement ___ History of Present Illness: Mr. ___ is a ___ gentleman with a history of stage IIA breast cancer ___ left mastectomy and currently on Tamoxifen and also with history of relapsed AML status post allogeneic RIC MRD stem cell transplant for intermediate risk AML in CR1 after being in remission for ___ years. He was re-induced with MEC upon relapse (___). BM aspirate and biopsy repeated with recovery of counts post-re-induction with MEC showed no morphologic evidence of leukemia. After extensive discussion with patient and family, patient underwent DLI from sister on ___. In ___, he relapsed post DLI with 12% myeloblasts. He is now admitted for Cycle 1 of Decitabine (x10 doses) induction therapy. ROS: Overall, he reports feeling well. No fevers, chills, rigors, chest pain, palpitations, headache, dizziness, lightheadedness, abdominal pain, nausea, vomiting, diarrhea, constipation, new rashes/bruising, ___ edema or pain. Does endorse clear runny nose this is not a new symptom. Appetite is good. No recent weight loss, tremors, numbness on fingers/toes. All other ROS negative. Past Medical History: PAST MEDICAL HISTORY: AML, Intermediate risk (normal cytogenetics, FLT3/NPM1 neg, diagnosed in ___. Enrolled in ___ 2906, received induction with 7+3 with ___, consolidation with midAC x 1. MRD AlloSCT with reduced intensity flu/bu on ECOG 2906, d0 ___. Received 4.62 x 10^6 CD34+/kg cells. Male Breast Cancer s/p Mastectomy (___) Aspergillosis (___) Prostatitis (___) Seizure vs. Syncope ___ all negative Lyme Disease (___) Social History: ___ Family History: Mr. ___ has one brother with history of stroke. His father died of lung cancer at age ___. His mother died at age ___. Physical Exam: ADMISSION PHYSICAL EXAM: VS: TC 97.6 PO 119/56 95 18 99%RA WT: 187 lbs. HEAD/NECK: No facial rash. Bilateral conjunctiva normal. No discharge. Oral mucosa with moist mucous membranes. No lichenoid changes noted. CARDIAC: S1/S2. No S3 or S4, regular rate and rhythm. RESPIRATORY: Lung sounds bilateral are clear to auscultation. No wheezes, crackles, or diminished breath sounds ABDOMEN: Positive bowel sounds, soft, non-tender; no appreciable organomegaly and palpable masses EXTREMITIES: Bilateral upper and lower extremities w/o edema SKIN: No stiffness or tremors ACCESS: RUE PICC in place. DISCHARGE PHYSICAL EXAM: VS: TC 97.8 PO 102 / 70 76 18 95 Ra WT: 182.9 HEAD/NECK: No facial rash. Bilateral conjunctiva normal. No discharge. Oral mucosa with moist mucous membranes. No lichenoid changes noted. CARDIAC: S1/S2. No S3 or S4, regular rate and rhythm. RESPIRATORY: Lung sounds bilateral are clear to auscultation. No wheezes, crackles, or diminished breath sounds ABDOMEN: Positive bowel sounds, soft, non-tender; no appreciable organomegaly and palpable masses EXTREMITIES: Bilateral upper and lower extremities w/o edema SKIN: No stiffness or tremors ACCESS: RUE ___ in place. Pertinent Results: ___ 12:00AM BLOOD WBC-7.3 RBC-3.61* Hgb-12.4* Hct-36.2* MCV-100* MCH-34.3* MCHC-34.3 RDW-13.9 RDWSD-51.2* Plt Ct-46* ___ 08:45AM BLOOD WBC-5.3 RBC-4.02* Hgb-13.8 Hct-40.2 MCV-100* MCH-34.3* MCHC-34.3 RDW-14.1 RDWSD-51.4* Plt Ct-74* ___ 12:00AM BLOOD Neuts-64 Bands-1 Lymphs-17* Monos-3* Eos-4 Baso-0 ___ Myelos-0 Blasts-11* NRBC-1* Other-0 AbsNeut-4.75 AbsLymp-1.24 AbsMono-0.22 AbsEos-0.29 AbsBaso-0.00* ___ 08:45AM BLOOD Neuts-66 Bands-0 Lymphs-17* Monos-2* Eos-2 Baso-0 ___ Metas-1* Myelos-0 Blasts-12* Other-0 AbsNeut-3.50 AbsLymp-0.90* AbsMono-0.11* AbsEos-0.11 AbsBaso-0.00* ___ 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-NORMAL Spheroc-1+ Ovalocy-1+ Schisto-OCCASIONAL Tear Dr-1+ ___ 08:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-2+ Microcy-NORMAL Polychr-1+ Tear Dr-OCCASIONAL ___ 12:00AM BLOOD Plt Ct-46* ___ 08:45AM BLOOD Plt Smr-VERY LOW Plt Ct-74* ___ 12:00AM BLOOD Glucose-98 UreaN-17 Creat-1.1 Na-137 K-3.7 Cl-102 HCO3-25 AnGap-14 ___:45AM BLOOD Glucose-114* ___ 12:00AM BLOOD Albumin-3.8 Calcium-8.4 Phos-2.7 Mg-2.2 UricAcd-5.4 ___ 08:45AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.2 ___ 12:00AM BLOOD ALT-25 AST-28 LD(LDH)-424* AlkPhos-64 TotBili-<0.2 ___ 08:45AM BLOOD ALT-29 AST-32 LD(LDH)-440* AlkPhos-79 TotBili-<0.___SSESSMENT AND PLAN: Mr. ___ is a ___ gentleman with history of stage IIA breast cancer ___ left mastectomy and currently on Tamoxifen and also relapsed AML status post allogeneic RIC MRD stem cell transplant relapsed after ___ years, re-induced with MEC, s/p DLI in ___ who presents for cycle 1 of Decitabine #Relapsed AML: relapse after being in remission for ___ years post allogeneic transplant. AML relapse was diagnosed on ___ with appearance of D835H mutation, normal cytogenetics and 97% donor T-cells on peripheral blood chimerism. Re-induced with MEC (___), s/p DLI from sister on ___ and now presenting for cycle 1 of Decitabine (x 10D); received three doses while in-house with plan to receive remaining doses outpatient. Has appointment with Dr. ___ on ___ -Decitabine 41 mg IV Days 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. ___, /___ and ___ (20 mg/m2); Infuse over 1 hour -continue allopurinol given peripheral blasts #History of Pulmonary Aspergillus prior to transplant, B/l GGO (___) and COP (___): remote history, refer to Dr. ___ ___ ___ for details, remains on voriconazole 150mg BID. No respiratory complaints this hospital course #Stage II Invasive Breast Cancer (ER/PR pos, HER-2 neg, BrCA negative): s/p Left mastectomy and excisional LN biopsy. Followed by Dr. ___. Started Tamoxifen on ___, continues on this regimen [20mg PO daily]. #Dizziness/Orthostatic Symptoms: (resolved). Noted during admission from ___. Differential includes autonomic neuropathy ___ chemotherapy vs. medication side effect (reported on voriconazole PI but incidence not included). Endocrine and cardiac sources less likely based on normal ___ stem (___), normal TSH (___), and normal LVEF (___). The role of anemia at that time was also considered as patient received PRBCs transfusions for support. Patient was discharged on Midodrine 7.5mg BID and 10mg QPM and recently tapered off medication on ___. No symptoms of orthostasis this hospital course. #ID Prophylaxis: acyclovir 400mg TID and voriconazole 150mg BID ACCESS: ___ placed ___ CODE STATUS: Full Code (presumed) EMERGENCY CONTACT: ___, Wife, ___ DISPO: Discharged ___. RTC ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 2. Multivitamins 1 TAB PO DAILY 3. Tamoxifen Citrate 20 mg PO QAM 4. Vitamin D 1000 UNIT PO DAILY 5. Acyclovir 400 mg PO TID 6. Voriconazole 150 mg PO Q12H Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Decitabine 41 mg IV Days 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. ___, ___ and ___ (20 mg/m2 (Weight used: Actual Weight = 84.69 kg BSA: 2.05 m2)) you will receive daily injections at the clinic until you complete 10 doses 3. Lorazepam 0.5 mg PO Q6H:PRN anxiety/nausea/vomiting RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 6 hours Disp #*30 Tablet Refills:*0 4. Acyclovir 400 mg PO TID 5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 6. Multivitamins 1 TAB PO DAILY 7. Tamoxifen Citrate 20 mg PO QAM 8. Vitamin D 1000 UNIT PO DAILY 9. Voriconazole 150 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Relapsed AML Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to receive the first cycle of Decitabine (Dacogen). You received 3 doses and tolerated them well and will be discharged to complete remaining doses outpatient. Refer below for your outpatient appointment with Dr. ___. It was a pleasure taking care of you. Sincerely, Your ___ TEAM Followup Instructions: ___
[ "Z5111", "C9202", "Z9484", "Z853", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: admission for cycle 1 of dacogen Major Surgical or Invasive Procedure: [MASKED] placement [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] gentleman with a history of stage IIA breast cancer [MASKED] left mastectomy and currently on Tamoxifen and also with history of relapsed AML status post allogeneic RIC MRD stem cell transplant for intermediate risk AML in CR1 after being in remission for [MASKED] years. He was re-induced with MEC upon relapse ([MASKED]). BM aspirate and biopsy repeated with recovery of counts post-re-induction with MEC showed no morphologic evidence of leukemia. After extensive discussion with patient and family, patient underwent DLI from sister on [MASKED]. In [MASKED], he relapsed post DLI with 12% myeloblasts. He is now admitted for Cycle 1 of Decitabine (x10 doses) induction therapy. ROS: Overall, he reports feeling well. No fevers, chills, rigors, chest pain, palpitations, headache, dizziness, lightheadedness, abdominal pain, nausea, vomiting, diarrhea, constipation, new rashes/bruising, [MASKED] edema or pain. Does endorse clear runny nose this is not a new symptom. Appetite is good. No recent weight loss, tremors, numbness on fingers/toes. All other ROS negative. Past Medical History: PAST MEDICAL HISTORY: AML, Intermediate risk (normal cytogenetics, FLT3/NPM1 neg, diagnosed in [MASKED]. Enrolled in [MASKED] 2906, received induction with 7+3 with [MASKED], consolidation with midAC x 1. MRD AlloSCT with reduced intensity flu/bu on ECOG 2906, d0 [MASKED]. Received 4.62 x 10^6 CD34+/kg cells. Male Breast Cancer s/p Mastectomy ([MASKED]) Aspergillosis ([MASKED]) Prostatitis ([MASKED]) Seizure vs. Syncope [MASKED] all negative Lyme Disease ([MASKED]) Social History: [MASKED] Family History: Mr. [MASKED] has one brother with history of stroke. His father died of lung cancer at age [MASKED]. His mother died at age [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM: VS: TC 97.6 PO 119/56 95 18 99%RA WT: 187 lbs. HEAD/NECK: No facial rash. Bilateral conjunctiva normal. No discharge. Oral mucosa with moist mucous membranes. No lichenoid changes noted. CARDIAC: S1/S2. No S3 or S4, regular rate and rhythm. RESPIRATORY: Lung sounds bilateral are clear to auscultation. No wheezes, crackles, or diminished breath sounds ABDOMEN: Positive bowel sounds, soft, non-tender; no appreciable organomegaly and palpable masses EXTREMITIES: Bilateral upper and lower extremities w/o edema SKIN: No stiffness or tremors ACCESS: RUE PICC in place. DISCHARGE PHYSICAL EXAM: VS: TC 97.8 PO 102 / 70 76 18 95 Ra WT: 182.9 HEAD/NECK: No facial rash. Bilateral conjunctiva normal. No discharge. Oral mucosa with moist mucous membranes. No lichenoid changes noted. CARDIAC: S1/S2. No S3 or S4, regular rate and rhythm. RESPIRATORY: Lung sounds bilateral are clear to auscultation. No wheezes, crackles, or diminished breath sounds ABDOMEN: Positive bowel sounds, soft, non-tender; no appreciable organomegaly and palpable masses EXTREMITIES: Bilateral upper and lower extremities w/o edema SKIN: No stiffness or tremors ACCESS: RUE [MASKED] in place. Pertinent Results: [MASKED] 12:00AM BLOOD WBC-7.3 RBC-3.61* Hgb-12.4* Hct-36.2* MCV-100* MCH-34.3* MCHC-34.3 RDW-13.9 RDWSD-51.2* Plt Ct-46* [MASKED] 08:45AM BLOOD WBC-5.3 RBC-4.02* Hgb-13.8 Hct-40.2 MCV-100* MCH-34.3* MCHC-34.3 RDW-14.1 RDWSD-51.4* Plt Ct-74* [MASKED] 12:00AM BLOOD Neuts-64 Bands-1 Lymphs-17* Monos-3* Eos-4 Baso-0 [MASKED] Myelos-0 Blasts-11* NRBC-1* Other-0 AbsNeut-4.75 AbsLymp-1.24 AbsMono-0.22 AbsEos-0.29 AbsBaso-0.00* [MASKED] 08:45AM BLOOD Neuts-66 Bands-0 Lymphs-17* Monos-2* Eos-2 Baso-0 [MASKED] Metas-1* Myelos-0 Blasts-12* Other-0 AbsNeut-3.50 AbsLymp-0.90* AbsMono-0.11* AbsEos-0.11 AbsBaso-0.00* [MASKED] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-NORMAL Spheroc-1+ Ovalocy-1+ Schisto-OCCASIONAL Tear Dr-1+ [MASKED] 08:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-2+ Microcy-NORMAL Polychr-1+ Tear Dr-OCCASIONAL [MASKED] 12:00AM BLOOD Plt Ct-46* [MASKED] 08:45AM BLOOD Plt Smr-VERY LOW Plt Ct-74* [MASKED] 12:00AM BLOOD Glucose-98 UreaN-17 Creat-1.1 Na-137 K-3.7 Cl-102 HCO3-25 AnGap-14 [MASKED]:45AM BLOOD Glucose-114* [MASKED] 12:00AM BLOOD Albumin-3.8 Calcium-8.4 Phos-2.7 Mg-2.2 UricAcd-5.4 [MASKED] 08:45AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.2 [MASKED] 12:00AM BLOOD ALT-25 AST-28 LD(LDH)-424* AlkPhos-64 TotBili-<0.2 [MASKED] 08:45AM BLOOD ALT-29 AST-32 LD(LDH)-440* AlkPhos-79 TotBili-<0. SSESSMENT AND PLAN: Mr. [MASKED] is a [MASKED] gentleman with history of stage IIA breast cancer [MASKED] left mastectomy and currently on Tamoxifen and also relapsed AML status post allogeneic RIC MRD stem cell transplant relapsed after [MASKED] years, re-induced with MEC, s/p DLI in [MASKED] who presents for cycle 1 of Decitabine #Relapsed AML: relapse after being in remission for [MASKED] years post allogeneic transplant. AML relapse was diagnosed on [MASKED] with appearance of D835H mutation, normal cytogenetics and 97% donor T-cells on peripheral blood chimerism. Re-induced with MEC ([MASKED]), s/p DLI from sister on [MASKED] and now presenting for cycle 1 of Decitabine (x 10D); received three doses while in-house with plan to receive remaining doses outpatient. Has appointment with Dr. [MASKED] on [MASKED] -Decitabine 41 mg IV Days 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. [MASKED], /[MASKED] and [MASKED] (20 mg/m2); Infuse over 1 hour -continue allopurinol given peripheral blasts #History of Pulmonary Aspergillus prior to transplant, B/l GGO ([MASKED]) and COP ([MASKED]): remote history, refer to Dr. [MASKED] [MASKED] [MASKED] for details, remains on voriconazole 150mg BID. No respiratory complaints this hospital course #Stage II Invasive Breast Cancer (ER/PR pos, HER-2 neg, BrCA negative): s/p Left mastectomy and excisional LN biopsy. Followed by Dr. [MASKED]. Started Tamoxifen on [MASKED], continues on this regimen [20mg PO daily]. #Dizziness/Orthostatic Symptoms: (resolved). Noted during admission from [MASKED]. Differential includes autonomic neuropathy [MASKED] chemotherapy vs. medication side effect (reported on voriconazole PI but incidence not included). Endocrine and cardiac sources less likely based on normal [MASKED] stem ([MASKED]), normal TSH ([MASKED]), and normal LVEF ([MASKED]). The role of anemia at that time was also considered as patient received PRBCs transfusions for support. Patient was discharged on Midodrine 7.5mg BID and 10mg QPM and recently tapered off medication on [MASKED]. No symptoms of orthostasis this hospital course. #ID Prophylaxis: acyclovir 400mg TID and voriconazole 150mg BID ACCESS: [MASKED] placed [MASKED] CODE STATUS: Full Code (presumed) EMERGENCY CONTACT: [MASKED], Wife, [MASKED] DISPO: Discharged [MASKED]. RTC [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 2. Multivitamins 1 TAB PO DAILY 3. Tamoxifen Citrate 20 mg PO QAM 4. Vitamin D 1000 UNIT PO DAILY 5. Acyclovir 400 mg PO TID 6. Voriconazole 150 mg PO Q12H Discharge Medications: 1. Allopurinol [MASKED] mg PO DAILY 2. Decitabine 41 mg IV Days 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. [MASKED], [MASKED] and [MASKED] (20 mg/m2 (Weight used: Actual Weight = 84.69 kg BSA: 2.05 m2)) you will receive daily injections at the clinic until you complete 10 doses 3. Lorazepam 0.5 mg PO Q6H:PRN anxiety/nausea/vomiting RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 6 hours Disp #*30 Tablet Refills:*0 4. Acyclovir 400 mg PO TID 5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 6. Multivitamins 1 TAB PO DAILY 7. Tamoxifen Citrate 20 mg PO QAM 8. Vitamin D 1000 UNIT PO DAILY 9. Voriconazole 150 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Relapsed AML Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to receive the first cycle of Decitabine (Dacogen). You received 3 doses and tolerated them well and will be discharged to complete remaining doses outpatient. Refer below for your outpatient appointment with Dr. [MASKED]. It was a pleasure taking care of you. Sincerely, Your [MASKED] TEAM Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C9202: Acute myeloblastic leukemia, in relapse", "Z9484: Stem cells transplant status", "Z853: Personal history of malignant neoplasm of breast", "Z87891: Personal history of nicotine dependence" ]
10,035,631
29,276,678
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypoxia, AMS Major Surgical or Invasive Procedure: Intubated ___ R pheresis line ___ Pheresis ___ History of Present Illness: ___ male with history of stage IIA breast cancer ___ left mastectomy and currently on Tamoxifen and relapse of AML post allogeneic RIC MRD (sister) stem cell transplant (Day 0: ___ for intermediate risk AML in CR1 after being in remission for ___ years. He was re-induced with MEC upon relapse (___) and rcd DLI from same donor (sister) on ___ after achieving remission subsequently found to have relapse post-DLI with 12% myeloblasts on ___ and now s/p 10 days decitabine (___) without response and increasing WBC/blasts who presented with hypoxia, dyspnea on exertion, and diffuse bone pain. He reported ___ days of worsening pain in multiple areas of his body, predominantly on the left side, but the pain had been rotating. He reported shortness of breath with exertion but no dyspnea at rest. His ___ came to the house yesterday and checked his vitals and found O2 sat to be in the low ___ while at rest. He called his oncologist who recommended coming to the ___ ED. He also noted one episode of non-bloody emesis yesterday. He denied any chest pain other than the rib pain. He denied fever, cough, abdominal pain, and diarrhea. He did note decrease in urinary frequency and darkening or urine color. He denied any sick contacts. On arrival to the ED, initial vitals were 98.2 99 98/60 23 78% RA. Labs were notable for WBC 44.0 (PMNs 2%, lymphs 4%, blasts 86%), H/H 10.8/32.4, Plt 30, Na 130, BUN/Cr ___, ALT 55, AST 94, UA with moderate blood, lactate 1.6, and influenza PCR negative. CXR and CTA chest were negative for PE but did report note new small bilateral pleural effusions and distended stomach/esophagus. Patient was given dilaudid 0.5mg IV and 1L NS. Prior to transfer vitals were 98.8 101 ___ 94% 4L. On the floor he was started on broad coverage with vanc/cefepime to treat possible bacterial pneumonia as well as voriconazole to cover for aspergillus and high dose Bactrim to cover for possible PCP. He was also empirically diuresed with 10mg IV Lasix with 1L of urine output but no significant improvement in dyspnea. He was noted to be intermittently confused. He also spiked a fever to 100.3. He had a persistent oxygen requirement of ___ with sats in the low to mid ___. He was eventually placed on a non-rebreather, reportedly more for comfort. Oxygen saturations were 100% on non-rebreather. Due to concern for leukostasis given his hypoxia and altered mental status he was transferred to the FICU for initiation of pheresis. On arrival to the MICU, his sats were 95-96% on non-rebreather. He reported total body pain as well as some shortness of breath. Past Medical History: Oncologic History: He was initially diagnosed with AML intermediate risk on ___. He was enrolled on clinical trial protocol number ___. He rcd 7 plus 3 and once cycle of HiDAC consolidation. Following CR1, he proceeded to matched sibling RIC allogeneic stem cell transplant with Flu/Bu on ___. He was also diagnosed with male breast ___. He is s/p left mastectomy and excisional sentinal LN ___. Final pathology demonstrated a 2.0 cm grade 2 invasive ductal carcinoma with low-grade DCIS. No LVI or EIC was seen. Surgical margins were 3 mm or greater. One sentinel node was negative. This was ER/PR positive and HER-2/neu negative. Final stage: Stage IIA carcinoma left breast. Followed by Dr ___. The Recurrence Score makes clear that if he were to take ___ years cof Tamoxifen the recurrence risk would be very small, i.e., 5%. and hence Tamoxifen recommended. Started Tamoxifen on ___. - ___: Admitted to the hospital for elective bronchoscopy for diffuse pulmonary opacities b/l predominantly in the lower lobes. Pt was SOB after playing tennis for 45 minutes which led to the CT scan and bronchoscopy. All cultures including pathology were unremarkable. Pt was started on Vfend 350mg po bid in hospital for presumed fungal infection which was decreased. - ___: Diagnosed with COP based on Chest CT and PFT's likely sequele of a viral infection. Started on macrolide therapy with Clarithromycin and Singulair given clinical stability and lack of hypoxia. CT chest 6 weeks later on ___ did not show improvement. Repeat PFT's on ___ showed mild to mod reduced DLCO in the 64% range c.w 76% prior to transplant. Given stability of clinical symptoms it was decided to watch closely and not intervene. - ___: Worsening SOB. CT chest and PFT's suggestive of worsening COP and DLCO. Hence started on PSE 40mg/day on ___ tapered to 30mg on ___, 20mg on ___ and 10mg on ___ given steady improvement and eventually weaned off. - ___: Tacrolimus was stopped. - ___: Diagnosed with relapse of AML. FLT3 D835H TKD mutation identified. Re-induced with MEC. Peripheral blood Lineage specific chimerism demonstrated 97% donor CD3 cells and BM aspirate demonstrated 1.5% donor cells by FISH. However lineage specific chimerism demonstrated > 95% donor CD3s in peripheral blood. - ___: BM aspirate/biopsy repeated with recovery of counts post-re-induction with MEC. No morphologic evidence of leukemia seen. No e.o FLT3 TKD D___ mutation identified. Lineage specific chimerism on peripheral blood upon count recovery and FISH on BM aspirate demonstrated full donor chimerism. - ___: After extensive discussion with family and ___ team, plan made to proceed with DLI from same donor i.e his sister. Pt received DLI=1X10^7/kg. - ___: Found to have drop in plt count to 87K along with viral infection. - ___: Ct chest demonstrated atypical viral infection associated changes. Beta glucan/Galactomannan were negative. Viral swab neg for Flu. - ___: Peripheral blood flow cytometry demonstrated 12% blasts. PAST MEDICAL HISTORY: - Male Breast Cancer s/p Mastectomy (___) - Aspergillosis (___) - Prostatitis (___) - Seizure vs. Syncope ___ all negative - Lyme Disease (___) Social History: ___ Family History: Mr. ___ has one brother with history of stroke. His father died of lung cancer at age ___. His mother died at age ___. Physical Exam: ICU TRANSFER EXAM: GENERAL: ill appearing HEENT: AT/NC NECK: nontender supple neck, no LAD, no JVD CARDIAC: tachycardic, regular, S1/S2, no MRG LUNG: some accessory muscle use 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: No gross motor/coordination abnormalities Discharge exam; pt expired Pertinent Results: ADMISSION LABS: ___ 10:40AM WBC-36.4* RBC-3.66* HGB-12.4* HCT-36.4* MCV-100* MCH-33.9* MCHC-34.1 RDW-14.4 RDWSD-52.7* ___ 10:40AM NEUTS-5* BANDS-0 LYMPHS-17* MONOS-3* EOS-0 BASOS-0 ___ MYELOS-0 BLASTS-75* AbsNeut-1.82 AbsLymp-6.19* AbsMono-1.09* AbsEos-0.00* AbsBaso-0.00* ___ 12:55PM PLT COUNT-53*# ___ 10:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL ___ 04:16PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-4.9* MAGNESIUM-2.3 URIC ACID-6.0 ___ 04:16PM LIPASE-12 ___ 04:16PM ALT(SGPT)-55* AST(SGOT)-94* LD(LDH)-2161* ALK PHOS-78 TOT BILI-0.3 ___ 04:16PM GLUCOSE-165* UREA N-27* CREAT-1.4* SODIUM-130* POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-22 ANION GAP-19 ___ 04:35PM LACTATE-1.6 ___ 08:00PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 08:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 08:30PM URINE RBC-3* WBC-3 BACTERIA-FEW YEAST-NONE EPI-6 CTA CHEST ___. No evidence of pulmonary embolism or aortic dissection. 2. Peribronchial nodular opacities within the upper lobe are similar compared to ___, likely infectious or inflammatory nature. 3. New small bilateral pleural effusions with associated atelectasis. 4. The esophagus and partially imaged stomach are extremely distended with fluid. Esophagus is quite distended with fluid/debris from the stomach to the upper chest. Query slow transit from the stomach. This also places patient at increased risk for aspiration. ECHO ___ Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. XR ABD ___ Nonspecific bowel gas pattern. No evidence of obstruction or ileus. CXR ___ The endotracheal tube is not visualized. The gastric tube extends into the stomach. The tip of a right internal jugular central venous catheter projects over the mid SVC. The tip of an incompletely evaluated PICC line projects over the upper right atrium. Re-demonstration of diffuse bilateral opacities, greater in both lower lung zones which likely reflect atelectasis and pleural effusions. Mild superimposed pulmonary edema is also present. The size of the cardiac silhouette is unchanged. Persisting gaseous distention of the stomach. Derm path ___ Focal dyskeratosis involving epidermal basal layer and follicular epithelium, see note. Note: The findings are subtle but are suggestive of early acute graft versus host disease. Initial and level sections are examined. Echo ___ The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Views of the right ventricule are limited but it appears that the right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular global and regional systolic function. Mild mitral regurgication. At least mild pulmonary artery systolic hypertension. Brief Hospital Course: Mr. ___ is a ___ male with history of stage IIA breast cancer ___ left mastectomy and currently on Tamoxifen and relapse of AML post allogeneic RIC MRD (sister) stem cell transplant (Day 0: ___ for intermediate risk AML in CR1 after being in remission for ___ years. He was re-induced with MEC upon relapse (___) and rcd DLI from same donor (sister) on ___ after achieving remission subsequently found to have relapse post-DLI with 12% myeloblasts on ___ and now s/p 10 days decitabine (___) without response and increasing WBC/blasts who presented with hypoxia, dyspnea on exertion, and diffuse bone pain. MICU COURSE: # Goals of care: upon arrival to ICU, had long discussions w/ family and oncology about his prognosis and goals. Initially patient and family decided to proceed with leukopheresis, curative intent chemotherapy to transplant, and intubation with the understanding that cure and overall improvement could not be guaranteed. As his multiorgan failure progressed and felt his AML could not be cured given persistent blasts, renal failure, GVHD, and inability to get to transplant, the family decided to transition to CMO on ___ and he was terminally extubated with family at bedside. He was transferred to the floor where he passed away on ___. # Acute Hypoxic Respiratory Failure # Dyspnea on Exertion: found to be hypoxic at home to low ___ while at rest. Not symptomatic except more recently with exertion. Likely multiple factors contributing. Severe bone pain in chest/ribs likely limiting air movement and resulting in atelectasis. Also concern for leukostasis given progressively worsening WBC and blasts and so received pheresis upon arrival. CTA negative for PE but did note new small effusions and stable pulmonary opacities. Of note, recent work-up for URI symptoms revealed pulmonary opacities as above and positive B-glucan. Therefore, he was treated broadly for bacterial and fungal sources as well as PJP. Influenza PCR negative. He was intubated prior to initiating chemo given his respiratory status and anticipated worsening respiratory function with chemotherapy. In discussion with ID and oncology felt infectious cause was overall less likely but given severity of illness was covered with broad antibiotics and antifungals, which were adjusted with his renal failure (below) and transaminitis. Overall, his poor respiratory status was felt ___ leukemia/leukostasis, volume overload ___ renal failure. He also intermittently required pressors to maintain his blood pressures, felt perhaps related to his sedation but also covered for infections. He transitioned to CMO on ___ so abx were stopped and he was terminally extubated. # Relapsed AML with neutropenia: relapse after being in remission for ___ years post allogeneic transplant. AML relapse was diagnosed on ___ with appearance of D835H mutation, normal cytogenetics and 97% donor T-cells on peripheral blood chimerism. Re-induced with MEC (___), s/p DLI from sister on ___ and now s/p 10 days of decitabine with increasing WBC/blasts. ___ protocol started ___ and completed his first cycle. He was monitored for tumor lysis and received rasburicase as needed. Also received allopurinol and hydroxyurea was stopped. GCSF was started given his neutropenia. Given his renal failure he was not a candidate to receive another transplant. His course was also complicated by GVHD which manifested as diffuse erythema and skin sloughing w/ positive nikolsky. Derm was consulted and skin biopsy showed GVHD. In discussion with onc and his poor prognosis from these findings, he was transitioned to CMO on ___. # Acute Kidney Injury & TLS: likely prerenal ___ initially that resolved but then worsened while on pressors and after chemo started on ___. Also had contrast load earlier in hospitalization, several nephrotoxic meds and TLS despite management as above. Renal was consulted and initially he was trialed on Lasix gtt without good response. Because of his volume overload affecting his respiratory status and electrolyte derangements, he was started on CVVH. This was stopped on ___ as above. #AF with RVR, STE, tropinemia: his course was also complicated by AF with RVR and STE with tropinemia. Cardiology was consulted and felt his ST elevations and elevated troponins were related to demand and global myocardial ischemia as opposed to focal infarcts. Given his overall poor health and instability, did not feel he was a candidate for catheterization or for systemic anticoagulation. His echo did not show any focal wall motion abnormalities and showed hyperdynamic LV function. He was rate controlled as tolerated. # Thrombocytopenia/Anemia: secondary to AML. No evidence of active bleeding. Expect to drop with chemo. He was transfused as needed. He did have episodes of frank hemoptysis with clots suctioned from his ETT for which he was managed supportively. # Diffuse Bone Pain # Cancer-Related Pain: likely secondary to bone marrow involvement from progressive AML with rising blasts. Sedated w/ fentanyl and then transitioned to dilaudid gtt. Greater than 30 minutes were spent on planning and execution of this discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO TID 2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath/wheezing 3. Multivitamins 1 TAB PO DAILY 4. Tamoxifen Citrate 20 mg PO QAM 5. Vitamin D 1000 UNIT PO DAILY 6. Voriconazole 150 mg PO Q12H 7. Allopurinol ___ mg PO DAILY 8. Lorazepam 0.5 mg PO Q6H:PRN anxiety/nausea/vomiting 9. Hydroxyurea 1000 mg PO BID 10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: Multiple myeloma sepsis acute kidney failure Discharge Condition: Expired Discharge Instructions: none Followup Instructions: ___
[ "J9601", "E883", "R6520", "A419", "B441", "J90", "B59", "E872", "J159", "D89813", "Z9484", "C92Z0", "J9811", "N179", "E871", "I248", "R042", "D689", "D709", "R5081", "E860", "E875", "G893", "I4891", "D6959", "D630", "H1133", "T451X5A", "Z66", "Z515", "Z781", "Z006", "Z853", "Z9012", "Z87891", "Y92230" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Hypoxia, AMS Major Surgical or Invasive Procedure: Intubated [MASKED] R pheresis line [MASKED] Pheresis [MASKED] History of Present Illness: [MASKED] male with history of stage IIA breast cancer [MASKED] left mastectomy and currently on Tamoxifen and relapse of AML post allogeneic RIC MRD (sister) stem cell transplant (Day 0: [MASKED] for intermediate risk AML in CR1 after being in remission for [MASKED] years. He was re-induced with MEC upon relapse ([MASKED]) and rcd DLI from same donor (sister) on [MASKED] after achieving remission subsequently found to have relapse post-DLI with 12% myeloblasts on [MASKED] and now s/p 10 days decitabine ([MASKED]) without response and increasing WBC/blasts who presented with hypoxia, dyspnea on exertion, and diffuse bone pain. He reported [MASKED] days of worsening pain in multiple areas of his body, predominantly on the left side, but the pain had been rotating. He reported shortness of breath with exertion but no dyspnea at rest. His [MASKED] came to the house yesterday and checked his vitals and found O2 sat to be in the low [MASKED] while at rest. He called his oncologist who recommended coming to the [MASKED] ED. He also noted one episode of non-bloody emesis yesterday. He denied any chest pain other than the rib pain. He denied fever, cough, abdominal pain, and diarrhea. He did note decrease in urinary frequency and darkening or urine color. He denied any sick contacts. On arrival to the ED, initial vitals were 98.2 99 98/60 23 78% RA. Labs were notable for WBC 44.0 (PMNs 2%, lymphs 4%, blasts 86%), H/H 10.8/32.4, Plt 30, Na 130, BUN/Cr [MASKED], ALT 55, AST 94, UA with moderate blood, lactate 1.6, and influenza PCR negative. CXR and CTA chest were negative for PE but did report note new small bilateral pleural effusions and distended stomach/esophagus. Patient was given dilaudid 0.5mg IV and 1L NS. Prior to transfer vitals were 98.8 101 [MASKED] 94% 4L. On the floor he was started on broad coverage with vanc/cefepime to treat possible bacterial pneumonia as well as voriconazole to cover for aspergillus and high dose Bactrim to cover for possible PCP. He was also empirically diuresed with 10mg IV Lasix with 1L of urine output but no significant improvement in dyspnea. He was noted to be intermittently confused. He also spiked a fever to 100.3. He had a persistent oxygen requirement of [MASKED] with sats in the low to mid [MASKED]. He was eventually placed on a non-rebreather, reportedly more for comfort. Oxygen saturations were 100% on non-rebreather. Due to concern for leukostasis given his hypoxia and altered mental status he was transferred to the FICU for initiation of pheresis. On arrival to the MICU, his sats were 95-96% on non-rebreather. He reported total body pain as well as some shortness of breath. Past Medical History: Oncologic History: He was initially diagnosed with AML intermediate risk on [MASKED]. He was enrolled on clinical trial protocol number [MASKED]. He rcd 7 plus 3 and once cycle of HiDAC consolidation. Following CR1, he proceeded to matched sibling RIC allogeneic stem cell transplant with Flu/Bu on [MASKED]. He was also diagnosed with male breast [MASKED]. He is s/p left mastectomy and excisional sentinal LN [MASKED]. Final pathology demonstrated a 2.0 cm grade 2 invasive ductal carcinoma with low-grade DCIS. No LVI or EIC was seen. Surgical margins were 3 mm or greater. One sentinel node was negative. This was ER/PR positive and HER-2/neu negative. Final stage: Stage IIA carcinoma left breast. Followed by Dr [MASKED]. The Recurrence Score makes clear that if he were to take [MASKED] years cof Tamoxifen the recurrence risk would be very small, i.e., 5%. and hence Tamoxifen recommended. Started Tamoxifen on [MASKED]. - [MASKED]: Admitted to the hospital for elective bronchoscopy for diffuse pulmonary opacities b/l predominantly in the lower lobes. Pt was SOB after playing tennis for 45 minutes which led to the CT scan and bronchoscopy. All cultures including pathology were unremarkable. Pt was started on Vfend 350mg po bid in hospital for presumed fungal infection which was decreased. - [MASKED]: Diagnosed with COP based on Chest CT and PFT's likely sequele of a viral infection. Started on macrolide therapy with Clarithromycin and Singulair given clinical stability and lack of hypoxia. CT chest 6 weeks later on [MASKED] did not show improvement. Repeat PFT's on [MASKED] showed mild to mod reduced DLCO in the 64% range c.w 76% prior to transplant. Given stability of clinical symptoms it was decided to watch closely and not intervene. - [MASKED]: Worsening SOB. CT chest and PFT's suggestive of worsening COP and DLCO. Hence started on PSE 40mg/day on [MASKED] tapered to 30mg on [MASKED], 20mg on [MASKED] and 10mg on [MASKED] given steady improvement and eventually weaned off. - [MASKED]: Tacrolimus was stopped. - [MASKED]: Diagnosed with relapse of AML. FLT3 D835H TKD mutation identified. Re-induced with MEC. Peripheral blood Lineage specific chimerism demonstrated 97% donor CD3 cells and BM aspirate demonstrated 1.5% donor cells by FISH. However lineage specific chimerism demonstrated > 95% donor CD3s in peripheral blood. - [MASKED]: BM aspirate/biopsy repeated with recovery of counts post-re-induction with MEC. No morphologic evidence of leukemia seen. No e.o FLT3 TKD D mutation identified. Lineage specific chimerism on peripheral blood upon count recovery and FISH on BM aspirate demonstrated full donor chimerism. - [MASKED]: After extensive discussion with family and [MASKED] team, plan made to proceed with DLI from same donor i.e his sister. Pt received DLI=1X10^7/kg. - [MASKED]: Found to have drop in plt count to 87K along with viral infection. - [MASKED]: Ct chest demonstrated atypical viral infection associated changes. Beta glucan/Galactomannan were negative. Viral swab neg for Flu. - [MASKED]: Peripheral blood flow cytometry demonstrated 12% blasts. PAST MEDICAL HISTORY: - Male Breast Cancer s/p Mastectomy ([MASKED]) - Aspergillosis ([MASKED]) - Prostatitis ([MASKED]) - Seizure vs. Syncope [MASKED] all negative - Lyme Disease ([MASKED]) Social History: [MASKED] Family History: Mr. [MASKED] has one brother with history of stroke. His father died of lung cancer at age [MASKED]. His mother died at age [MASKED]. Physical Exam: ICU TRANSFER EXAM: GENERAL: ill appearing HEENT: AT/NC NECK: nontender supple neck, no LAD, no JVD CARDIAC: tachycardic, regular, S1/S2, no MRG LUNG: some accessory muscle use 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: No gross motor/coordination abnormalities Discharge exam; pt expired Pertinent Results: ADMISSION LABS: [MASKED] 10:40AM WBC-36.4* RBC-3.66* HGB-12.4* HCT-36.4* MCV-100* MCH-33.9* MCHC-34.1 RDW-14.4 RDWSD-52.7* [MASKED] 10:40AM NEUTS-5* BANDS-0 LYMPHS-17* MONOS-3* EOS-0 BASOS-0 [MASKED] MYELOS-0 BLASTS-75* AbsNeut-1.82 AbsLymp-6.19* AbsMono-1.09* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:55PM PLT COUNT-53*# [MASKED] 10:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL [MASKED] 04:16PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-4.9* MAGNESIUM-2.3 URIC ACID-6.0 [MASKED] 04:16PM LIPASE-12 [MASKED] 04:16PM ALT(SGPT)-55* AST(SGOT)-94* LD(LDH)-2161* ALK PHOS-78 TOT BILI-0.3 [MASKED] 04:16PM GLUCOSE-165* UREA N-27* CREAT-1.4* SODIUM-130* POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-22 ANION GAP-19 [MASKED] 04:35PM LACTATE-1.6 [MASKED] 08:00PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 08:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 08:30PM URINE RBC-3* WBC-3 BACTERIA-FEW YEAST-NONE EPI-6 CTA CHEST [MASKED]. No evidence of pulmonary embolism or aortic dissection. 2. Peribronchial nodular opacities within the upper lobe are similar compared to [MASKED], likely infectious or inflammatory nature. 3. New small bilateral pleural effusions with associated atelectasis. 4. The esophagus and partially imaged stomach are extremely distended with fluid. Esophagus is quite distended with fluid/debris from the stomach to the upper chest. Query slow transit from the stomach. This also places patient at increased risk for aspiration. ECHO [MASKED] Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. XR ABD [MASKED] Nonspecific bowel gas pattern. No evidence of obstruction or ileus. CXR [MASKED] The endotracheal tube is not visualized. The gastric tube extends into the stomach. The tip of a right internal jugular central venous catheter projects over the mid SVC. The tip of an incompletely evaluated PICC line projects over the upper right atrium. Re-demonstration of diffuse bilateral opacities, greater in both lower lung zones which likely reflect atelectasis and pleural effusions. Mild superimposed pulmonary edema is also present. The size of the cardiac silhouette is unchanged. Persisting gaseous distention of the stomach. Derm path [MASKED] Focal dyskeratosis involving epidermal basal layer and follicular epithelium, see note. Note: The findings are subtle but are suggestive of early acute graft versus host disease. Initial and level sections are examined. Echo [MASKED] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Views of the right ventricule are limited but it appears that the right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular global and regional systolic function. Mild mitral regurgication. At least mild pulmonary artery systolic hypertension. Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with history of stage IIA breast cancer [MASKED] left mastectomy and currently on Tamoxifen and relapse of AML post allogeneic RIC MRD (sister) stem cell transplant (Day 0: [MASKED] for intermediate risk AML in CR1 after being in remission for [MASKED] years. He was re-induced with MEC upon relapse ([MASKED]) and rcd DLI from same donor (sister) on [MASKED] after achieving remission subsequently found to have relapse post-DLI with 12% myeloblasts on [MASKED] and now s/p 10 days decitabine ([MASKED]) without response and increasing WBC/blasts who presented with hypoxia, dyspnea on exertion, and diffuse bone pain. MICU COURSE: # Goals of care: upon arrival to ICU, had long discussions w/ family and oncology about his prognosis and goals. Initially patient and family decided to proceed with leukopheresis, curative intent chemotherapy to transplant, and intubation with the understanding that cure and overall improvement could not be guaranteed. As his multiorgan failure progressed and felt his AML could not be cured given persistent blasts, renal failure, GVHD, and inability to get to transplant, the family decided to transition to CMO on [MASKED] and he was terminally extubated with family at bedside. He was transferred to the floor where he passed away on [MASKED]. # Acute Hypoxic Respiratory Failure # Dyspnea on Exertion: found to be hypoxic at home to low [MASKED] while at rest. Not symptomatic except more recently with exertion. Likely multiple factors contributing. Severe bone pain in chest/ribs likely limiting air movement and resulting in atelectasis. Also concern for leukostasis given progressively worsening WBC and blasts and so received pheresis upon arrival. CTA negative for PE but did note new small effusions and stable pulmonary opacities. Of note, recent work-up for URI symptoms revealed pulmonary opacities as above and positive B-glucan. Therefore, he was treated broadly for bacterial and fungal sources as well as PJP. Influenza PCR negative. He was intubated prior to initiating chemo given his respiratory status and anticipated worsening respiratory function with chemotherapy. In discussion with ID and oncology felt infectious cause was overall less likely but given severity of illness was covered with broad antibiotics and antifungals, which were adjusted with his renal failure (below) and transaminitis. Overall, his poor respiratory status was felt [MASKED] leukemia/leukostasis, volume overload [MASKED] renal failure. He also intermittently required pressors to maintain his blood pressures, felt perhaps related to his sedation but also covered for infections. He transitioned to CMO on [MASKED] so abx were stopped and he was terminally extubated. # Relapsed AML with neutropenia: relapse after being in remission for [MASKED] years post allogeneic transplant. AML relapse was diagnosed on [MASKED] with appearance of D835H mutation, normal cytogenetics and 97% donor T-cells on peripheral blood chimerism. Re-induced with MEC ([MASKED]), s/p DLI from sister on [MASKED] and now s/p 10 days of decitabine with increasing WBC/blasts. [MASKED] protocol started [MASKED] and completed his first cycle. He was monitored for tumor lysis and received rasburicase as needed. Also received allopurinol and hydroxyurea was stopped. GCSF was started given his neutropenia. Given his renal failure he was not a candidate to receive another transplant. His course was also complicated by GVHD which manifested as diffuse erythema and skin sloughing w/ positive nikolsky. Derm was consulted and skin biopsy showed GVHD. In discussion with onc and his poor prognosis from these findings, he was transitioned to CMO on [MASKED]. # Acute Kidney Injury & TLS: likely prerenal [MASKED] initially that resolved but then worsened while on pressors and after chemo started on [MASKED]. Also had contrast load earlier in hospitalization, several nephrotoxic meds and TLS despite management as above. Renal was consulted and initially he was trialed on Lasix gtt without good response. Because of his volume overload affecting his respiratory status and electrolyte derangements, he was started on CVVH. This was stopped on [MASKED] as above. #AF with RVR, STE, tropinemia: his course was also complicated by AF with RVR and STE with tropinemia. Cardiology was consulted and felt his ST elevations and elevated troponins were related to demand and global myocardial ischemia as opposed to focal infarcts. Given his overall poor health and instability, did not feel he was a candidate for catheterization or for systemic anticoagulation. His echo did not show any focal wall motion abnormalities and showed hyperdynamic LV function. He was rate controlled as tolerated. # Thrombocytopenia/Anemia: secondary to AML. No evidence of active bleeding. Expect to drop with chemo. He was transfused as needed. He did have episodes of frank hemoptysis with clots suctioned from his ETT for which he was managed supportively. # Diffuse Bone Pain # Cancer-Related Pain: likely secondary to bone marrow involvement from progressive AML with rising blasts. Sedated w/ fentanyl and then transitioned to dilaudid gtt. Greater than 30 minutes were spent on planning and execution of this discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO TID 2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath/wheezing 3. Multivitamins 1 TAB PO DAILY 4. Tamoxifen Citrate 20 mg PO QAM 5. Vitamin D 1000 UNIT PO DAILY 6. Voriconazole 150 mg PO Q12H 7. Allopurinol [MASKED] mg PO DAILY 8. Lorazepam 0.5 mg PO Q6H:PRN anxiety/nausea/vomiting 9. Hydroxyurea 1000 mg PO BID 10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: Multiple myeloma sepsis acute kidney failure Discharge Condition: Expired Discharge Instructions: none Followup Instructions: [MASKED]
[]
[ "J9601", "E872", "N179", "E871", "I4891", "Z66", "Z515", "Z87891", "Y92230" ]
[ "J9601: Acute respiratory failure with hypoxia", "E883: Tumor lysis syndrome", "R6520: Severe sepsis without septic shock", "A419: Sepsis, unspecified organism", "B441: Other pulmonary aspergillosis", "J90: Pleural effusion, not elsewhere classified", "B59: Pneumocystosis", "E872: Acidosis", "J159: Unspecified bacterial pneumonia", "D89813: Graft-versus-host disease, unspecified", "Z9484: Stem cells transplant status", "C92Z0: Other myeloid leukemia not having achieved remission", "J9811: Atelectasis", "N179: Acute kidney failure, unspecified", "E871: Hypo-osmolality and hyponatremia", "I248: Other forms of acute ischemic heart disease", "R042: Hemoptysis", "D689: Coagulation defect, unspecified", "D709: Neutropenia, unspecified", "R5081: Fever presenting with conditions classified elsewhere", "E860: Dehydration", "E875: Hyperkalemia", "G893: Neoplasm related pain (acute) (chronic)", "I4891: Unspecified atrial fibrillation", "D6959: Other secondary thrombocytopenia", "D630: Anemia in neoplastic disease", "H1133: Conjunctival hemorrhage, bilateral", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z781: Physical restraint status", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z853: Personal history of malignant neoplasm of breast", "Z9012: Acquired absence of left breast and nipple", "Z87891: Personal history of nicotine dependence", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,035,780
21,074,018
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: Fever/Lethargy/Confusion Major Surgical or Invasive Procedure: Hemodialysis ___ History of Present Illness: This patient is a ___ yo F with a hx of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV presenting with lethargy and fever following dialysis. The patient's daughter noted that she was not as interactive when she was receiving dialysis yesterday, and complaining of feeling hot. She brought her into the ED where she was febrile to 100.8, and found to have a WBC of 19.1, lactate of 2.6, and UA showing numerous WBCs (CT head negative). A trigger was called for unresponsiveness. She responded well to empiric coverage with vanc/cefepime/flagyl. The daughter mentioned that she has been getting UTIs frequently, and her last one in ___ was similar in presentation. On transfer to the floor, the patient was doing much better. This morning, she appeared 60% of her baseline (in terms of mental status) as per her daughter's report. Currently, she denies dysuria, f/c, abdominal pain, chest pain, or leg pain. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in ___ - h/o C diff Social History: ___ Family History: She is widowed and she has 7 children, and in apparently good health. Physical Exam: ADMISSION ========= VITALS: 97.6 | 135/57 | 89 | 18 | 97 RA GENERAL: NAD, ___ only, alert, oriented x 2 (knew name, ___," and ___ but couldn't give date or year) HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, fistula at R forearm w/ dressing PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength 4+/5 in all extremities SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE ========== VITALS: 98.2 | 153/62 | 81 | 20 | 97RA GENERAL: NAD, ___ only, alert HEENT: anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, slight holosystolic murmur at the base LUNG: CTAB, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, slight peripheral edema in ___, fistula at L forearm PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII grossly intact, mildly weak in all extremities SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: CBC ==== ___ 06:19AM BLOOD WBC-8.5 RBC-3.37* Hgb-11.0* Hct-32.9* MCV-98 MCH-32.6* MCHC-33.4 RDW-14.6 RDWSD-51.3* Plt ___ ___ 08:20AM BLOOD WBC-8.8 RBC-3.46* Hgb-11.2 Hct-34.5 MCV-100* MCH-32.4* MCHC-32.5 RDW-14.8 RDWSD-53.1* Plt ___ ___ 07:30AM BLOOD WBC-7.9 RBC-3.34* Hgb-10.8* Hct-33.4* MCV-100* MCH-32.3* MCHC-32.3 RDW-14.8 RDWSD-53.7* Plt ___ ___ 06:22AM BLOOD WBC-10.6* RBC-3.48* Hgb-11.2 Hct-33.9* MCV-97 MCH-32.2* MCHC-33.0 RDW-14.4 RDWSD-51.1* Plt ___ ___ 08:11AM BLOOD WBC-10.9* RBC-3.60* Hgb-11.7 Hct-35.3 MCV-98 MCH-32.5* MCHC-33.1 RDW-14.7 RDWSD-53.0* Plt ___ ___ 03:37PM BLOOD WBC-19.1* RBC-4.37 Hgb-14.2# Hct-41.9 MCV-96 MCH-32.5* MCHC-33.9 RDW-14.7 RDWSD-51.5* Plt ___ BMP ==== ___ 06:19AM BLOOD Glucose-109* UreaN-76* Creat-3.6*# Na-133 K-4.3 Cl-93* HCO3-25 AnGap-19 ___ 08:20AM BLOOD Glucose-101* UreaN-55* Creat-3.2* Na-135 K-4.4 Cl-94* HCO3-27 AnGap-18 ___ 07:30AM BLOOD Glucose-107* UreaN-36* Creat-2.6* Na-136 K-4.2 Cl-97 HCO3-27 AnGap-16 ___ 06:22AM BLOOD Glucose-143* UreaN-69* Creat-3.6* Na-132* K-3.9 Cl-95* HCO3-22 AnGap-19 ___ 08:11AM BLOOD Glucose-114* UreaN-40* Creat-3.0* Na-132* K-3.9 Cl-96 HCO3-23 AnGap-17 ___ 03:37PM BLOOD Glucose-179* UreaN-24* Creat-2.2* Na-128* K-7.6* Cl-87* HCO3-26 AnGap-23* LFTs ==== ___ 07:30AM BLOOD ALT-80* AST-109* AlkPhos-119* TotBili-0.3 ___ 08:11AM BLOOD ALT-86* AST-104* AlkPhos-125* TotBili-0.4 ___ 03:37PM BLOOD ALT-101* AST-219* AlkPhos-142* TotBili-0.5 LACTATE ======= ___ 10:39AM BLOOD Lactate-1.0 ___ 03:58PM BLOOD Lactate-2.6* URINE ===== ___ 12:30PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 04:00PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12:30PM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG ___ 12:30PM URINE RBC-3* WBC-47* Bacteri-FEW Yeast-NONE Epi-3 ___ 04:00PM URINE RBC-1 WBC-143* Bacteri-MANY Yeast-NONE Epi-<1 MICRO ====== ___ 12:49 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Time Taken Not Noted Log-In Date/Time: ___ 9:59 pm URINE Site: NOT SPECIFIED CHEM S# ___ UCU ADDED 05.18. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R CT HEAD- ___ ============ IMPRESSION: No acute intracranial process. Lacunar infarct in the right pons. Additional chronic changes. MRI is more sensitive in detecting acute ischemia. RUQ US= ___ ============ IMPRESSION: Prominent extra hepatic bile duct measuring up to 10 mm without intrahepatic dilatation. This finding is stable since prior exam however if LFTs suggest biliary obstruction further evaluation with MRCP could be obtained. Brief Hospital Course: Ms. ___ is a ___ yo F with a hx of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV presenting with lethargy and fever following dialysis. The patient's daughter noted that she was not as interactive when she was receiving dialysis on ___, and complaining of feeling hot. She brought her into the ED where she was febrile to 100.8, and found to have a WBC of 19.1, lactate of 2.6, and UA showing numerous WBCs (CT head negative). A trigger was called for unresponsiveness in the ED. She responded well to empiric coverage with vanc/cefepime/flagyl before transfer to the floor. Of note, the daughter mentioned that she has been getting UTIs frequently, and that her last one in ___ was similar in presentation. # Urinary tract infection: Ms. ___ was treated with IV ceftriaxone until her UCx speciation returned positive for multidrug resistant E. coli. Her WBC continued to downtrend from the initial level of 19 on admission. She was switched to IV ceftazadime once her sensitivities returned, and completed her treatment course on ___. Given her history of multiple UTIs recently, it was suggested that her PCP consider imaging/urogynocological evaluation or prophylactic abx moving forward. # Transaminitis: Patient has a history of HCV/HBV coinfection, however, it was thought that her initial transaminitis on admission (ALT 101 AST 219) was due to septic pathology (possibly insufficient hepatic perfusion from hypotension during volume shifts during dialysis). There was no evidence of cirrhosis or synthetic dysfunction (RUQ US with no change). Her LFTs continued to downtrend throughout the admission. # Elevated lactate- she initially presented with an elevated lactate of 2.5, likely caused by urosepsis vs. hypotension in the setting of volume shifts during dialysis. The lactate downtrended to 1 by the first day of admission. # Acute Encephalopathy: Ms. ___ presented with altered mental status on admission likely secondary to toxic metabolic effects, and had a negative head CT in the ED. Her mental status steadily improved with IV antibiotics and was close to baseline at the time of discharge. # Dialysis- Ms. ___ received dialysis on her usual MWF schedule while admitted. Last dialysis session was ___. # Chronic- Ms. ___ received her home medications for DM, HTN, osteoporosis, asthma, and gout while admitted. TRANSITIONAL ISSUES: ==================== [] F/u with PCP within one week to discuss urogyn evaluation, further imaging, or prophylactic antibiotics to prevent future UTIs (based on her prior speciation/sensitivities, however, there may not be a good oral antibiotic for prophylaxis in her case) [] Discuss possible need for anticoagulation with PCP given diagnosis of atrial fibrillation with RVR (diagnosed during ___ admission, never in afib during current admission) [] Discuss possible need to uptitrate antihypertensive medications (systolic BPs in the 140s-160s while admitted) [] F/u ___ blood cultures to final result [] consider checking LFTs at PCP appointment on ___ [] NEW MEDICATIONS: Loperamide 2mg every 2 hrs as needed for diarrhea [] CHANGED MEDICATIONS: none [] STOPPED MEDICATIONS: none [] APPOINTMENTS: PCP appointment on ___ at 11am [] follow 2gm low salt diet, 2g potassium CODE STATUS: FULL CODE HCP/CONTACT: daughter, ___ To ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO BID 2. Aspirin EC 325 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Furosemide 80 mg PO BID 6. Losartan Potassium 100 mg PO 4X/WEEK (___) 7. Metoprolol Succinate XL 200 mg PO DAILY 8. Montelukast 10 mg PO DAILY 9. NIFEdipine CR 90 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Omeprazole 20 mg PO BID 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 13. Alendronate Sodium 35 mg PO QWED 14. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 15. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 16. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 17. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 18. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 19. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol ___ mg PO BID 4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Furosemide 80 mg PO BID 9. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 10. Losartan Potassium 100 mg PO 4X/WEEK (___) 11. Metoprolol Succinate XL 200 mg PO DAILY 12. NIFEdipine CR 90 mg PO DAILY 13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 14. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 15. Montelukast 10 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Omeprazole 20 mg PO BID 18. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 19. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 20. LOPERamide 2 mg PO QID:PRN diarrhea RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by mouth four times a day Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Urinary Tract Infection - Transaminitis Secondary Diagnoses: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - Osteoporosis - HLD - Asthma - Anemia - HBV /HCV - Gout - GERD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You were admitted to ___ on ___ because of lethargy, confusion, and fever after your dialysis session. When you came to the hospital, we found out that you had a urinary tract infection, similar to ones you have had in the past. This is likely what caused your symptoms. After treating you with IV antibiotics, your confusion and fever improved. You finished your last dose of antibiotics on ___ ___, and won't require any antibiotics on discharge. While here, you also had some diarrhea. This can often happen when on antibiotics. We determined that it was not caused by a separate intestinal infection. It should resolve over the next several days. To prevent urinary tract infections, it is important to practice good hygiene. The most common source of bacteria is stool, so ensuring that you clean well after stooling is important. You should discuss with your PCP whether or not long term antibiotics to prevent infection is an option for you. Please continue to take all your medications as prescribed. See below for a list of follow up appointments. Thank you for allowing us to participate in your care. Sincerely, Your ___ Medicine team Followup Instructions: ___
[ "A419", "G9341", "E1122", "I120", "N186", "N390", "R6520", "A498", "Z1624", "Z992", "Z794", "I2510", "Z8619", "Z87440", "M1990", "M810", "E785", "J45909", "D649", "M109", "K219", "Z7982" ]
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: Fever/Lethargy/Confusion Major Surgical or Invasive Procedure: Hemodialysis [MASKED] History of Present Illness: This patient is a [MASKED] yo F with a hx of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV presenting with lethargy and fever following dialysis. The patient's daughter noted that she was not as interactive when she was receiving dialysis yesterday, and complaining of feeling hot. She brought her into the ED where she was febrile to 100.8, and found to have a WBC of 19.1, lactate of 2.6, and UA showing numerous WBCs (CT head negative). A trigger was called for unresponsiveness. She responded well to empiric coverage with vanc/cefepime/flagyl. The daughter mentioned that she has been getting UTIs frequently, and her last one in [MASKED] was similar in presentation. On transfer to the floor, the patient was doing much better. This morning, she appeared 60% of her baseline (in terms of mental status) as per her daughter's report. Currently, she denies dysuria, f/c, abdominal pain, chest pain, or leg pain. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG [MASKED] - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in [MASKED] - h/o C diff Social History: [MASKED] Family History: She is widowed and she has 7 children, and in apparently good health. Physical Exam: ADMISSION ========= VITALS: 97.6 | 135/57 | 89 | 18 | 97 RA GENERAL: NAD, [MASKED] only, alert, oriented x 2 (knew name, [MASKED]," and [MASKED] but couldn't give date or year) HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, fistula at R forearm w/ dressing PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength 4+/5 in all extremities SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE ========== VITALS: 98.2 | 153/62 | 81 | 20 | 97RA GENERAL: NAD, [MASKED] only, alert HEENT: anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, slight holosystolic murmur at the base LUNG: CTAB, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, slight peripheral edema in [MASKED], fistula at L forearm PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII grossly intact, mildly weak in all extremities SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: CBC ==== [MASKED] 06:19AM BLOOD WBC-8.5 RBC-3.37* Hgb-11.0* Hct-32.9* MCV-98 MCH-32.6* MCHC-33.4 RDW-14.6 RDWSD-51.3* Plt [MASKED] [MASKED] 08:20AM BLOOD WBC-8.8 RBC-3.46* Hgb-11.2 Hct-34.5 MCV-100* MCH-32.4* MCHC-32.5 RDW-14.8 RDWSD-53.1* Plt [MASKED] [MASKED] 07:30AM BLOOD WBC-7.9 RBC-3.34* Hgb-10.8* Hct-33.4* MCV-100* MCH-32.3* MCHC-32.3 RDW-14.8 RDWSD-53.7* Plt [MASKED] [MASKED] 06:22AM BLOOD WBC-10.6* RBC-3.48* Hgb-11.2 Hct-33.9* MCV-97 MCH-32.2* MCHC-33.0 RDW-14.4 RDWSD-51.1* Plt [MASKED] [MASKED] 08:11AM BLOOD WBC-10.9* RBC-3.60* Hgb-11.7 Hct-35.3 MCV-98 MCH-32.5* MCHC-33.1 RDW-14.7 RDWSD-53.0* Plt [MASKED] [MASKED] 03:37PM BLOOD WBC-19.1* RBC-4.37 Hgb-14.2# Hct-41.9 MCV-96 MCH-32.5* MCHC-33.9 RDW-14.7 RDWSD-51.5* Plt [MASKED] BMP ==== [MASKED] 06:19AM BLOOD Glucose-109* UreaN-76* Creat-3.6*# Na-133 K-4.3 Cl-93* HCO3-25 AnGap-19 [MASKED] 08:20AM BLOOD Glucose-101* UreaN-55* Creat-3.2* Na-135 K-4.4 Cl-94* HCO3-27 AnGap-18 [MASKED] 07:30AM BLOOD Glucose-107* UreaN-36* Creat-2.6* Na-136 K-4.2 Cl-97 HCO3-27 AnGap-16 [MASKED] 06:22AM BLOOD Glucose-143* UreaN-69* Creat-3.6* Na-132* K-3.9 Cl-95* HCO3-22 AnGap-19 [MASKED] 08:11AM BLOOD Glucose-114* UreaN-40* Creat-3.0* Na-132* K-3.9 Cl-96 HCO3-23 AnGap-17 [MASKED] 03:37PM BLOOD Glucose-179* UreaN-24* Creat-2.2* Na-128* K-7.6* Cl-87* HCO3-26 AnGap-23* LFTs ==== [MASKED] 07:30AM BLOOD ALT-80* AST-109* AlkPhos-119* TotBili-0.3 [MASKED] 08:11AM BLOOD ALT-86* AST-104* AlkPhos-125* TotBili-0.4 [MASKED] 03:37PM BLOOD ALT-101* AST-219* AlkPhos-142* TotBili-0.5 LACTATE ======= [MASKED] 10:39AM BLOOD Lactate-1.0 [MASKED] 03:58PM BLOOD Lactate-2.6* URINE ===== [MASKED] 12:30PM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 04:00PM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 12:30PM URINE Blood-SM Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD [MASKED] 04:00PM URINE Blood-NEG Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG [MASKED] 12:30PM URINE RBC-3* WBC-47* Bacteri-FEW Yeast-NONE Epi-3 [MASKED] 04:00PM URINE RBC-1 WBC-143* Bacteri-MANY Yeast-NONE Epi-<1 MICRO ====== [MASKED] 12:49 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Time Taken Not Noted Log-In Date/Time: [MASKED] 9:59 pm URINE Site: NOT SPECIFIED CHEM S# [MASKED] UCU ADDED 05.18. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R CT HEAD- [MASKED] ============ IMPRESSION: No acute intracranial process. Lacunar infarct in the right pons. Additional chronic changes. MRI is more sensitive in detecting acute ischemia. RUQ US= [MASKED] ============ IMPRESSION: Prominent extra hepatic bile duct measuring up to 10 mm without intrahepatic dilatation. This finding is stable since prior exam however if LFTs suggest biliary obstruction further evaluation with MRCP could be obtained. Brief Hospital Course: Ms. [MASKED] is a [MASKED] yo F with a hx of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV presenting with lethargy and fever following dialysis. The patient's daughter noted that she was not as interactive when she was receiving dialysis on [MASKED], and complaining of feeling hot. She brought her into the ED where she was febrile to 100.8, and found to have a WBC of 19.1, lactate of 2.6, and UA showing numerous WBCs (CT head negative). A trigger was called for unresponsiveness in the ED. She responded well to empiric coverage with vanc/cefepime/flagyl before transfer to the floor. Of note, the daughter mentioned that she has been getting UTIs frequently, and that her last one in [MASKED] was similar in presentation. # Urinary tract infection: Ms. [MASKED] was treated with IV ceftriaxone until her UCx speciation returned positive for multidrug resistant E. coli. Her WBC continued to downtrend from the initial level of 19 on admission. She was switched to IV ceftazadime once her sensitivities returned, and completed her treatment course on [MASKED]. Given her history of multiple UTIs recently, it was suggested that her PCP consider imaging/urogynocological evaluation or prophylactic abx moving forward. # Transaminitis: Patient has a history of HCV/HBV coinfection, however, it was thought that her initial transaminitis on admission (ALT 101 AST 219) was due to septic pathology (possibly insufficient hepatic perfusion from hypotension during volume shifts during dialysis). There was no evidence of cirrhosis or synthetic dysfunction (RUQ US with no change). Her LFTs continued to downtrend throughout the admission. # Elevated lactate- she initially presented with an elevated lactate of 2.5, likely caused by urosepsis vs. hypotension in the setting of volume shifts during dialysis. The lactate downtrended to 1 by the first day of admission. # Acute Encephalopathy: Ms. [MASKED] presented with altered mental status on admission likely secondary to toxic metabolic effects, and had a negative head CT in the ED. Her mental status steadily improved with IV antibiotics and was close to baseline at the time of discharge. # Dialysis- Ms. [MASKED] received dialysis on her usual MWF schedule while admitted. Last dialysis session was [MASKED]. # Chronic- Ms. [MASKED] received her home medications for DM, HTN, osteoporosis, asthma, and gout while admitted. TRANSITIONAL ISSUES: ==================== [] F/u with PCP within one week to discuss urogyn evaluation, further imaging, or prophylactic antibiotics to prevent future UTIs (based on her prior speciation/sensitivities, however, there may not be a good oral antibiotic for prophylaxis in her case) [] Discuss possible need for anticoagulation with PCP given diagnosis of atrial fibrillation with RVR (diagnosed during [MASKED] admission, never in afib during current admission) [] Discuss possible need to uptitrate antihypertensive medications (systolic BPs in the 140s-160s while admitted) [] F/u [MASKED] blood cultures to final result [] consider checking LFTs at PCP appointment on [MASKED] [] NEW MEDICATIONS: Loperamide 2mg every 2 hrs as needed for diarrhea [] CHANGED MEDICATIONS: none [] STOPPED MEDICATIONS: none [] APPOINTMENTS: PCP appointment on [MASKED] at 11am [] follow 2gm low salt diet, 2g potassium CODE STATUS: FULL CODE HCP/CONTACT: daughter, [MASKED] To [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO BID 2. Aspirin EC 325 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Furosemide 80 mg PO BID 6. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 7. Metoprolol Succinate XL 200 mg PO DAILY 8. Montelukast 10 mg PO DAILY 9. NIFEdipine CR 90 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Omeprazole 20 mg PO BID 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 13. Alendronate Sodium 35 mg PO QWED 14. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 15. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 16. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 17. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 18. Artificial Tears [MASKED] DROP BOTH EYES BID:PRN dry eyes 19. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol [MASKED] mg PO BID 4. Artificial Tears [MASKED] DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Furosemide 80 mg PO BID 9. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 10. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 11. Metoprolol Succinate XL 200 mg PO DAILY 12. NIFEdipine CR 90 mg PO DAILY 13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 14. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 15. Montelukast 10 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Omeprazole 20 mg PO BID 18. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 19. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 20. LOPERamide 2 mg PO QID:PRN diarrhea RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by mouth four times a day Disp #*21 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Urinary Tract Infection - Transaminitis Secondary Diagnoses: - DMII - ESRD on HD MWF, LUE AVG [MASKED] - HTN - Osteoporosis - HLD - Asthma - Anemia - HBV /HCV - Gout - GERD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. You were admitted to [MASKED] on [MASKED] because of lethargy, confusion, and fever after your dialysis session. When you came to the hospital, we found out that you had a urinary tract infection, similar to ones you have had in the past. This is likely what caused your symptoms. After treating you with IV antibiotics, your confusion and fever improved. You finished your last dose of antibiotics on [MASKED] [MASKED], and won't require any antibiotics on discharge. While here, you also had some diarrhea. This can often happen when on antibiotics. We determined that it was not caused by a separate intestinal infection. It should resolve over the next several days. To prevent urinary tract infections, it is important to practice good hygiene. The most common source of bacteria is stool, so ensuring that you clean well after stooling is important. You should discuss with your PCP whether or not long term antibiotics to prevent infection is an option for you. Please continue to take all your medications as prescribed. See below for a list of follow up appointments. Thank you for allowing us to participate in your care. Sincerely, Your [MASKED] Medicine team Followup Instructions: [MASKED]
[]
[ "E1122", "N390", "Z794", "I2510", "E785", "J45909", "D649", "M109", "K219" ]
[ "A419: Sepsis, unspecified organism", "G9341: Metabolic encephalopathy", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "N390: Urinary tract infection, site not specified", "R6520: Severe sepsis without septic shock", "A498: Other bacterial infections of unspecified site", "Z1624: Resistance to multiple antibiotics", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z8619: Personal history of other infectious and parasitic diseases", "Z87440: Personal history of urinary (tract) infections", "M1990: Unspecified osteoarthritis, unspecified site", "M810: Age-related osteoporosis without current pathological fracture", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "D649: Anemia, unspecified", "M109: Gout, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7982: Long term (current) use of aspirin" ]
10,035,780
23,172,477
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: AV fistula thrombectomy History of Present Illness: Ms ___ is a ___ y/o ___ speaking patient with PMH significant for Alzheimer's dementia, HTN, HLD, ESRD (on ___ HD), who originally presented to ___ thrombectomy, but was determined to not have capacity to consent to procedure, and ___ was unable to get consent from HCP, thus was sent to the ED. Patient presented to the ED from ___ after she was unable to provide consent for planned thrombectomy for clotted left fistula. They attempted to contact the patient's healthcare proxy multiple times but were unable to reach her. The ED was also unable to reach her. In the ED, the patient is mildly confused, which appears to be her baseline. She notes mild abdominal pain but no other symptoms. In the ED... - Initial vitals: 97.9 76 180/79 16 97% RA - Labs/studies notable for: Cr > 9, K 5.0 - Patient was given: 10 IV labetalol Past Medical History: - DMII - ESRD on HD ___, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in ___ - h/o C diff Social History: ___ Family History: She is widowed and has 7 children, all in apparently good health. No notable family hx. Physical Exam: ADMISSION PHYSICAL EXAM: =========================== ___ 2340 Temp: 98.1 PO BP: 190/95 HR: 81 RR: 18 Dyspnea: 0 RASS: 0 Pain Score: ___ GEN: Chronically ill appearing, NAD HEENT: Conjunctiva clear, PERRL, MMM NECK: No JVD. LUNGS: CTAB HEART: RRR, nl S1, S2. No m/r/g. ABD: Mild epigastric tenderness normal bowel sounds. EXTREMITIES: No edema. WWP. Left AV fistula. SKIN: No rashes. NEURO: Alert, unable to establish orientation. DISCHARGE PHYSICAL EXAM: =========================== 24 HR Data (last updated ___ @ 1234) Temp: 98.0 (Tm 98.1), BP: 172/84 (154-179/68-84), HR: 78 (70-78), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery: Ra, Wt: 95.46 lb/43.3 kg GEN: NAD HEENT: Jaundice, Normocephalic, atraumatic NECK: No JVD. LUNGS: CTAB HEART: RRR, nl S1, S2. No m/r/g. ABD: normal bowel sounds. EXTREMITIES: No edema. WWP. Left AV fistula with some bruising. Good thrill/bruit. SKIN: No rashes. NEURO: Alert, unable to establish orientation. Pertinent Results: Pertinent Results: ADMISSION LABS ============== ___ 03:20PM BLOOD WBC-8.7 RBC-3.00* Hgb-10.1* Hct-31.5* MCV-105* MCH-33.7* MCHC-32.1 RDW-14.2 RDWSD-53.3* Plt ___ ___ 03:20PM BLOOD Plt ___ ___ 03:20PM BLOOD Glucose-94 UreaN-53* Creat-9.4*# Na-135 K-5.0 Cl-94* HCO3-24 AnGap-17 RELEVANT LABS: ============== ___ 09:29AM BLOOD WBC-9.0 RBC-2.96* Hgb-10.1* Hct-30.9* MCV-104* MCH-34.1* MCHC-32.7 RDW-14.8 RDWSD-54.6* Plt ___ ___ 05:08AM BLOOD WBC-7.9 RBC-2.93* Hgb-10.0* Hct-30.7* MCV-105* MCH-34.1* MCHC-32.6 RDW-15.2 RDWSD-57.1* Plt ___ ___ 05:34AM BLOOD WBC-4.0 RBC-2.34* Hgb-7.9* Hct-25.4* MCV-109* MCH-33.8* MCHC-31.1* RDW-15.9* RDWSD-62.4* Plt Ct-71* ___ 06:03AM BLOOD WBC-4.5 RBC-2.13* Hgb-7.3* Hct-22.7* MCV-107* MCH-34.3* MCHC-32.2 RDW-15.6* RDWSD-61.2* Plt Ct-67* ___ 05:31AM BLOOD WBC-3.8* RBC-1.94* Hgb-6.6* Hct-21.3* MCV-110* MCH-34.0* MCHC-31.0* RDW-15.5 RDWSD-62.4* Plt Ct-56* ___ 05:00PM BLOOD WBC-5.5 RBC-2.90* Hgb-9.5* Hct-30.5* MCV-105* MCH-32.8* MCHC-31.1* RDW-18.7* RDWSD-72.4* Plt Ct-70* ___ 07:05AM BLOOD WBC-4.7 RBC-2.67* Hgb-8.7* Hct-27.6* MCV-103* MCH-32.6* MCHC-31.5* RDW-18.5* RDWSD-70.4* Plt Ct-70* ___ 05:25AM BLOOD WBC-4.6 RBC-2.63* Hgb-8.6* Hct-27.9* MCV-106* MCH-32.7* MCHC-30.8* RDW-17.5* RDWSD-69.1* Plt Ct-60* ___ 07:05AM BLOOD Neuts-62.1 ___ Monos-9.6 Eos-5.4 Baso-0.4 Im ___ AbsNeut-2.90 AbsLymp-1.03* AbsMono-0.45 AbsEos-0.25 AbsBaso-0.02 ___ 09:29AM BLOOD Plt ___ ___ 07:37AM BLOOD Plt ___ ___ 05:32AM BLOOD Plt ___ ___ 05:34AM BLOOD Plt Smr-VERY LOW* Plt Ct-71* ___ 06:03AM BLOOD Plt Ct-67* ___ 05:31AM BLOOD Plt Ct-56* ___ 06:48AM BLOOD ___ PTT-29.1 ___ ___ 05:00PM BLOOD Plt Ct-70* ___ 07:05AM BLOOD Plt Ct-70* ___ 05:25AM BLOOD Plt Ct-60* ___ 08:00AM BLOOD Plt Ct-71* ___ 06:48AM BLOOD ___ ___ 06:03AM BLOOD Ret Aut-4.5* Abs Ret-0.10 ___ 05:31AM BLOOD Ret Aut-4.4* Abs Ret-0.09 ___ 09:19PM BLOOD HIT Ab-NEG HIT ___ ___ 09:29AM BLOOD Glucose-81 UreaN-58* Creat-10.4* Na-135 K-5.3 Cl-93* HCO3-25 AnGap-17 ___ 08:21PM BLOOD Glucose-197* UreaN-67* Creat-12.1* Na-132* K-4.9 Cl-91* HCO3-23 AnGap-18 ___ 05:32AM BLOOD Glucose-98 UreaN-18 Creat-5.2* Na-142 K-3.7 Cl-100 HCO3-27 AnGap-15 ___ 06:03AM BLOOD Glucose-112* UreaN-30* Creat-8.4*# Na-140 K-4.6 Cl-99 HCO3-21* AnGap-20* ___ 05:25AM BLOOD Glucose-89 UreaN-10 Creat-3.3*# Na-141 K-4.3 Cl-100 HCO3-31 AnGap-10 ___ 08:00AM BLOOD Glucose-94 UreaN-27* Creat-4.8*# Na-140 K-4.3 Cl-101 HCO3-29 AnGap-10 ___ 05:34AM BLOOD ALT-12 LD(LDH)-202 AlkPhos-53 TotBili-0.5 ___ 06:03AM BLOOD ALT-13 AST-32 LD(LDH)-344* AlkPhos-46 TotBili-0.5 ___ 09:29AM BLOOD Calcium-8.8 Phos-6.2* Mg-2.2 ___ 08:21PM BLOOD Calcium-9.9 Phos-5.9* Mg-2.2 ___ 02:18AM BLOOD Calcium-8.0* Phos-4.2 Mg-2.0 ___ 06:03AM BLOOD Calcium-8.6 Phos-7.6* Mg-2.0 ___ 07:05AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0 ___ 08:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 ___ 06:03AM BLOOD Hapto-<10* ___ 05:31AM BLOOD Hapto-12* ___ 07:37AM BLOOD VitB12-1069* ___ 05:08AM BLOOD VitB12-1280* Folate->20 ___ 09:29AM BLOOD %HbA1c-4.2 eAG-74 ___ 05:31AM BLOOD TSH-2.4 ___ 09:29AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* ___ 08:00AM BLOOD IgM HBc-PND ___ 07:05AM BLOOD CMV IgG-PND CMV IgM-PND CMVI-PND EBV IgG-PND EBNA-PND EBV IgM-PND EBVI-PND ___ 05:00PM BLOOD HCV VL-NOT DETECT ___ 07:05AM BLOOD HCV VL-NOT DETECT ___ 07:05AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-PND MICROBIOLOGY ============ ___ 5:00 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. IMAGING ======= ___ Imaging AV FISTULOGRAM SCH IMPRESSION: Satisfactory restoration of flow following chemical and mechanical thrombolysis with a good angiographic and clinical result. ___ Imaging ART DUP EXT UP UNI OR L IMPRESSION: Small pseudoaneurysm immediately anterior to the AV fistula in the left antecubital fossa. DISCHARGE LABS: =============== ___ 08:00AM BLOOD WBC-5.0 RBC-2.60* Hgb-8.5* Hct-27.3* MCV-105* MCH-32.7* MCHC-31.1* RDW-17.5* RDWSD-67.6* Plt Ct-71* ___ 08:00AM BLOOD Plt Ct-71* ___ 08:00AM BLOOD Glucose-94 UreaN-27* Creat-4.8*# Na-140 K-4.3 Cl-101 HCO3-29 AnGap-10 ___ 08:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 Brief Hospital Course: Ms ___ is a ___ y/o ___ speaking patient with PMH significant for Alzheimer's dementia, ESRD, and HTN, who presented for thrombectomy, but was determined to not have capacity to consent to procedure, and ___ was unable to get consent, thus admitted for ___ procedure and dialysis. On ___, Ms. ___ received a temp. line and recieved HD given worsening of her condition. Eventually, HCP was contacted and She had a AVF thrombectomy on ___. Her course was complicated by pancytopenia requiring 1u pRBCs with improvement in cell counts prior to discharge. ACUTE ISSUES: # Thrombosed Fistula- Resolved Patient was originally transferred from nursing home for ___ intervention on clotted left AV fistula. She was unable to consent for the procedure and was admitted to medicine service. She had a temporary HD line placed to get HD while awaiting consent from HCP. Consent was obtained and she underwent thrombectomy on ___. She had HD successfully with her fistula after thrombectomy. She had temporary HD line removed afterwards. #Pancytopenia Patient was noted to have new onset pancytopenia during her hospitalization. Etiology was unclear and felt to likely be related to either viral infection or dysplastic bone marrow. Hematology was consulted and assisted in infectious work up which was unremarkable at time of discharge. Work up was notable for negative HIT antibodies, mild evidence of hemolysis that improved, normal bilirubin, normal B12 and folate, negative ___, and HCV VL not detected. Pending work up included CMV IgG Ab, CMV IgM Ab, EBV Ab Panel, HBC-IGM, and parvovirus B19 antibodies. Hgb nadir was 6.6 for which the patient received 1u of PRBCs. Her discharge Hgb was 8.5. Platelets nadir of 60 with discharge platelet count of 71. She required no platelet transfusions during her hospitalization. Patient should have repeat CBC at HD on ___. Could consider outpatient hematology follow up if pancytopenia does not improve. # ESRD On MWF dialysis. As noted above, had temporary HD line placed for HD that was removed after fistula was fixed. Last HD session on ___. Will need HD on ___. Continue home calcium with meals, sevelamer with meals. # HTN Patient was persistently hypertensive during her hospitalization. Her losartan was increased from non-HD days to daily and she remained on her home metoprolol succinate. Could consider adding hydralazine as outpatient if BP remains elevated. CHRONIC/STABLE ISSUES: #Dementia Mental status was trended throughout her hospitalization and was felt to be at baseline. # COPD - Hold home dulera (NF), duonebs q6hr prn - Continue home montelukast # GERD - Continue ranitidine # Hx Hep C S/p treatment in ___. # CODE STATUS: DNR/DNI per MOLST on file. Transitional Issues: =============================== [ ] Recheck CBC on ___ with HD [ ] Consider hematology follow up if persistently pancytopenic [ ] Follow up infectious work up: CMV IgG Ab, CMV IgM Ab, EBV Ab Panel, HBC-IGM, and parvovirus B19 antibodies [ ] Consider addition of hydralazine if BP remains elevated [ ] Discontinued aspirin for primary prevention [ ] Consider a family meeting regarding proxy - daughter hoping to transition HCP to son Patient seen and examined on day of discharge. Stable for discharge to facility. >30 minutes on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ranitidine 150 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Allopurinol ___ mg PO BID 4. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 5. Loratadine 10 mg PO DAILY 6. Alendronate Sodium 35 mg PO QFRI 7. Losartan Potassium 100 mg PO 4X/WEEK (___) 8. Terazosin 2 mg PO QHS 9. Metoprolol Succinate XL 200 mg PO DAILY 10. Montelukast 10 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. LOPERamide 2 mg PO QID:PRN diarrhea 13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 14. Calcium Acetate 667 mg PO TID W/MEALS 15. Ferric Citrate 210 mg PO TID W/MEALS 16. sevelamer CARBONATE 800 mg PO TID W/MEALS Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 2. Losartan Potassium 100 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Alendronate Sodium 35 mg PO QFRI 5. Allopurinol ___ mg PO BID 6. Calcium Acetate 667 mg PO TID W/MEALS 7. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 8. Ferric Citrate 210 mg PO TID W/MEALS Administer with food. Separate administration of other medications by at least 2 hours. 9. LOPERamide 2 mg PO QID:PRN diarrhea 10. Loratadine 10 mg PO DAILY 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Ranitidine 150 mg PO DAILY 14. sevelamer CARBONATE 800 mg PO TID W/MEALS 15. Terazosin 2 mg PO QHS 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: #Thrombocytopenia #Thrombosed Fistula 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: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a privilege caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you needed your fistula fixed. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had your fistula fixed so you could get dialysis. - You had low red blood cell counts and platelets. You were given one unit of red blood cells with improvement in your blood counts. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "T82868A", "N186", "I120", "D61818", "B1910", "Y832", "Y92129", "G309", "F0280", "E1122", "D696", "J449", "K219", "Z66", "M1990", "M810", "D631", "E11649", "E1165", "E8339", "E875", "M109", "Z992", "Z7984", "Z8619", "Z7982", "Z8611" ]
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: AV fistula thrombectomy History of Present Illness: Ms [MASKED] is a [MASKED] y/o [MASKED] speaking patient with PMH significant for Alzheimer's dementia, HTN, HLD, ESRD (on [MASKED] HD), who originally presented to [MASKED] thrombectomy, but was determined to not have capacity to consent to procedure, and [MASKED] was unable to get consent from HCP, thus was sent to the ED. Patient presented to the ED from [MASKED] after she was unable to provide consent for planned thrombectomy for clotted left fistula. They attempted to contact the patient's healthcare proxy multiple times but were unable to reach her. The ED was also unable to reach her. In the ED, the patient is mildly confused, which appears to be her baseline. She notes mild abdominal pain but no other symptoms. In the ED... - Initial vitals: 97.9 76 180/79 16 97% RA - Labs/studies notable for: Cr > 9, K 5.0 - Patient was given: 10 IV labetalol Past Medical History: - DMII - ESRD on HD [MASKED], LUE AVG [MASKED] - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in [MASKED] - h/o C diff Social History: [MASKED] Family History: She is widowed and has 7 children, all in apparently good health. No notable family hx. Physical Exam: ADMISSION PHYSICAL EXAM: =========================== [MASKED] 2340 Temp: 98.1 PO BP: 190/95 HR: 81 RR: 18 Dyspnea: 0 RASS: 0 Pain Score: [MASKED] GEN: Chronically ill appearing, NAD HEENT: Conjunctiva clear, PERRL, MMM NECK: No JVD. LUNGS: CTAB HEART: RRR, nl S1, S2. No m/r/g. ABD: Mild epigastric tenderness normal bowel sounds. EXTREMITIES: No edema. WWP. Left AV fistula. SKIN: No rashes. NEURO: Alert, unable to establish orientation. DISCHARGE PHYSICAL EXAM: =========================== 24 HR Data (last updated [MASKED] @ 1234) Temp: 98.0 (Tm 98.1), BP: 172/84 (154-179/68-84), HR: 78 (70-78), RR: 18 ([MASKED]), O2 sat: 100% (97-100), O2 delivery: Ra, Wt: 95.46 lb/43.3 kg GEN: NAD HEENT: Jaundice, Normocephalic, atraumatic NECK: No JVD. LUNGS: CTAB HEART: RRR, nl S1, S2. No m/r/g. ABD: normal bowel sounds. EXTREMITIES: No edema. WWP. Left AV fistula with some bruising. Good thrill/bruit. SKIN: No rashes. NEURO: Alert, unable to establish orientation. Pertinent Results: Pertinent Results: ADMISSION LABS ============== [MASKED] 03:20PM BLOOD WBC-8.7 RBC-3.00* Hgb-10.1* Hct-31.5* MCV-105* MCH-33.7* MCHC-32.1 RDW-14.2 RDWSD-53.3* Plt [MASKED] [MASKED] 03:20PM BLOOD Plt [MASKED] [MASKED] 03:20PM BLOOD Glucose-94 UreaN-53* Creat-9.4*# Na-135 K-5.0 Cl-94* HCO3-24 AnGap-17 RELEVANT LABS: ============== [MASKED] 09:29AM BLOOD WBC-9.0 RBC-2.96* Hgb-10.1* Hct-30.9* MCV-104* MCH-34.1* MCHC-32.7 RDW-14.8 RDWSD-54.6* Plt [MASKED] [MASKED] 05:08AM BLOOD WBC-7.9 RBC-2.93* Hgb-10.0* Hct-30.7* MCV-105* MCH-34.1* MCHC-32.6 RDW-15.2 RDWSD-57.1* Plt [MASKED] [MASKED] 05:34AM BLOOD WBC-4.0 RBC-2.34* Hgb-7.9* Hct-25.4* MCV-109* MCH-33.8* MCHC-31.1* RDW-15.9* RDWSD-62.4* Plt Ct-71* [MASKED] 06:03AM BLOOD WBC-4.5 RBC-2.13* Hgb-7.3* Hct-22.7* MCV-107* MCH-34.3* MCHC-32.2 RDW-15.6* RDWSD-61.2* Plt Ct-67* [MASKED] 05:31AM BLOOD WBC-3.8* RBC-1.94* Hgb-6.6* Hct-21.3* MCV-110* MCH-34.0* MCHC-31.0* RDW-15.5 RDWSD-62.4* Plt Ct-56* [MASKED] 05:00PM BLOOD WBC-5.5 RBC-2.90* Hgb-9.5* Hct-30.5* MCV-105* MCH-32.8* MCHC-31.1* RDW-18.7* RDWSD-72.4* Plt Ct-70* [MASKED] 07:05AM BLOOD WBC-4.7 RBC-2.67* Hgb-8.7* Hct-27.6* MCV-103* MCH-32.6* MCHC-31.5* RDW-18.5* RDWSD-70.4* Plt Ct-70* [MASKED] 05:25AM BLOOD WBC-4.6 RBC-2.63* Hgb-8.6* Hct-27.9* MCV-106* MCH-32.7* MCHC-30.8* RDW-17.5* RDWSD-69.1* Plt Ct-60* [MASKED] 07:05AM BLOOD Neuts-62.1 [MASKED] Monos-9.6 Eos-5.4 Baso-0.4 Im [MASKED] AbsNeut-2.90 AbsLymp-1.03* AbsMono-0.45 AbsEos-0.25 AbsBaso-0.02 [MASKED] 09:29AM BLOOD Plt [MASKED] [MASKED] 07:37AM BLOOD Plt [MASKED] [MASKED] 05:32AM BLOOD Plt [MASKED] [MASKED] 05:34AM BLOOD Plt Smr-VERY LOW* Plt Ct-71* [MASKED] 06:03AM BLOOD Plt Ct-67* [MASKED] 05:31AM BLOOD Plt Ct-56* [MASKED] 06:48AM BLOOD [MASKED] PTT-29.1 [MASKED] [MASKED] 05:00PM BLOOD Plt Ct-70* [MASKED] 07:05AM BLOOD Plt Ct-70* [MASKED] 05:25AM BLOOD Plt Ct-60* [MASKED] 08:00AM BLOOD Plt Ct-71* [MASKED] 06:48AM BLOOD [MASKED] [MASKED] 06:03AM BLOOD Ret Aut-4.5* Abs Ret-0.10 [MASKED] 05:31AM BLOOD Ret Aut-4.4* Abs Ret-0.09 [MASKED] 09:19PM BLOOD HIT Ab-NEG HIT [MASKED] [MASKED] 09:29AM BLOOD Glucose-81 UreaN-58* Creat-10.4* Na-135 K-5.3 Cl-93* HCO3-25 AnGap-17 [MASKED] 08:21PM BLOOD Glucose-197* UreaN-67* Creat-12.1* Na-132* K-4.9 Cl-91* HCO3-23 AnGap-18 [MASKED] 05:32AM BLOOD Glucose-98 UreaN-18 Creat-5.2* Na-142 K-3.7 Cl-100 HCO3-27 AnGap-15 [MASKED] 06:03AM BLOOD Glucose-112* UreaN-30* Creat-8.4*# Na-140 K-4.6 Cl-99 HCO3-21* AnGap-20* [MASKED] 05:25AM BLOOD Glucose-89 UreaN-10 Creat-3.3*# Na-141 K-4.3 Cl-100 HCO3-31 AnGap-10 [MASKED] 08:00AM BLOOD Glucose-94 UreaN-27* Creat-4.8*# Na-140 K-4.3 Cl-101 HCO3-29 AnGap-10 [MASKED] 05:34AM BLOOD ALT-12 LD(LDH)-202 AlkPhos-53 TotBili-0.5 [MASKED] 06:03AM BLOOD ALT-13 AST-32 LD(LDH)-344* AlkPhos-46 TotBili-0.5 [MASKED] 09:29AM BLOOD Calcium-8.8 Phos-6.2* Mg-2.2 [MASKED] 08:21PM BLOOD Calcium-9.9 Phos-5.9* Mg-2.2 [MASKED] 02:18AM BLOOD Calcium-8.0* Phos-4.2 Mg-2.0 [MASKED] 06:03AM BLOOD Calcium-8.6 Phos-7.6* Mg-2.0 [MASKED] 07:05AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0 [MASKED] 08:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 [MASKED] 06:03AM BLOOD Hapto-<10* [MASKED] 05:31AM BLOOD Hapto-12* [MASKED] 07:37AM BLOOD VitB12-1069* [MASKED] 05:08AM BLOOD VitB12-1280* Folate->20 [MASKED] 09:29AM BLOOD %HbA1c-4.2 eAG-74 [MASKED] 05:31AM BLOOD TSH-2.4 [MASKED] 09:29AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* [MASKED] 08:00AM BLOOD IgM HBc-PND [MASKED] 07:05AM BLOOD CMV IgG-PND CMV IgM-PND CMVI-PND EBV IgG-PND EBNA-PND EBV IgM-PND EBVI-PND [MASKED] 05:00PM BLOOD HCV VL-NOT DETECT [MASKED] 07:05AM BLOOD HCV VL-NOT DETECT [MASKED] 07:05AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-PND MICROBIOLOGY ============ [MASKED] 5:00 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. IMAGING ======= [MASKED] Imaging AV FISTULOGRAM SCH IMPRESSION: Satisfactory restoration of flow following chemical and mechanical thrombolysis with a good angiographic and clinical result. [MASKED] Imaging ART DUP EXT UP UNI OR L IMPRESSION: Small pseudoaneurysm immediately anterior to the AV fistula in the left antecubital fossa. DISCHARGE LABS: =============== [MASKED] 08:00AM BLOOD WBC-5.0 RBC-2.60* Hgb-8.5* Hct-27.3* MCV-105* MCH-32.7* MCHC-31.1* RDW-17.5* RDWSD-67.6* Plt Ct-71* [MASKED] 08:00AM BLOOD Plt Ct-71* [MASKED] 08:00AM BLOOD Glucose-94 UreaN-27* Creat-4.8*# Na-140 K-4.3 Cl-101 HCO3-29 AnGap-10 [MASKED] 08:00AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1 Brief Hospital Course: Ms [MASKED] is a [MASKED] y/o [MASKED] speaking patient with PMH significant for Alzheimer's dementia, ESRD, and HTN, who presented for thrombectomy, but was determined to not have capacity to consent to procedure, and [MASKED] was unable to get consent, thus admitted for [MASKED] procedure and dialysis. On [MASKED], Ms. [MASKED] received a temp. line and recieved HD given worsening of her condition. Eventually, HCP was contacted and She had a AVF thrombectomy on [MASKED]. Her course was complicated by pancytopenia requiring 1u pRBCs with improvement in cell counts prior to discharge. ACUTE ISSUES: # Thrombosed Fistula- Resolved Patient was originally transferred from nursing home for [MASKED] intervention on clotted left AV fistula. She was unable to consent for the procedure and was admitted to medicine service. She had a temporary HD line placed to get HD while awaiting consent from HCP. Consent was obtained and she underwent thrombectomy on [MASKED]. She had HD successfully with her fistula after thrombectomy. She had temporary HD line removed afterwards. #Pancytopenia Patient was noted to have new onset pancytopenia during her hospitalization. Etiology was unclear and felt to likely be related to either viral infection or dysplastic bone marrow. Hematology was consulted and assisted in infectious work up which was unremarkable at time of discharge. Work up was notable for negative HIT antibodies, mild evidence of hemolysis that improved, normal bilirubin, normal B12 and folate, negative [MASKED], and HCV VL not detected. Pending work up included CMV IgG Ab, CMV IgM Ab, EBV Ab Panel, HBC-IGM, and parvovirus B19 antibodies. Hgb nadir was 6.6 for which the patient received 1u of PRBCs. Her discharge Hgb was 8.5. Platelets nadir of 60 with discharge platelet count of 71. She required no platelet transfusions during her hospitalization. Patient should have repeat CBC at HD on [MASKED]. Could consider outpatient hematology follow up if pancytopenia does not improve. # ESRD On MWF dialysis. As noted above, had temporary HD line placed for HD that was removed after fistula was fixed. Last HD session on [MASKED]. Will need HD on [MASKED]. Continue home calcium with meals, sevelamer with meals. # HTN Patient was persistently hypertensive during her hospitalization. Her losartan was increased from non-HD days to daily and she remained on her home metoprolol succinate. Could consider adding hydralazine as outpatient if BP remains elevated. CHRONIC/STABLE ISSUES: #Dementia Mental status was trended throughout her hospitalization and was felt to be at baseline. # COPD - Hold home dulera (NF), duonebs q6hr prn - Continue home montelukast # GERD - Continue ranitidine # Hx Hep C S/p treatment in [MASKED]. # CODE STATUS: DNR/DNI per MOLST on file. Transitional Issues: =============================== [ ] Recheck CBC on [MASKED] with HD [ ] Consider hematology follow up if persistently pancytopenic [ ] Follow up infectious work up: CMV IgG Ab, CMV IgM Ab, EBV Ab Panel, HBC-IGM, and parvovirus B19 antibodies [ ] Consider addition of hydralazine if BP remains elevated [ ] Discontinued aspirin for primary prevention [ ] Consider a family meeting regarding proxy - daughter hoping to transition HCP to son Patient seen and examined on day of discharge. Stable for discharge to facility. >30 minutes on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ranitidine 150 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Allopurinol [MASKED] mg PO BID 4. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 5. Loratadine 10 mg PO DAILY 6. Alendronate Sodium 35 mg PO QFRI 7. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 8. Terazosin 2 mg PO QHS 9. Metoprolol Succinate XL 200 mg PO DAILY 10. Montelukast 10 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. LOPERamide 2 mg PO QID:PRN diarrhea 13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 14. Calcium Acetate 667 mg PO TID W/MEALS 15. Ferric Citrate 210 mg PO TID W/MEALS 16. sevelamer CARBONATE 800 mg PO TID W/MEALS Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 2. Losartan Potassium 100 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Alendronate Sodium 35 mg PO QFRI 5. Allopurinol [MASKED] mg PO BID 6. Calcium Acetate 667 mg PO TID W/MEALS 7. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 8. Ferric Citrate 210 mg PO TID W/MEALS Administer with food. Separate administration of other medications by at least 2 hours. 9. LOPERamide 2 mg PO QID:PRN diarrhea 10. Loratadine 10 mg PO DAILY 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Ranitidine 150 mg PO DAILY 14. sevelamer CARBONATE 800 mg PO TID W/MEALS 15. Terazosin 2 mg PO QHS 16. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: #Thrombocytopenia #Thrombosed Fistula 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: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. [MASKED], It was a privilege caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you needed your fistula fixed. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had your fistula fixed so you could get dialysis. - You had low red blood cell counts and platelets. You were given one unit of red blood cells with improvement in your blood counts. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "E1122", "D696", "J449", "K219", "Z66", "E1165", "M109" ]
[ "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "D61818: Other pancytopenia", "B1910: Unspecified viral hepatitis B without hepatic coma", "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", "Y92129: Unspecified place in nursing home as the place of occurrence of the external cause", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "D696: Thrombocytopenia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z66: Do not resuscitate", "M1990: Unspecified osteoarthritis, unspecified site", "M810: Age-related osteoporosis without current pathological fracture", "D631: Anemia in chronic kidney disease", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E8339: Other disorders of phosphorus metabolism", "E875: Hyperkalemia", "M109: Gout, unspecified", "Z992: Dependence on renal dialysis", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z8619: Personal history of other infectious and parasitic diseases", "Z7982: Long term (current) use of aspirin", "Z8611: Personal history of tuberculosis" ]
10,035,780
25,186,901
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ y/o female with a past medical history of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV, GERD, Gout and osteoporosis who present with fever, cough and general malaise. History was obtained via review of records and via phone interpreter. Majority of history was obtained from daughter. Patient was recently treated for a UTI with PO antibiotics and she has been doing well until yesterday when she developed general malaise, fever, nausea and lightheadedness. Also has been complaining of shortness of breath which has improved with albuterol inhalers. This morning the patient had 2 episodes of emesis as well as a productive cough. Today during HD she was found to have a fever to 100.8 and leukocytosis and was transferred to ___ for further evaluation. In the ED, initial vitals: T 98.5, BP 147/54, HR 95, RR 18, 98% RA. Labs were significant for WBC 17 (85% PMN), Hb 8.9, PLT 268. Na 132, Cr 2.6 (on HD), gluc 190, AP 152, AST 85, ALT 47, BNP 7841. UA + WBC + epi. Flu was negative. BCx and UCx were drawn. CXR showed no acute cardiopulmonary process and no consolidation. Patient received ceftriaxone 1 g, levofloxacin 750 mg, vanco 1000 mg. Vitals prior to transfer: T 98.8, HR 83, BP 137/60, RR 17, 99% RA. Upon arrival to the floor Tc 87.7, BP 149/59, HR 83, RR 20, 100% RA, weight 59.6 kg. Patient was resting in bed and in no acute distress. Reported that her breathing was uncomfortable but improved with inhalers. Also reported a heavy sensation on her chest which has persisted throughout the day. States that she get dizzy when going from a sitting to a standing position. ROS: reports fever at HD today. No chills. + SOB as stated above. Chronic cough, no change. No sick contacts. No travel. + nausea, + vomiting. No diarrhea. + mild lower extremity edema. No rashes. No recent dysuria (however just finished treatment for a UTI and had dysuria at the beginning of that course). Otherwise, ___ ROS was negative unless stated above. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in ___ - h/o C diff Social History: ___ Family History: She is widowed and she has 7 children, and in apparently good health. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: Tc 97.7, BP 149/59, HR 83, RR 20, 100% RA, weight 59.6 kg GEN: Alert, lying flat in bed, no acute distress; oriented to self, but not place or time HEENT: sclera anicteric, oropharynx MMM, EOMI NECK: Supple without LAD, unable to visualize JVD PULM: bibasilar crackles R>L, no wheezing COR: RRR (+)S1/S2 no m/r/g ABD: Soft, ___, mildly distended, no fluid wave, normal bowel sounds EXTREM: Warm, ___, trace peripheral edema b/l; LUE fistula with palpable thrill NEURO: CN ___ grossly intact, motor function grossly normal DISCHARGE PHYSICAL EXAM ======================== VS: Tc 97.9, Tm 99.0, BP ___, HR ___, RR 18, 98% RA, weight 57.6 kg, BMx5 (small soft stools), finger stick 130s GEN: Alert, sitting up in bed, no acute distress HEENT: sclera anicteric, oropharynx MMM, EOMI NECK: Supple, unable to visualize JVD PULM: CTAB, no wheezing COR: RRR normal S1 and S2, ___ systolic murmur heard throughout ABD: Soft, ___, mildly distended, no fluid wave, normal bowel sounds EXTREM: Warm, ___, trace peripheral edema b/l; LUE fistula NEURO: CN ___ grossly intact, motor function grossly normal Pertinent Results: ADMISSION LABS ================ ___ 09:40AM BLOOD ___ ___ Plt ___ ___ 09:40AM BLOOD ___ ___ ___ 09:40AM BLOOD ___ ___ 09:40AM BLOOD ___ ___ 09:40AM BLOOD cTropnT-<0.01 ___ 07:18PM BLOOD ___ cTropnT-<0.01 ___ 05:40AM BLOOD cTropnT-<0.01 ___ 09:40AM BLOOD ___ ___ 06:35AM BLOOD ___ ___ 09:08AM BLOOD ___ ___ ___ 09:08AM BLOOD HCV ___ DISCHARGE LABS ================ ___ 07:00AM BLOOD ___ ___ Plt ___ ___ 07:00AM BLOOD ___ ___ ___ 07:00AM BLOOD ___ IMAGING ================ ___ TTE The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. 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%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild pulmonary artery systolic hypertension. Increased PCWP. ___ RUQ US 1. No evidence of focal hepatic lesions. 2. No ascites. 3. Dilatation of the common bile duct is similar to prior, and likely relates to ___ state. ___ CXR No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. MICRO ============== ___ 10:49 am URINE TAKEN FROM ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. ___ ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ENTEROCOCCUS SP. | | AMIKACIN-------------- 4 S AMPICILLIN------------ =>32 R <=2 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ 1 S ___ 11:55 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference ___. ___ 9:30 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:45 am BLOOD CULTURE #2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: Ms. ___ is a ___ y/o female with a past medical history of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV, GERD, Gout and osteoporosis who present with fever, cough and general malaise found to have E coli UTI. Hospital course was complicated by AF with RVR. Hospital course is outlined below by problem: # E coli UTI: Pt endorsed dysuria prior to presentation. She was started on vanc/cefepime empirically. UCx grew E coli sensitive to ceftriaxone and her antibiotics were transitioned to ceftriaxone. She received a 7 day course of antibiotics. Her last day of antibiotics was ___. # AF with RVR: patient was found to have new afib with RVR during this hospitalization. Her AF was controlled with AV nodal agents. TSH was wnl. TTE was performed and did not show valvular disease. We discussed anticoagulation with the patient and her daughter. We explained that there is a risk of stroke in the setting of AF however given that the patient is a high fall and bleeding risk we wanted to discuss the risks/benefits of anticoagulation with her outpatient provider. Her primary care doctor was called but was unreachable. Anticoagulation will be a transitional issue and should be discussed in the outpatient setting. She remained on aspirin 325 mg daily and metoprolol 200 mg XL daily. # Chest pain: patient had chest pain on admission with negative troponins and EKG. This was likely due to palpitations in the setting of AF with RVR. Her pain improved with better HR control. # Dyspnea: patient complained of dyspnea on admission. The patient had a difficult time explaining her symptoms but quickly resolved. CXR did not show an acute process. She remained on RA and received inhalers for asthma. # Transaminitis, alk phos elevation: patient has known HCV and HBV but no diagnosis of cirrhosis. AST/ALT 85/47 and ALK phos 152 TB 0.3 on admission. A RUQ US was performed and did not show evidence of cholangitis or hepatic lesions. LFTs were noted to downtrend. # Diarrhea: patient had diarrhea after receiving antibiotics. There was concern for C diff initially and she was started on empiric treatment with flagyl. Her C diff returned negative, however given that she had C diff in the past she received flagyl prophyalxis while on ceftriaxone. Her diarrhea was attributed to antibiotic associated diarrhea and received Imodium prn. # Hyponatremia: patient's sodium was noted to decrease to ___. This was attributed to low solute intake and she was encouraged to eat more during meals. CHRONIC ISSUES # Gout: continued allopurinol ___ mg QOD # DM: patient was placed on a sliding scale and required small amounts of Humalog during her hospitalization. It is unclear what she takes as an outpatient for her diabetes but possibly takes Januvia. This will need to be clarified. # HTN: continued ___, metoprolol, nifedipine # ESRD on HD: continued ___ dialysis. Patient will need to have HD on ___ and ___ the week of ___. Her regular HD schedule will resume the following week on ___. # GERD: continued home PPI TRANSITIONAL ISSUES ===================== - patient is considered to be a high fall risk and the risk of starting anticoagulation may outweigh the benefit in the setting of AF. A discussion was held with her family about this issue. The patient and family will need to discuss anticoagulation for Afib with outpatient PCP - discharged to rehab, will need f/u with outpatient PCP - ___ the week of ___, patient will need HD on ___ and ___. Her regular HD schedule will resume the following week on ___. - patient was kept on a SSI during this hospital stay with minimal insulin requirements. It is unclear what medication she takes at home for her diabetes (possibly Januvia). This will need to be clarified. # CODE STATUS: Full # CONTACT: daughter ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Allopurinol ___ mg PO EVERY OTHER DAY 3. Aspirin EC 325 mg PO DAILY 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. ___ Diskus (250/50) 1 INH IH BID 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK (___) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. TraMADOL (Ultram) 50 mg PO BID:PRN pain 14. Vitamin D 1000 UNIT PO DAILY 15. Calcium 600 + D(3) (calcium ___ D3) 600 mg(1,500mg) -400 unit oral BID 16. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 18. Alendronate Sodium 35 mg PO QWED Discharge Medications: 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Aspirin EC 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 5. ___ Diskus (250/50) 1 INH IH BID 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK (___) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 13. Omeprazole 20 mg PO BID 14. TraMADOL (Ultram) 50 mg PO BID:PRN pain 15. Vitamin D 1000 UNIT PO DAILY 16. Calcium 600 + D(3) (calcium ___ D3) 600 mg(1,500mg) -400 unit oral BID 17. Alendronate Sodium 35 mg PO QWED 18. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 19. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: urinary tract infection, atrial fibrillation Secondary diagnosis: ESRD, hypertension, DM, diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted with a fever. While you were here you received antibiotics and your symptoms improved. You also received dialysis. You were found to have an abnormal heart rhythm call atrial fibrillation. We spoke to you about starting a blood thinner and you will need to continue having conversations with your primary care doctor. You are being discharged to a rehab facility to get stronger before you go home. We wish you the best, Your ___ Team Followup Instructions: ___
[ "N390", "N186", "I120", "I4891", "K521", "N2581", "E871", "B9620", "E119", "I2510", "K219", "B1920", "R740", "E876", "M109", "M810", "J45909", "E785", "Z9049", "R079", "D649", "Y92239", "T361X5A", "Z7982", "Z23", "Z992", "Z794" ]
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: fever Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] y/o female with a past medical history of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV, GERD, Gout and osteoporosis who present with fever, cough and general malaise. History was obtained via review of records and via phone interpreter. Majority of history was obtained from daughter. Patient was recently treated for a UTI with PO antibiotics and she has been doing well until yesterday when she developed general malaise, fever, nausea and lightheadedness. Also has been complaining of shortness of breath which has improved with albuterol inhalers. This morning the patient had 2 episodes of emesis as well as a productive cough. Today during HD she was found to have a fever to 100.8 and leukocytosis and was transferred to [MASKED] for further evaluation. In the ED, initial vitals: T 98.5, BP 147/54, HR 95, RR 18, 98% RA. Labs were significant for WBC 17 (85% PMN), Hb 8.9, PLT 268. Na 132, Cr 2.6 (on HD), gluc 190, AP 152, AST 85, ALT 47, BNP 7841. UA + WBC + epi. Flu was negative. BCx and UCx were drawn. CXR showed no acute cardiopulmonary process and no consolidation. Patient received ceftriaxone 1 g, levofloxacin 750 mg, vanco 1000 mg. Vitals prior to transfer: T 98.8, HR 83, BP 137/60, RR 17, 99% RA. Upon arrival to the floor Tc 87.7, BP 149/59, HR 83, RR 20, 100% RA, weight 59.6 kg. Patient was resting in bed and in no acute distress. Reported that her breathing was uncomfortable but improved with inhalers. Also reported a heavy sensation on her chest which has persisted throughout the day. States that she get dizzy when going from a sitting to a standing position. ROS: reports fever at HD today. No chills. + SOB as stated above. Chronic cough, no change. No sick contacts. No travel. + nausea, + vomiting. No diarrhea. + mild lower extremity edema. No rashes. No recent dysuria (however just finished treatment for a UTI and had dysuria at the beginning of that course). Otherwise, [MASKED] ROS was negative unless stated above. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG [MASKED] - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in [MASKED] - h/o C diff Social History: [MASKED] Family History: She is widowed and she has 7 children, and in apparently good health. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: Tc 97.7, BP 149/59, HR 83, RR 20, 100% RA, weight 59.6 kg GEN: Alert, lying flat in bed, no acute distress; oriented to self, but not place or time HEENT: sclera anicteric, oropharynx MMM, EOMI NECK: Supple without LAD, unable to visualize JVD PULM: bibasilar crackles R>L, no wheezing COR: RRR (+)S1/S2 no m/r/g ABD: Soft, [MASKED], mildly distended, no fluid wave, normal bowel sounds EXTREM: Warm, [MASKED], trace peripheral edema b/l; LUE fistula with palpable thrill NEURO: CN [MASKED] grossly intact, motor function grossly normal DISCHARGE PHYSICAL EXAM ======================== VS: Tc 97.9, Tm 99.0, BP [MASKED], HR [MASKED], RR 18, 98% RA, weight 57.6 kg, BMx5 (small soft stools), finger stick 130s GEN: Alert, sitting up in bed, no acute distress HEENT: sclera anicteric, oropharynx MMM, EOMI NECK: Supple, unable to visualize JVD PULM: CTAB, no wheezing COR: RRR normal S1 and S2, [MASKED] systolic murmur heard throughout ABD: Soft, [MASKED], mildly distended, no fluid wave, normal bowel sounds EXTREM: Warm, [MASKED], trace peripheral edema b/l; LUE fistula NEURO: CN [MASKED] grossly intact, motor function grossly normal Pertinent Results: ADMISSION LABS ================ [MASKED] 09:40AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 09:40AM BLOOD [MASKED] [MASKED] [MASKED] 09:40AM BLOOD [MASKED] [MASKED] 09:40AM BLOOD [MASKED] [MASKED] 09:40AM BLOOD cTropnT-<0.01 [MASKED] 07:18PM BLOOD [MASKED] cTropnT-<0.01 [MASKED] 05:40AM BLOOD cTropnT-<0.01 [MASKED] 09:40AM BLOOD [MASKED] [MASKED] 06:35AM BLOOD [MASKED] [MASKED] 09:08AM BLOOD [MASKED] [MASKED] [MASKED] 09:08AM BLOOD HCV [MASKED] DISCHARGE LABS ================ [MASKED] 07:00AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 07:00AM BLOOD [MASKED] [MASKED] [MASKED] 07:00AM BLOOD [MASKED] IMAGING ================ [MASKED] TTE The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. 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%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Mild pulmonary artery systolic hypertension. Increased PCWP. [MASKED] RUQ US 1. No evidence of focal hepatic lesions. 2. No ascites. 3. Dilatation of the common bile duct is similar to prior, and likely relates to [MASKED] state. [MASKED] CXR No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. MICRO ============== [MASKED] 10:49 am URINE TAKEN FROM [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. [MASKED] ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | ENTEROCOCCUS SP. | | AMIKACIN-------------- 4 S AMPICILLIN------------ =>32 R <=2 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ 1 S [MASKED] 11:55 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference [MASKED]. [MASKED] 9:30 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 5:45 am BLOOD CULTURE #2. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. Brief Hospital Course: Ms. [MASKED] is a [MASKED] y/o female with a past medical history of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV, GERD, Gout and osteoporosis who present with fever, cough and general malaise found to have E coli UTI. Hospital course was complicated by AF with RVR. Hospital course is outlined below by problem: # E coli UTI: Pt endorsed dysuria prior to presentation. She was started on vanc/cefepime empirically. UCx grew E coli sensitive to ceftriaxone and her antibiotics were transitioned to ceftriaxone. She received a 7 day course of antibiotics. Her last day of antibiotics was [MASKED]. # AF with RVR: patient was found to have new afib with RVR during this hospitalization. Her AF was controlled with AV nodal agents. TSH was wnl. TTE was performed and did not show valvular disease. We discussed anticoagulation with the patient and her daughter. We explained that there is a risk of stroke in the setting of AF however given that the patient is a high fall and bleeding risk we wanted to discuss the risks/benefits of anticoagulation with her outpatient provider. Her primary care doctor was called but was unreachable. Anticoagulation will be a transitional issue and should be discussed in the outpatient setting. She remained on aspirin 325 mg daily and metoprolol 200 mg XL daily. # Chest pain: patient had chest pain on admission with negative troponins and EKG. This was likely due to palpitations in the setting of AF with RVR. Her pain improved with better HR control. # Dyspnea: patient complained of dyspnea on admission. The patient had a difficult time explaining her symptoms but quickly resolved. CXR did not show an acute process. She remained on RA and received inhalers for asthma. # Transaminitis, alk phos elevation: patient has known HCV and HBV but no diagnosis of cirrhosis. AST/ALT 85/47 and ALK phos 152 TB 0.3 on admission. A RUQ US was performed and did not show evidence of cholangitis or hepatic lesions. LFTs were noted to downtrend. # Diarrhea: patient had diarrhea after receiving antibiotics. There was concern for C diff initially and she was started on empiric treatment with flagyl. Her C diff returned negative, however given that she had C diff in the past she received flagyl prophyalxis while on ceftriaxone. Her diarrhea was attributed to antibiotic associated diarrhea and received Imodium prn. # Hyponatremia: patient's sodium was noted to decrease to [MASKED]. This was attributed to low solute intake and she was encouraged to eat more during meals. CHRONIC ISSUES # Gout: continued allopurinol [MASKED] mg QOD # DM: patient was placed on a sliding scale and required small amounts of Humalog during her hospitalization. It is unclear what she takes as an outpatient for her diabetes but possibly takes Januvia. This will need to be clarified. # HTN: continued [MASKED], metoprolol, nifedipine # ESRD on HD: continued [MASKED] dialysis. Patient will need to have HD on [MASKED] and [MASKED] the week of [MASKED]. Her regular HD schedule will resume the following week on [MASKED]. # GERD: continued home PPI TRANSITIONAL ISSUES ===================== - patient is considered to be a high fall risk and the risk of starting anticoagulation may outweigh the benefit in the setting of AF. A discussion was held with her family about this issue. The patient and family will need to discuss anticoagulation for Afib with outpatient PCP - discharged to rehab, will need f/u with outpatient PCP - [MASKED] the week of [MASKED], patient will need HD on [MASKED] and [MASKED]. Her regular HD schedule will resume the following week on [MASKED]. - patient was kept on a SSI during this hospital stay with minimal insulin requirements. It is unclear what medication she takes at home for her diabetes (possibly Januvia). This will need to be clarified. # CODE STATUS: Full # CONTACT: daughter [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Allopurinol [MASKED] mg PO EVERY OTHER DAY 3. Aspirin EC 325 mg PO DAILY 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. [MASKED] Diskus (250/50) 1 INH IH BID 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. TraMADOL (Ultram) 50 mg PO BID:PRN pain 14. Vitamin D 1000 UNIT PO DAILY 15. Calcium 600 + D(3) (calcium [MASKED] D3) 600 mg(1,500mg) -400 unit oral BID 16. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 18. Alendronate Sodium 35 mg PO QWED Discharge Medications: 1. Allopurinol [MASKED] mg PO EVERY OTHER DAY 2. Aspirin EC 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 5. [MASKED] Diskus (250/50) 1 INH IH BID 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. Nephrocaps 1 CAP PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 13. Omeprazole 20 mg PO BID 14. TraMADOL (Ultram) 50 mg PO BID:PRN pain 15. Vitamin D 1000 UNIT PO DAILY 16. Calcium 600 + D(3) (calcium [MASKED] D3) 600 mg(1,500mg) -400 unit oral BID 17. Alendronate Sodium 35 mg PO QWED 18. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 19. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: urinary tract infection, atrial fibrillation Secondary diagnosis: ESRD, hypertension, DM, diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted with a fever. While you were here you received antibiotics and your symptoms improved. You also received dialysis. You were found to have an abnormal heart rhythm call atrial fibrillation. We spoke to you about starting a blood thinner and you will need to continue having conversations with your primary care doctor. You are being discharged to a rehab facility to get stronger before you go home. We wish you the best, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N390", "I4891", "E871", "E119", "I2510", "K219", "M109", "J45909", "E785", "D649", "Z794" ]
[ "N390: Urinary tract infection, site not specified", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I4891: Unspecified atrial fibrillation", "K521: Toxic gastroenteritis and colitis", "N2581: Secondary hyperparathyroidism of renal origin", "E871: Hypo-osmolality and hyponatremia", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E119: Type 2 diabetes mellitus without complications", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "B1920: Unspecified viral hepatitis C without hepatic coma", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "E876: Hypokalemia", "M109: Gout, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "J45909: Unspecified asthma, uncomplicated", "E785: Hyperlipidemia, unspecified", "Z9049: Acquired absence of other specified parts of digestive tract", "R079: Chest pain, unspecified", "D649: Anemia, unspecified", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "T361X5A: Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter", "Z7982: Long term (current) use of aspirin", "Z23: Encounter for immunization", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin" ]
10,035,780
27,291,894
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___ ___ Complaint: Hypotension and ?Altered Mental Status during dialysis Major Surgical or Invasive Procedure: None History of Present Illness: ___ only; History obtained from chart, nephew/niece over phone call, and with the assistance of language line interpreter): Ms. ___ is a ___ year old ___ and ___ speaking woman with a history of extrapulmonary TB (lymphadenitis) on RIPE since ___, UTI treated on recent admission (___), DM2, ESRD on HD (MWF), chronic HBV/HCV, HTN, and CAD who presented with confusion and transient hypotension (SBPs to ___ during dialysis. Approximately one week prior to admission, the patient's daughter noted foul smelling urine that was very dark in color, and per the daughter, the patient experienced some dysuria. The patient endorsed "feeling drunk" at this time along with several episodes of vomiting, though both resolved at the time of admission. She also endorsed weakness; at baseline, she ambulates with the occasional assistance of a cane at home, and she noted that she has had to use the cane in the days leading up to admission due to this weakness and "shakiness" in the legs. Per ED note, the patient presented to her regular hemodialysis yesterday (___) and was noted to have transient hypotension to the ___ which corrected with administration of IV fluids. She was then transferred to the ___ ED. Notably, per chart review, she was recently hospitalized at the ___ from ___ to ___nd head strike with no traumatic injury identified on CT Head but extrapulmonary TB found incidentally on CT Torso after workup for lymphadenopathy; three induced sputa with concentrated smears were negative for TB and NAAT testing was negative. Urinalysis and urine culture were positive for E. coli on admission and she completed 5 days of IV ceftriaxone. She was discharged to ___ rehab on ___ and initiated RIPE on ___. She was discharged from ___ on ___. Regarding her baseline status, her niece, ___, last saw her at ___, but spoke with a cousin who last saw her approximately 5 days prior to admission. She noted that the patient seemed well this week: alert, attentive, and able to engage in conversation. She did note that the patient does not leave the home very often and it is very possible she is not aware of the date at baseline. Notably, the patient never learned how to read and has poor eyesight. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in ___ - h/o C diff Social History: ___ Family History: She is widowed and has 7 children, all in apparently good health. No notable family hx. Physical Exam: ============== ADMISSION EXAM ============== Vital Signs: T 98.3 BP 179/106 HR 78 RR 16 O2 Sat 99RA General: Alert, oriented to person (gives last name only), place (initially says home but acknowledges when prompted with hospital), but not time ___ no acute distress HEENT: Cutaneous horn noted below left eye. Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact. ============== DISCHARGE EXAM ============== Vitals: T 97.9 BP 178/77 P 69 RR 18 O2 Sat 96RA General: Alert, oriented to person and place, date ___ no acute distress HEENT: Cutaneous horn noted below left eye. Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact. Pertinent Results: ADMISSION LABS ============== ___ 08:20PM BLOOD cTropnT-0.04* ___ 07:00AM BLOOD cTropnT-0.09* ___ 07:00AM BLOOD cTropnT-0.09* ___ 03:40PM BLOOD cTropnT-0.08* ___ 07:50AM BLOOD CK-MB-3 ___ 03:40PM BLOOD CK-MB-3 ___ 10:52PM BLOOD WBC-13.7*# RBC-3.34*# Hgb-11.4# Hct-34.9# MCV-105*# MCH-34.1* MCHC-32.7 RDW-16.3* RDWSD-61.8* Plt ___ ___ 10:52PM BLOOD Neuts-87.6* Lymphs-4.3* Monos-6.6 Eos-0.1* Baso-0.7 Im ___ AbsNeut-11.98*# AbsLymp-0.59* AbsMono-0.90* AbsEos-0.01* AbsBaso-0.09* ___ 08:20PM BLOOD Glucose-88 UreaN-9 Creat-2.0* Na-137 K-3.2* Cl-92* HCO3-23 AnGap-25* ___ 03:40PM BLOOD Glucose-99 UreaN-18 Creat-3.2*# Na-138 K-4.2 Cl-97 HCO3-24 AnGap-21* ___ 03:40PM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8 ___ 08:20PM BLOOD ALT-20 AST-54* AlkPhos-100 TotBili-0.2 ___ 08:20PM BLOOD Albumin-3.7 ___ 08:20PM BLOOD Lipase-29 DISCHARGE LABS ============== ___ 06:00AM BLOOD WBC-6.2# RBC-2.99* Hgb-10.2* Hct-30.4* MCV-102* MCH-34.1* MCHC-33.6 RDW-16.0* RDWSD-59.1* Plt ___ ___ 06:00AM BLOOD Glucose-97 UreaN-29* Creat-3.7* Na-137 K-3.9 Cl-97 HCO3-25 AnGap-19 ___ 06:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.8 ___ 03:11AM URINE RBC-1 WBC-17* Bacteri-FEW Yeast-NONE Epi-0 ___ 03:11AM URINE Blood-TR Nitrite-NEG Protein->300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.5 Leuks-NEG ___ 03:11AM URINE Color-Yellow Appear-Clear Sp ___ IMAGING/STUDIES =============== ___ (PA & LAT) Chronic findings as noted above. No evidence of mass, hemorrhage or infarction. ___ CHEST/ABD/PELVIS W/O 1. No acute abnormality within the chest, abdomen, or pelvis. 2. Stable lymphadenopathy of mediastinal and porta hepatis lymph nodes remains unclear in etiology. ___ HEAD W/O CONTRAST Chronic findings as noted above. No evidence of mass, hemorrhage or infarction. Brief Hospital Course: ___ ___ speaking ONLY) with DM2, ESRD on HD (MWF), chronic HCV/HBV, HTN, extrapulmonary TB (lymphadenitis) on RIPE who presented from HD with hypotension and recent UTI. #Foul-smelling urine/ recent UTI: Started 5-day course of ciprofloxacin by PCP ___ ___ for symptomatic complaints, consistent with UTI. Received dose of ceftriaxone in ED on ___, to complete 5-day course of antibiotics. Afebrile, no chills or flank pain or CVA tenderness, not complaining of dysuria or other urinary symptoms, urine was not foul-smelling during admission. U/A was negative for leukocyte esterase and nitrites, few bacteria, 17 WBC, >300 mg/dL protein; the proteinuria is her baseline. Notably, she has had recurrent UTIs, several of which were cipro-resistant bacteria. Given entire picture, decided to hold further antibiotics. Pt was discharged prior to urine culture resulting; when culture finalized on ___, patient and PCP were contacted to inform them that the urine culture was negative and no further intervention was required. #Transient Hypotension in dialysis, elevated troponins: No records from dialysis, note indicates SBPs to ___ but unclear duration. Normotensive upon arrival to ___ ED. Pt had troponin leak (peak 0.09 with subsequent downtrend) w/ transient ST segment depressions in V5/6 on initial EKG that resolved on subsequent EKGs. Pt denied cardiac or pulmonary complaints. Unclear whether hypotension preceded troponin leak or vice versa. Suspect that hypotension occurred in the setting of UTI and poor PO intake preceding HD session on ___, which led her to become hypotensive while undergoing ultrafiltration. Troponin elevation was likely in the setting of demand ischemia, which improved with resolution of hypotensive episode. #Hypertension: SBPs in 170s-180s;asymptomatic. Did not receive home anti-hypertensives for >24 hours in ED. Restarted on all home antihypertensives with improvement of BP to 160s. #Altered Mental Status: Per son, who lives with patient, that patient was at her baseline mental status. Patient has a history of dementia noted during previous admission, but further details are unclear and family does not seem to be aware. Alert and oriented to person and place, and able to relate recent history clearly with no fluctuating consciousness. CT Head negative for acute changes, demonstrates chronic atrophic changes and white matter hypodensities. #Osteoporosis: Alendronate held at previous admission given ESRD, deferred to PCP ___: restarting. Continued to hold alendronate during admission. #ESRD on HD: has HD on ___ - did not require dialysis while admitted. Continued Calcium and Vit D. #DM2: blood glucose 99 at admission. Did not require insulin for glucose management during admission. #Asthma: Continued albuterol, montelukast. Given advair 250/50 instead of dulera; will restart Dulera as outpatient #GERD: Continued PPI #Gout: continued allopurinol, changed dosing to HD dosing, 150 mg after HD TRANSITIONAL ISSUES =================== [x] inpatient team will follow-up the result of urine culture and contact one of the ___ relatives ___, ___. ___, niece, ___ for any interventions that need to take place pending the results of the culture -- this was completed prior to completion of this discharge summary. Culture was negative; pt and PCP contacted, no antibiotics required. [ ] close follow-up of blood pressure with primary care physician ___ than 30 minutes was spent on this patient's discharge day management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Allopurinol ___ mg PO DAILY 3. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 4. Aspirin EC 325 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK (___) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. NIFEdipine CR 90 mg PO DAILY 11. Omeprazole 20 mg PO BID 12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 13. Benzonatate 100 mg PO TID 14. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 15. Docusate Sodium 100 mg PO BID 16. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 17. Alendronate Sodium 35 mg PO QWED 18. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 19. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 20. LOPERamide 2 mg PO QID:PRN diarrhea 21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 22. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis 23. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 24. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 25. Polyethylene Glycol 17 g PO DAILY:PRN constipation 26. GuaiFENesin ___ mL PO Q6H 27. Rifampin 900 mg PO 3X/WEEK (___) 28. Isoniazid ___ mg PO 3X/WEEK (___) 29. Pyrazinamide ___ mg PO 3X/WEEK (___) 30. Ethambutol HCl 1200 mg PO 3X/WEEK (___) 31. Pyridoxine 50 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO 3X/WEEK (___) 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 7. Docusate Sodium 100 mg PO BID 8. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 9. Ethambutol HCl 1200 mg PO 3X/WEEK (___) 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 11. Furosemide 80 mg PO BID 12. Isoniazid ___ mg PO 3X/WEEK (___) 13. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 14. LOPERamide 2 mg PO QID:PRN diarrhea 15. Losartan Potassium 100 mg PO 4X/WEEK (___) 16. Metoprolol Succinate XL 200 mg PO DAILY 17. Montelukast 10 mg PO DAILY 18. NIFEdipine CR 90 mg PO DAILY 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 20. Omeprazole 20 mg PO BID 21. Polyethylene Glycol 17 g PO DAILY:PRN constipation 22. Pyrazinamide ___ mg PO 3X/WEEK (___) 23. Pyridoxine 50 mg PO DAILY 24. Rifampin 900 mg PO 3X/WEEK (___) 25. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis 26. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 27. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 28. HELD- Alendronate Sodium 35 mg PO QWED This medication was held. Do not restart Alendronate Sodium until another physician tells you to start taking this again. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Hypotension during hemodialysis Demand ischemia Secondary diagnoses: End stage renal disease on hemodialysis Hypertension Diabetes Asthma 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 ___ from ___ to ___. WHY WERE YOU ADMITTED TO THE HOSPITAL? - Your blood pressure was quite low during dialysis. - There was concern that you were confused and may have a urinary tract infection (UTI). WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - Your blood pressure was monitored overnight; it remained high, instead of low. We gave you all of your home medications to control your blood pressure. - We tested your urine - it showed no signs of infection. WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL? - Continue to take all of your medicines, as prescribed. - We will follow the results of your urine study to ensure that no bacteria grow. If any bacteria does grow, and we need to treat you for a urinary tract infection, we will call both you and your primary care doctor, Dr ___, so we can prescribe you an antibiotic. - You should follow-up with your primary care doctor, Dr ___ ___, some time this week to check-in. We wish you the best with your health going forward. If you have any further questions regarding your care here, please do not hesitate to contact us at ___ ___ 7 front desk). Your ___ Medicine Team Followup Instructions: ___
[ "I953", "I248", "E1122", "I120", "N186", "J45909", "B181", "B182", "A182", "R4182", "M810", "K219", "M109" ]
Allergies: Motrin / lisinopril / metformin / amlodipine [MASKED] Complaint: Hypotension and ?Altered Mental Status during dialysis Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] only; History obtained from chart, nephew/niece over phone call, and with the assistance of language line interpreter): Ms. [MASKED] is a [MASKED] year old [MASKED] and [MASKED] speaking woman with a history of extrapulmonary TB (lymphadenitis) on RIPE since [MASKED], UTI treated on recent admission ([MASKED]), DM2, ESRD on HD (MWF), chronic HBV/HCV, HTN, and CAD who presented with confusion and transient hypotension (SBPs to [MASKED] during dialysis. Approximately one week prior to admission, the patient's daughter noted foul smelling urine that was very dark in color, and per the daughter, the patient experienced some dysuria. The patient endorsed "feeling drunk" at this time along with several episodes of vomiting, though both resolved at the time of admission. She also endorsed weakness; at baseline, she ambulates with the occasional assistance of a cane at home, and she noted that she has had to use the cane in the days leading up to admission due to this weakness and "shakiness" in the legs. Per ED note, the patient presented to her regular hemodialysis yesterday ([MASKED]) and was noted to have transient hypotension to the [MASKED] which corrected with administration of IV fluids. She was then transferred to the [MASKED] ED. Notably, per chart review, she was recently hospitalized at the [MASKED] from [MASKED] to nd head strike with no traumatic injury identified on CT Head but extrapulmonary TB found incidentally on CT Torso after workup for lymphadenopathy; three induced sputa with concentrated smears were negative for TB and NAAT testing was negative. Urinalysis and urine culture were positive for E. coli on admission and she completed 5 days of IV ceftriaxone. She was discharged to [MASKED] rehab on [MASKED] and initiated RIPE on [MASKED]. She was discharged from [MASKED] on [MASKED]. Regarding her baseline status, her niece, [MASKED], last saw her at [MASKED], but spoke with a cousin who last saw her approximately 5 days prior to admission. She noted that the patient seemed well this week: alert, attentive, and able to engage in conversation. She did note that the patient does not leave the home very often and it is very possible she is not aware of the date at baseline. Notably, the patient never learned how to read and has poor eyesight. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG [MASKED] - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in [MASKED] - h/o C diff Social History: [MASKED] Family History: She is widowed and has 7 children, all in apparently good health. No notable family hx. Physical Exam: ============== ADMISSION EXAM ============== Vital Signs: T 98.3 BP 179/106 HR 78 RR 16 O2 Sat 99RA General: Alert, oriented to person (gives last name only), place (initially says home but acknowledges when prompted with hospital), but not time [MASKED] no acute distress HEENT: Cutaneous horn noted below left eye. Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact. ============== DISCHARGE EXAM ============== Vitals: T 97.9 BP 178/77 P 69 RR 18 O2 Sat 96RA General: Alert, oriented to person and place, date [MASKED] no acute distress HEENT: Cutaneous horn noted below left eye. Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact. Pertinent Results: ADMISSION LABS ============== [MASKED] 08:20PM BLOOD cTropnT-0.04* [MASKED] 07:00AM BLOOD cTropnT-0.09* [MASKED] 07:00AM BLOOD cTropnT-0.09* [MASKED] 03:40PM BLOOD cTropnT-0.08* [MASKED] 07:50AM BLOOD CK-MB-3 [MASKED] 03:40PM BLOOD CK-MB-3 [MASKED] 10:52PM BLOOD WBC-13.7*# RBC-3.34*# Hgb-11.4# Hct-34.9# MCV-105*# MCH-34.1* MCHC-32.7 RDW-16.3* RDWSD-61.8* Plt [MASKED] [MASKED] 10:52PM BLOOD Neuts-87.6* Lymphs-4.3* Monos-6.6 Eos-0.1* Baso-0.7 Im [MASKED] AbsNeut-11.98*# AbsLymp-0.59* AbsMono-0.90* AbsEos-0.01* AbsBaso-0.09* [MASKED] 08:20PM BLOOD Glucose-88 UreaN-9 Creat-2.0* Na-137 K-3.2* Cl-92* HCO3-23 AnGap-25* [MASKED] 03:40PM BLOOD Glucose-99 UreaN-18 Creat-3.2*# Na-138 K-4.2 Cl-97 HCO3-24 AnGap-21* [MASKED] 03:40PM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8 [MASKED] 08:20PM BLOOD ALT-20 AST-54* AlkPhos-100 TotBili-0.2 [MASKED] 08:20PM BLOOD Albumin-3.7 [MASKED] 08:20PM BLOOD Lipase-29 DISCHARGE LABS ============== [MASKED] 06:00AM BLOOD WBC-6.2# RBC-2.99* Hgb-10.2* Hct-30.4* MCV-102* MCH-34.1* MCHC-33.6 RDW-16.0* RDWSD-59.1* Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-97 UreaN-29* Creat-3.7* Na-137 K-3.9 Cl-97 HCO3-25 AnGap-19 [MASKED] 06:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.8 [MASKED] 03:11AM URINE RBC-1 WBC-17* Bacteri-FEW Yeast-NONE Epi-0 [MASKED] 03:11AM URINE Blood-TR Nitrite-NEG Protein->300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.5 Leuks-NEG [MASKED] 03:11AM URINE Color-Yellow Appear-Clear Sp [MASKED] IMAGING/STUDIES =============== [MASKED] (PA & LAT) Chronic findings as noted above. No evidence of mass, hemorrhage or infarction. [MASKED] CHEST/ABD/PELVIS W/O 1. No acute abnormality within the chest, abdomen, or pelvis. 2. Stable lymphadenopathy of mediastinal and porta hepatis lymph nodes remains unclear in etiology. [MASKED] HEAD W/O CONTRAST Chronic findings as noted above. No evidence of mass, hemorrhage or infarction. Brief Hospital Course: [MASKED] [MASKED] speaking ONLY) with DM2, ESRD on HD (MWF), chronic HCV/HBV, HTN, extrapulmonary TB (lymphadenitis) on RIPE who presented from HD with hypotension and recent UTI. #Foul-smelling urine/ recent UTI: Started 5-day course of ciprofloxacin by PCP [MASKED] [MASKED] for symptomatic complaints, consistent with UTI. Received dose of ceftriaxone in ED on [MASKED], to complete 5-day course of antibiotics. Afebrile, no chills or flank pain or CVA tenderness, not complaining of dysuria or other urinary symptoms, urine was not foul-smelling during admission. U/A was negative for leukocyte esterase and nitrites, few bacteria, 17 WBC, >300 mg/dL protein; the proteinuria is her baseline. Notably, she has had recurrent UTIs, several of which were cipro-resistant bacteria. Given entire picture, decided to hold further antibiotics. Pt was discharged prior to urine culture resulting; when culture finalized on [MASKED], patient and PCP were contacted to inform them that the urine culture was negative and no further intervention was required. #Transient Hypotension in dialysis, elevated troponins: No records from dialysis, note indicates SBPs to [MASKED] but unclear duration. Normotensive upon arrival to [MASKED] ED. Pt had troponin leak (peak 0.09 with subsequent downtrend) w/ transient ST segment depressions in V5/6 on initial EKG that resolved on subsequent EKGs. Pt denied cardiac or pulmonary complaints. Unclear whether hypotension preceded troponin leak or vice versa. Suspect that hypotension occurred in the setting of UTI and poor PO intake preceding HD session on [MASKED], which led her to become hypotensive while undergoing ultrafiltration. Troponin elevation was likely in the setting of demand ischemia, which improved with resolution of hypotensive episode. #Hypertension: SBPs in 170s-180s;asymptomatic. Did not receive home anti-hypertensives for >24 hours in ED. Restarted on all home antihypertensives with improvement of BP to 160s. #Altered Mental Status: Per son, who lives with patient, that patient was at her baseline mental status. Patient has a history of dementia noted during previous admission, but further details are unclear and family does not seem to be aware. Alert and oriented to person and place, and able to relate recent history clearly with no fluctuating consciousness. CT Head negative for acute changes, demonstrates chronic atrophic changes and white matter hypodensities. #Osteoporosis: Alendronate held at previous admission given ESRD, deferred to PCP [MASKED]: restarting. Continued to hold alendronate during admission. #ESRD on HD: has HD on [MASKED] - did not require dialysis while admitted. Continued Calcium and Vit D. #DM2: blood glucose 99 at admission. Did not require insulin for glucose management during admission. #Asthma: Continued albuterol, montelukast. Given advair 250/50 instead of dulera; will restart Dulera as outpatient #GERD: Continued PPI #Gout: continued allopurinol, changed dosing to HD dosing, 150 mg after HD TRANSITIONAL ISSUES =================== [x] inpatient team will follow-up the result of urine culture and contact one of the [MASKED] relatives [MASKED], [MASKED]. [MASKED], niece, [MASKED] for any interventions that need to take place pending the results of the culture -- this was completed prior to completion of this discharge summary. Culture was negative; pt and PCP contacted, no antibiotics required. [ ] close follow-up of blood pressure with primary care physician [MASKED] than 30 minutes was spent on this patient's discharge day management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Allopurinol [MASKED] mg PO DAILY 3. Artificial Tears [MASKED] DROP BOTH EYES BID:PRN dry eyes 4. Aspirin EC 325 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 6. Furosemide 80 mg PO BID 7. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 8. Metoprolol Succinate XL 200 mg PO DAILY 9. Montelukast 10 mg PO DAILY 10. NIFEdipine CR 90 mg PO DAILY 11. Omeprazole 20 mg PO BID 12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 13. Benzonatate 100 mg PO TID 14. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 15. Docusate Sodium 100 mg PO BID 16. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 17. Alendronate Sodium 35 mg PO QWED 18. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 19. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 20. LOPERamide 2 mg PO QID:PRN diarrhea 21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 22. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis 23. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 24. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 25. Polyethylene Glycol 17 g PO DAILY:PRN constipation 26. GuaiFENesin [MASKED] mL PO Q6H 27. Rifampin 900 mg PO 3X/WEEK ([MASKED]) 28. Isoniazid [MASKED] mg PO 3X/WEEK ([MASKED]) 29. Pyrazinamide [MASKED] mg PO 3X/WEEK ([MASKED]) 30. Ethambutol HCl 1200 mg PO 3X/WEEK ([MASKED]) 31. Pyridoxine 50 mg PO DAILY Discharge Medications: 1. Allopurinol [MASKED] mg PO 3X/WEEK ([MASKED]) 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 4. Artificial Tears [MASKED] DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 7. Docusate Sodium 100 mg PO BID 8. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 9. Ethambutol HCl 1200 mg PO 3X/WEEK ([MASKED]) 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 11. Furosemide 80 mg PO BID 12. Isoniazid [MASKED] mg PO 3X/WEEK ([MASKED]) 13. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 14. LOPERamide 2 mg PO QID:PRN diarrhea 15. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 16. Metoprolol Succinate XL 200 mg PO DAILY 17. Montelukast 10 mg PO DAILY 18. NIFEdipine CR 90 mg PO DAILY 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 20. Omeprazole 20 mg PO BID 21. Polyethylene Glycol 17 g PO DAILY:PRN constipation 22. Pyrazinamide [MASKED] mg PO 3X/WEEK ([MASKED]) 23. Pyridoxine 50 mg PO DAILY 24. Rifampin 900 mg PO 3X/WEEK ([MASKED]) 25. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis 26. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 27. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 28. HELD- Alendronate Sodium 35 mg PO QWED This medication was held. Do not restart Alendronate Sodium until another physician tells you to start taking this again. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Hypotension during hemodialysis Demand ischemia Secondary diagnoses: End stage renal disease on hemodialysis Hypertension Diabetes Asthma 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] from [MASKED] to [MASKED]. WHY WERE YOU ADMITTED TO THE HOSPITAL? - Your blood pressure was quite low during dialysis. - There was concern that you were confused and may have a urinary tract infection (UTI). WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - Your blood pressure was monitored overnight; it remained high, instead of low. We gave you all of your home medications to control your blood pressure. - We tested your urine - it showed no signs of infection. WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL? - Continue to take all of your medicines, as prescribed. - We will follow the results of your urine study to ensure that no bacteria grow. If any bacteria does grow, and we need to treat you for a urinary tract infection, we will call both you and your primary care doctor, Dr [MASKED], so we can prescribe you an antibiotic. - You should follow-up with your primary care doctor, Dr [MASKED] [MASKED], some time this week to check-in. We wish you the best with your health going forward. If you have any further questions regarding your care here, please do not hesitate to contact us at [MASKED] [MASKED] 7 front desk). Your [MASKED] Medicine Team Followup Instructions: [MASKED]
[]
[ "E1122", "J45909", "K219", "M109" ]
[ "I953: Hypotension of hemodialysis", "I248: Other forms of acute ischemic heart disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "J45909: Unspecified asthma, uncomplicated", "B181: Chronic viral hepatitis B without delta-agent", "B182: Chronic viral hepatitis C", "A182: Tuberculous peripheral lymphadenopathy", "R4182: Altered mental status, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified" ]
10,035,780
28,030,709
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___ Chief Complaint: Head Injury, s/p Fall Major Surgical or Invasive Procedure: EUS with biopsy ___ Mediastinoscopy with biopsy ___ History of Present Illness: Ms. ___ is a ___ yo woman with PMH of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV co-infection presenting after a fall. History obtained via son and daughter at bedside as patient speaks only ___. The patient reports that she got up to use commode ___ bedroom today then slipped off of it. She denies LOC, lightheadedness, or weakness and states it was purely due to slipping. She struck the bed and was reportedly down for 30 minutes with moderate blood loss from a head wound. The family put tobacco into the wound to try to stop the bleeding. She denies fevers though she reports feeling "cold" this AM. She denies dysuria or changes ___ urination aside from mildly reduced UOP. She has been eating and drinking normally. She denies feeling confused. She reports constipation over the last several hours, but denies focal numbness/tingling/weakness. She denies cough/SOB/rhinorrhea. She does note rare night sweats and ___ lb weight loss over 2 months. She had some blood ___ stool several days ago which self-resolved without further issues. She denies neck pain or any other pain elsewhere. ___ ED, initial vitals 97.4 88 150/66 20 100% RA. Imaging notable for CT Torso with LAD c/f lymphoma and segmental colitis; CT head without fracture or ICH; minimal anterolisthesis of C4 on C5 and C7 on T1 likely degenerative. Labs notable for WBC 16.7 with 74%PMN, Hgb 9.7 (most recent baseline ~11); trop negative x1; UA with >182 WBC and many bacteria, pos nit; lactate 2.1; Na 131 (recent baseline 127-132), Cr 3.3 (baseline around ___, Bicarb 17 with AG 20 (similar to recent values ___. Seen by spine, who note minimal anterolisthesis of C4-C5, likely degenerative and recommend keeping ___ hard C-collar spine as well as nonemergent MRI which can be performed inpt as pt is stable w/ a normal neuro exam. Received CTX 1g, TDaP x1. Skin staples placed to close head wound. Vitals on transfer 82 138/64 16 100% RA. On arrival to floor, patient denies complaints but requests water and to sit up ___ bed if possible. ROS: Positive as per HPI, all other systems reviewed and negative. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy ___ ___ - h/o C diff Social History: ___ Family History: She is widowed and has 7 children, all ___ apparently good health. No notable family hx. Physical Exam: ADMISSION VS: 97.8 174 / 82 97 16 95 RA General: Well appearing elderly woman lying ___ bed ___ NAD, hard C-collar ___ place Eyes: PERLL, EOMI, sclera anicteric HENT: Semicircular wound on right anterior scalp with closed with staples, c/d/i without notable erythema, no bleeding. MMM, oropharynx clear without exudate or lesions. Respiratory: CTAB without crackles, wheeze, rhonchi on anterior exam, limited by positioning with C-collar Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or gallops Gastrointestinal: Soft, nondistended, +BS, no masses or HSM, mild suprapubic tenderness to palpation Extremities: Warm and well perfused, no peripheral edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: Alert and oriented x2-3 (knows name, at ___, year ___ but unsure of date), CN2-12 intact, ___ strength ___ UE and ___ bilaterally, follows commands appropriately Discharge exam: Vitals: 98.1 PO 178/71 88 18 97 RA Gen - tired appearing, initially sleeping on entry into the room, seated upright ___ bed, breathing comfortably HEENT - head laceration is well healed, staples are removed, EOMI, poor dentition with multiple fillings/artificial teeth Heart - RR, ___ systolic murmur over R/LUSB, no r/g Lungs - clear to auscultation bilaterally, no wheezing or rhonchi noted today Abd - soft nontender, normoactive bowel sounds Ext - no edema, WWP Neuro - awake, alert, conversant ___ ___, moving all extremities purposefully with normal strength, no tremor or focal deficits appreciated Skin - there is some bruising at the clavicles at site of mediastinoscopy which is stable and some scattered bruising on her arms at phlebotomy sites Pertinent Results: LABS ========================== ADMISSION LABS ___ 09:00AM BLOOD WBC-16.7*# RBC-2.89* Hgb-9.7* Hct-30.6* MCV-106* MCH-33.6* MCHC-31.7* RDW-14.3 RDWSD-55.7* Plt ___ ___ 09:00AM BLOOD Glucose-173* UreaN-28* Creat-3.3* Na-131* K-4.3 Cl-94* HCO3-17* AnGap-24* DISCHARGE LABS: ___ 07:56AM BLOOD WBC-8.5 RBC-2.57* Hgb-8.3* Hct-24.7* MCV-96 MCH-32.3* MCHC-33.6 RDW-18.6* RDWSD-66.0* Plt ___ ___ 07:56AM BLOOD Glucose-108* UreaN-41* Creat-3.0*# Na-131* K-3.4 Cl-96 HCO3-23 AnGap-15 ___ 07:56AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.5* MICRIOBIOLOGY ========================== ___ 4:30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ blood culture x 2 NGTD ___ 2:11 am SPUTUM Source: Induced. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): pending ___ 5:53 pm SPUTUM Source: Induced. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): MTB Direct Amplification (Preliminary): M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT cannot rule out TB or other mycobacterial infection. . NAAT results will be followed by confirmatory testing with conventional culture and DST methods. This TB NAAT method has not been approved by FDA for clinical diagnostic purposes. However, ___ ___ (___) has established assay performance by ___ validation ___ accordance with ___ standards. . PERFORMED AT THE ___, ___. . RESULT REC'D BY PHONE-SAMPLE WILL BE FINALIZED UPON RECEIPT OF WRITTEN REPORT. ___ 11:06 am SPUTUM Site: INDUCED Source: Induced. GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ CLUSTERS. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): pending ___ 10:08 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. ___ Influenza A and B negative ___ RPR negative ___ cryptococcal antigen negative ___ 5:59 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ blood culture x 2 no growth final ___ 12:55 pm URINE CATHETER. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R IMAGING: ========================== ___ CXR FINDINGS: Trace pleural effusions. Mild left basilar opacity, likely atelectasis ___ the setting of shallow inspiration. ___ CXR IMPRESSION: ___ comparison with the scout radiograph from the CT of ___, there is little overall change. Prominence of these hilar and mediastinal regions are concerning for underlying malignancy. Following mediastinoscopy, there is no evidence of pneumothorax or pneumomediastinum. ___ MRI C-spine w/o con (wetread) Again seen is minimal anterolisthesis of C4 on C5 and C7 on T1, likely degenerative. There is no prevertebral edema or evidence of ligamentous injury. There is no evidence of acute fracture. Cord signal is within normal limits. Again seen is moderate right neural foraminal stenosis due to a facet osteophyte. Small posterior intervertebral osteophytes at multiple levels, but no high-grade spinal canal stenosis. ___ CT Torso w/con 1. No evidence of traumatic injury within the chest, abdomen or pelvis. 2. Numerous enlarged mediastinal lymph nodes, with gastrohepatic and portacaval lymph node conglomerate measuring up to 3.5 x 2.0 cm with cystic components, suspicious for malignancy, although a definite primary is not visualized on this examination. Lymphoma is a consideration. 3. Focal segment of proximal transverse colon demonstrating wall thickening and surrounding fat stranding, which likely represents segmental colitis. No nodularity to suggest an underlying primary malignancy. 4. Grade 1 anterolisthesis of L4 on L5, unchanged. ___ CT C spine without contrast 1. Minimal anterolisthesis of C4 on C5 and C7 on T1, likely degenerative ___ nature, however there are no priors for comparison. 2. No acute fractures. 3. Moderate right neural foraminal stenosis at C4-5. ___ CT Head w/o contrast Skin staples overlying a small right frontoparietal scalp hematoma without evidence of underlying fracture or intracranial hemorrhage. ___ MRI Cervical Spine 1. Grade 1 spondylolisthesis without evidence of ligamentous injury. 2. Mild multilevel degenerative changes of the cervical spine, as detailed above. 3. No evidence of bony or ligamentous injury. PATHOLOGY ================================= ___ final report SPECIMEN_1: LYMPH NODE, MEDIASTINAL 4R LYMPH NODE, EXCISION SPECIMEN_4: LYMPH NODE, MEDIASTINAL 4L LYMPH NODE, EXCISION. DIAGNOSIS: NECROTIZING GRANULOMAS, SEE NOTE. DIAGNOSIS: NECROTIZING GRANULOMAS, SEE NOTE. Note: Sections from Part 1 labeled as 4R lymph node compose of fragments of lymph nodes with extensive anthracotic pigment and focal granulomatous lesion. Sections from part 4, labeled as 4L lymph node, composed of fragments of lymphoid tissue with fibrosis and extensive necrosis. Special stains for infectious microorganisms (AFB, GMS, and Gram stain) performed on both specimens 1 and 2 are negative. The differential diagnosis includes infectious etiologies such as tuberculosis, and non-infectious causes such as necrotizing sarcoidosis, which is a diagnosis of exclusion. Correlation with clinical findings and microbiology cultures is highlight recommended. Brief Hospital Course: Ms. ___ is a ___ year old woman with past medical history of dementia, diabetes type 2 complicated by diabetic kidney disease / ESRD on HD, HBV/HCV co-infection admitted ___ following a fall with head laceration, incidentally also reporting recent GI bleed, with imaging concerning for malignancy # Fall / head laceration / cervical anterolisthesis: Per family, patient presented following a mechanical fall with head strike and large forehead laceration with significant bleeding. ___ the ED laceration was stapled and hemostasis was obtained. CT Head and torso were reassuring that there was no serious traumatic injury. Imaging identified scalp hematoma. CT and MRI C-spine showed mild anterolisthesis prompting spine service consult, who felt she had no ligamentous injury, and no acute surgical need. They recommended soft c-collar as needed with activity. Patient incidentally found to have several additional new medical issues listed below # Lymphadenopathy - Admission CT torso incidentally showed significant lymphadenopathy, concerning for malignancy / lymphoma. Oncology was consulted and recommended advanced endoscopy for EUS and biopsy. Obtained EUS with biopsy which was non-diagnostic. Patient then underwent midastinoscopy with thoracic surgery on ___ with lymph node biopsy. Final pathology consistent with necrotizing granulomas. Patient was r/o for active TB with 3 negative concentrated smears from induced sputa and negative NAAT. Rheumatology was consulted for concern for sarcoid, but did not believe this was likely. Patient should ___ ___ ID and ___ clinic. # Acute blood loss Anemia / GI Bleed NOS - Patient Hgb nadired at 5.9 from prior baseline of > 10 ___ setting of above head wound with significant bleeding at ___. Family also reported recent isolated episode of blood ___ patient's stool several days prior to presentation. ___ setting of CT scan with colonic thickening, and enlarged lymph nodes (as below), there was concern for malignant cause of recent bleeding. Per discussion with oncology, initially attempted to obtain EUS (as below) + colonoscopy to evaluate, however patient was noncompliant with bowel preparation x 2 successive nights despite counseling with family and interpreter. Discussed with family, and team felt that acute benefit of colonoscopy was outweighed by risk of continued attempts at preparation when patient did not wish to bowel prep. Given that priority was to obtain lymph tissue without additional delay, advanced endoscopy performed EUS with biopsy as below. There were no additional signs of GI bleeding and Hgb remained stable. Consider outpatient colonoscopy should patient and family wish to pursue. Patient did require 1 unit pRBC transition while EPO was held, but EPO was restarted once lymphoma was ruled out. # Cough - Patient developed cough during hospitalization. Three induced sputa with concentrated smears were negative for TB, NAAT testing was also negative. Sputum grew moderate commensal flora and multiple CXR were not consistent with pneumonia. Patient may have underlying non-tuberculous mycobacteria. She will f/u with ID as outpatient. She was treated symptomatically with improvement of cough and did not receive any antibiotics. # Latent TB - Patient's guantiferon gold was positive but as stated above, active TB testing at time of discharge was negative. Treatment will be per ID. # Hypertension - ___ setting of acute bleed on presentation, patient's antihypertensives were held. Once she was hemodynamically stable, restarted ___ nifedipine, Lasix, metoprolol, losartan. Of note, patient's BP noted to be high ___ the mornings prior to morning medication administration. Consider retiming medications to evening. # Atrial fibrillation - Patient had episodes of non sustained afib with RVR while at dialysis ___ setting of holding ___ metoprolol. These episodes were self limited and patient monitored on telemetry without any episodes of atrial fibrillation. Would consider outpatient Holter monitor to evaluate for afib. CHADS2 score of 3 VASc of 4 corresponding to a 5.9% and 6.4% risk of annual strokerespectively. Acute onset of AFib with rapid resolution is likely triggered from recent events described above. She has no prior history and is now ___ sinus rhythm. # Chest pain - Patient complaining of intermittent chest pain during hospitalization, likely MSK-related ___ setting of recent mediastinoscopy and pain exacerbated with coughing. EKG without any evidence of ischemic changes. # Urinary Tract Infection - On admission, patient found to have UA with bacteria and WBCs, as well as leukocytosis. Although it was unclear if she had symptoms, given her recent history of sepsis secondary to a UTI. risk of not treatment was felt to be high. Culture grew Ecoli and patient completed 5 days of IV CTX. # Osteoporosis - Given patient ESRD, held alendronate; could consider restarting at PCP ___. # ESRD on HD - Continued lasix as above. Continued calcium/VitD, Triphrocaps. Patient received ___ dialysis during hospitalization for scheduling purposes but was transitioned back to ___ dialysis prior to discharge. Next dialysis session should be ___. # Diabetes type 2 - Continued ASA and insulin sliding scale. She very rarely required any insulin for as BG was generally < 150. Thus, insulin was discontinued at discharge. # Asthma - Continued albuterol, Dulera, montelukast # GERD Continued PPI # Gout - Decreased dose of allopurinol given ESRD. > 30 minutes were spent on discharge planning and care coordination. TRANSITIONAL ISSUES: - Patient should have ID and rheumatology ___ for continued workup of extensive lymphadenopathy - pathology sample to be sent for molecular beacon testing by ID, no empiric treatment of TB recommended at this time - insulin sliding scale discontinued as patient did not require insulin during hospitalization - consider outpatient Holder monitor to evaluate for paroxysmal atrial fibrillation as patient had limited episodes during hospitalization - pending labs at discharge: ACE level, C4, C4, vitamin D, and RF Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol ___ mg PO DAILY 4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Furosemide 80 mg PO BID 8. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 9. Losartan Potassium 100 mg PO 4X/WEEK (___) 10. Montelukast 10 mg PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 14. LOPERamide 2 mg PO QID:PRN diarrhea 15. Metoprolol Succinate XL 200 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 18. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 19. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 20. Insulin SC Sliding Scale Insulin SC Sliding Scale using REG Insulin 21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Benzonatate 100 mg PO TID 3. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 4. Docusate Sodium 100 mg PO BID 5. GuaiFENesin ___ mL PO Q6H 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 8. Alendronate Sodium 35 mg PO QWED 9. Allopurinol ___ mg PO DAILY 10. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 11. Aspirin EC 325 mg PO DAILY 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 13. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 14. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 15. Furosemide 80 mg PO BID 16. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 17. LOPERamide 2 mg PO QID:PRN diarrhea 18. Losartan Potassium 100 mg PO 4X/WEEK (___) 19. Metoprolol Succinate XL 200 mg PO DAILY 20. Montelukast 10 mg PO DAILY 21. NIFEdipine CR 90 mg PO DAILY 22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 23. Omeprazole 20 mg PO BID 24. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis 25. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 26. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: # Lymphadenopathy # latent tuberculosis # Colonic abnormality # Acute blood loss Anemia # Fall with Head trauma/laceration # Hypertension # Urinary Tract Infection # Cervical Anterolisthesis # Osteoporosis # end stage renal disease # Diabetes type 2 # Asthma # GERD # Dementia - high risk for delirium # Gout Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. ___: It was a pleasure caring for you at ___. You were admitted with a fall and a large cut on your forehead. On a CAT scan you were found to have enlarged lymph nodes ___ your abdomen. You underwent a biopsy that showed granulomas. We performed multiple tests and determined you do not have cancer. We are not sure what is causing these large lymph nodes. It may due to TB (an infection), but testing is currently pending. You should ___ with the infectious disease and rheumatology doctors to determine what is causing your lymph nodes to be large. You are now ready for discharge to rehab. Please take care, Your ___ Team Followup Instructions: ___
[ "R591", "N186", "I120", "D62", "F0390", "B1910", "N390", "E871", "K922", "E1122", "Z992", "I2510", "S0102XA", "I4891", "E876", "M542", "D631", "K6389", "W01190A", "R7611", "R61", "R634", "Y92003", "E785", "J45909", "Z87440", "B1920", "K219", "M109", "Z794", "M4312", "M810" ]
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: Head Injury, s/p Fall Major Surgical or Invasive Procedure: EUS with biopsy [MASKED] Mediastinoscopy with biopsy [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman with PMH of ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV co-infection presenting after a fall. History obtained via son and daughter at bedside as patient speaks only [MASKED]. The patient reports that she got up to use commode [MASKED] bedroom today then slipped off of it. She denies LOC, lightheadedness, or weakness and states it was purely due to slipping. She struck the bed and was reportedly down for 30 minutes with moderate blood loss from a head wound. The family put tobacco into the wound to try to stop the bleeding. She denies fevers though she reports feeling "cold" this AM. She denies dysuria or changes [MASKED] urination aside from mildly reduced UOP. She has been eating and drinking normally. She denies feeling confused. She reports constipation over the last several hours, but denies focal numbness/tingling/weakness. She denies cough/SOB/rhinorrhea. She does note rare night sweats and [MASKED] lb weight loss over 2 months. She had some blood [MASKED] stool several days ago which self-resolved without further issues. She denies neck pain or any other pain elsewhere. [MASKED] ED, initial vitals 97.4 88 150/66 20 100% RA. Imaging notable for CT Torso with LAD c/f lymphoma and segmental colitis; CT head without fracture or ICH; minimal anterolisthesis of C4 on C5 and C7 on T1 likely degenerative. Labs notable for WBC 16.7 with 74%PMN, Hgb 9.7 (most recent baseline ~11); trop negative x1; UA with >182 WBC and many bacteria, pos nit; lactate 2.1; Na 131 (recent baseline 127-132), Cr 3.3 (baseline around [MASKED], Bicarb 17 with AG 20 (similar to recent values [MASKED]. Seen by spine, who note minimal anterolisthesis of C4-C5, likely degenerative and recommend keeping [MASKED] hard C-collar spine as well as nonemergent MRI which can be performed inpt as pt is stable w/ a normal neuro exam. Received CTX 1g, TDaP x1. Skin staples placed to close head wound. Vitals on transfer 82 138/64 16 100% RA. On arrival to floor, patient denies complaints but requests water and to sit up [MASKED] bed if possible. ROS: Positive as per HPI, all other systems reviewed and negative. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG [MASKED] - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy [MASKED] [MASKED] - h/o C diff Social History: [MASKED] Family History: She is widowed and has 7 children, all [MASKED] apparently good health. No notable family hx. Physical Exam: ADMISSION VS: 97.8 174 / 82 97 16 95 RA General: Well appearing elderly woman lying [MASKED] bed [MASKED] NAD, hard C-collar [MASKED] place Eyes: PERLL, EOMI, sclera anicteric HENT: Semicircular wound on right anterior scalp with closed with staples, c/d/i without notable erythema, no bleeding. MMM, oropharynx clear without exudate or lesions. Respiratory: CTAB without crackles, wheeze, rhonchi on anterior exam, limited by positioning with C-collar Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or gallops Gastrointestinal: Soft, nondistended, +BS, no masses or HSM, mild suprapubic tenderness to palpation Extremities: Warm and well perfused, no peripheral edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: Alert and oriented x2-3 (knows name, at [MASKED], year [MASKED] but unsure of date), CN2-12 intact, [MASKED] strength [MASKED] UE and [MASKED] bilaterally, follows commands appropriately Discharge exam: Vitals: 98.1 PO 178/71 88 18 97 RA Gen - tired appearing, initially sleeping on entry into the room, seated upright [MASKED] bed, breathing comfortably HEENT - head laceration is well healed, staples are removed, EOMI, poor dentition with multiple fillings/artificial teeth Heart - RR, [MASKED] systolic murmur over R/LUSB, no r/g Lungs - clear to auscultation bilaterally, no wheezing or rhonchi noted today Abd - soft nontender, normoactive bowel sounds Ext - no edema, WWP Neuro - awake, alert, conversant [MASKED] [MASKED], moving all extremities purposefully with normal strength, no tremor or focal deficits appreciated Skin - there is some bruising at the clavicles at site of mediastinoscopy which is stable and some scattered bruising on her arms at phlebotomy sites Pertinent Results: LABS ========================== ADMISSION LABS [MASKED] 09:00AM BLOOD WBC-16.7*# RBC-2.89* Hgb-9.7* Hct-30.6* MCV-106* MCH-33.6* MCHC-31.7* RDW-14.3 RDWSD-55.7* Plt [MASKED] [MASKED] 09:00AM BLOOD Glucose-173* UreaN-28* Creat-3.3* Na-131* K-4.3 Cl-94* HCO3-17* AnGap-24* DISCHARGE LABS: [MASKED] 07:56AM BLOOD WBC-8.5 RBC-2.57* Hgb-8.3* Hct-24.7* MCV-96 MCH-32.3* MCHC-33.6 RDW-18.6* RDWSD-66.0* Plt [MASKED] [MASKED] 07:56AM BLOOD Glucose-108* UreaN-41* Creat-3.0*# Na-131* K-3.4 Cl-96 HCO3-23 AnGap-15 [MASKED] 07:56AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.5* MICRIOBIOLOGY ========================== [MASKED] 4:30 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] blood culture x 2 NGTD [MASKED] 2:11 am SPUTUM Source: Induced. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): pending [MASKED] 5:53 pm SPUTUM Source: Induced. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): MTB Direct Amplification (Preliminary): M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT cannot rule out TB or other mycobacterial infection. . NAAT results will be followed by confirmatory testing with conventional culture and DST methods. This TB NAAT method has not been approved by FDA for clinical diagnostic purposes. However, [MASKED] [MASKED] ([MASKED]) has established assay performance by [MASKED] validation [MASKED] accordance with [MASKED] standards. . PERFORMED AT THE [MASKED], [MASKED]. . RESULT REC'D BY PHONE-SAMPLE WILL BE FINALIZED UPON RECEIPT OF WRITTEN REPORT. [MASKED] 11:06 am SPUTUM Site: INDUCED Source: Induced. GRAM STAIN (Final [MASKED]: <10 PMNs and <10 epithelial cells/100X field. 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS. 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] CLUSTERS. 2+ [MASKED] per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [MASKED]: MODERATE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): pending [MASKED] 10:08 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT [MASKED] Respiratory Viral Culture (Final [MASKED]: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [MASKED] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [MASKED]: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. [MASKED] Influenza A and B negative [MASKED] RPR negative [MASKED] cryptococcal antigen negative [MASKED] 5:59 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [MASKED] blood culture x 2 no growth final [MASKED] 12:55 pm URINE CATHETER. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R IMAGING: ========================== [MASKED] CXR FINDINGS: Trace pleural effusions. Mild left basilar opacity, likely atelectasis [MASKED] the setting of shallow inspiration. [MASKED] CXR IMPRESSION: [MASKED] comparison with the scout radiograph from the CT of [MASKED], there is little overall change. Prominence of these hilar and mediastinal regions are concerning for underlying malignancy. Following mediastinoscopy, there is no evidence of pneumothorax or pneumomediastinum. [MASKED] MRI C-spine w/o con (wetread) Again seen is minimal anterolisthesis of C4 on C5 and C7 on T1, likely degenerative. There is no prevertebral edema or evidence of ligamentous injury. There is no evidence of acute fracture. Cord signal is within normal limits. Again seen is moderate right neural foraminal stenosis due to a facet osteophyte. Small posterior intervertebral osteophytes at multiple levels, but no high-grade spinal canal stenosis. [MASKED] CT Torso w/con 1. No evidence of traumatic injury within the chest, abdomen or pelvis. 2. Numerous enlarged mediastinal lymph nodes, with gastrohepatic and portacaval lymph node conglomerate measuring up to 3.5 x 2.0 cm with cystic components, suspicious for malignancy, although a definite primary is not visualized on this examination. Lymphoma is a consideration. 3. Focal segment of proximal transverse colon demonstrating wall thickening and surrounding fat stranding, which likely represents segmental colitis. No nodularity to suggest an underlying primary malignancy. 4. Grade 1 anterolisthesis of L4 on L5, unchanged. [MASKED] CT C spine without contrast 1. Minimal anterolisthesis of C4 on C5 and C7 on T1, likely degenerative [MASKED] nature, however there are no priors for comparison. 2. No acute fractures. 3. Moderate right neural foraminal stenosis at C4-5. [MASKED] CT Head w/o contrast Skin staples overlying a small right frontoparietal scalp hematoma without evidence of underlying fracture or intracranial hemorrhage. [MASKED] MRI Cervical Spine 1. Grade 1 spondylolisthesis without evidence of ligamentous injury. 2. Mild multilevel degenerative changes of the cervical spine, as detailed above. 3. No evidence of bony or ligamentous injury. PATHOLOGY ================================= [MASKED] final report SPECIMEN 1: LYMPH NODE, MEDIASTINAL 4R LYMPH NODE, EXCISION SPECIMEN 4: LYMPH NODE, MEDIASTINAL 4L LYMPH NODE, EXCISION. DIAGNOSIS: NECROTIZING GRANULOMAS, SEE NOTE. DIAGNOSIS: NECROTIZING GRANULOMAS, SEE NOTE. Note: Sections from Part 1 labeled as 4R lymph node compose of fragments of lymph nodes with extensive anthracotic pigment and focal granulomatous lesion. Sections from part 4, labeled as 4L lymph node, composed of fragments of lymphoid tissue with fibrosis and extensive necrosis. Special stains for infectious microorganisms (AFB, GMS, and Gram stain) performed on both specimens 1 and 2 are negative. The differential diagnosis includes infectious etiologies such as tuberculosis, and non-infectious causes such as necrotizing sarcoidosis, which is a diagnosis of exclusion. Correlation with clinical findings and microbiology cultures is highlight recommended. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with past medical history of dementia, diabetes type 2 complicated by diabetic kidney disease / ESRD on HD, HBV/HCV co-infection admitted [MASKED] following a fall with head laceration, incidentally also reporting recent GI bleed, with imaging concerning for malignancy # Fall / head laceration / cervical anterolisthesis: Per family, patient presented following a mechanical fall with head strike and large forehead laceration with significant bleeding. [MASKED] the ED laceration was stapled and hemostasis was obtained. CT Head and torso were reassuring that there was no serious traumatic injury. Imaging identified scalp hematoma. CT and MRI C-spine showed mild anterolisthesis prompting spine service consult, who felt she had no ligamentous injury, and no acute surgical need. They recommended soft c-collar as needed with activity. Patient incidentally found to have several additional new medical issues listed below # Lymphadenopathy - Admission CT torso incidentally showed significant lymphadenopathy, concerning for malignancy / lymphoma. Oncology was consulted and recommended advanced endoscopy for EUS and biopsy. Obtained EUS with biopsy which was non-diagnostic. Patient then underwent midastinoscopy with thoracic surgery on [MASKED] with lymph node biopsy. Final pathology consistent with necrotizing granulomas. Patient was r/o for active TB with 3 negative concentrated smears from induced sputa and negative NAAT. Rheumatology was consulted for concern for sarcoid, but did not believe this was likely. Patient should [MASKED] [MASKED] ID and [MASKED] clinic. # Acute blood loss Anemia / GI Bleed NOS - Patient Hgb nadired at 5.9 from prior baseline of > 10 [MASKED] setting of above head wound with significant bleeding at [MASKED]. Family also reported recent isolated episode of blood [MASKED] patient's stool several days prior to presentation. [MASKED] setting of CT scan with colonic thickening, and enlarged lymph nodes (as below), there was concern for malignant cause of recent bleeding. Per discussion with oncology, initially attempted to obtain EUS (as below) + colonoscopy to evaluate, however patient was noncompliant with bowel preparation x 2 successive nights despite counseling with family and interpreter. Discussed with family, and team felt that acute benefit of colonoscopy was outweighed by risk of continued attempts at preparation when patient did not wish to bowel prep. Given that priority was to obtain lymph tissue without additional delay, advanced endoscopy performed EUS with biopsy as below. There were no additional signs of GI bleeding and Hgb remained stable. Consider outpatient colonoscopy should patient and family wish to pursue. Patient did require 1 unit pRBC transition while EPO was held, but EPO was restarted once lymphoma was ruled out. # Cough - Patient developed cough during hospitalization. Three induced sputa with concentrated smears were negative for TB, NAAT testing was also negative. Sputum grew moderate commensal flora and multiple CXR were not consistent with pneumonia. Patient may have underlying non-tuberculous mycobacteria. She will f/u with ID as outpatient. She was treated symptomatically with improvement of cough and did not receive any antibiotics. # Latent TB - Patient's guantiferon gold was positive but as stated above, active TB testing at time of discharge was negative. Treatment will be per ID. # Hypertension - [MASKED] setting of acute bleed on presentation, patient's antihypertensives were held. Once she was hemodynamically stable, restarted [MASKED] nifedipine, Lasix, metoprolol, losartan. Of note, patient's BP noted to be high [MASKED] the mornings prior to morning medication administration. Consider retiming medications to evening. # Atrial fibrillation - Patient had episodes of non sustained afib with RVR while at dialysis [MASKED] setting of holding [MASKED] metoprolol. These episodes were self limited and patient monitored on telemetry without any episodes of atrial fibrillation. Would consider outpatient Holter monitor to evaluate for afib. CHADS2 score of 3 VASc of 4 corresponding to a 5.9% and 6.4% risk of annual strokerespectively. Acute onset of AFib with rapid resolution is likely triggered from recent events described above. She has no prior history and is now [MASKED] sinus rhythm. # Chest pain - Patient complaining of intermittent chest pain during hospitalization, likely MSK-related [MASKED] setting of recent mediastinoscopy and pain exacerbated with coughing. EKG without any evidence of ischemic changes. # Urinary Tract Infection - On admission, patient found to have UA with bacteria and WBCs, as well as leukocytosis. Although it was unclear if she had symptoms, given her recent history of sepsis secondary to a UTI. risk of not treatment was felt to be high. Culture grew Ecoli and patient completed 5 days of IV CTX. # Osteoporosis - Given patient ESRD, held alendronate; could consider restarting at PCP [MASKED]. # ESRD on HD - Continued lasix as above. Continued calcium/VitD, Triphrocaps. Patient received [MASKED] dialysis during hospitalization for scheduling purposes but was transitioned back to [MASKED] dialysis prior to discharge. Next dialysis session should be [MASKED]. # Diabetes type 2 - Continued ASA and insulin sliding scale. She very rarely required any insulin for as BG was generally < 150. Thus, insulin was discontinued at discharge. # Asthma - Continued albuterol, Dulera, montelukast # GERD Continued PPI # Gout - Decreased dose of allopurinol given ESRD. > 30 minutes were spent on discharge planning and care coordination. TRANSITIONAL ISSUES: - Patient should have ID and rheumatology [MASKED] for continued workup of extensive lymphadenopathy - pathology sample to be sent for molecular beacon testing by ID, no empiric treatment of TB recommended at this time - insulin sliding scale discontinued as patient did not require insulin during hospitalization - consider outpatient Holder monitor to evaluate for paroxysmal atrial fibrillation as patient had limited episodes during hospitalization - pending labs at discharge: ACE level, C4, C4, vitamin D, and RF Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol [MASKED] mg PO DAILY 4. Artificial Tears [MASKED] DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Furosemide 80 mg PO BID 8. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 9. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 10. Montelukast 10 mg PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 14. LOPERamide 2 mg PO QID:PRN diarrhea 15. Metoprolol Succinate XL 200 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 18. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 19. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 20. Insulin SC Sliding Scale Insulin SC Sliding Scale using REG Insulin 21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Benzonatate 100 mg PO TID 3. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN sore throat 4. Docusate Sodium 100 mg PO BID 5. GuaiFENesin [MASKED] mL PO Q6H 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 8. Alendronate Sodium 35 mg PO QWED 9. Allopurinol [MASKED] mg PO DAILY 10. Artificial Tears [MASKED] DROP BOTH EYES BID:PRN dry eyes 11. Aspirin EC 325 mg PO DAILY 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 13. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation BID 14. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 15. Furosemide 80 mg PO BID 16. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 17. LOPERamide 2 mg PO QID:PRN diarrhea 18. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 19. Metoprolol Succinate XL 200 mg PO DAILY 20. Montelukast 10 mg PO DAILY 21. NIFEdipine CR 90 mg PO DAILY 22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 23. Omeprazole 20 mg PO BID 24. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN pruritis 25. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 26. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: # Lymphadenopathy # latent tuberculosis # Colonic abnormality # Acute blood loss Anemia # Fall with Head trauma/laceration # Hypertension # Urinary Tract Infection # Cervical Anterolisthesis # Osteoporosis # end stage renal disease # Diabetes type 2 # Asthma # GERD # Dementia - high risk for delirium # Gout Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [MASKED]: It was a pleasure caring for you at [MASKED]. You were admitted with a fall and a large cut on your forehead. On a CAT scan you were found to have enlarged lymph nodes [MASKED] your abdomen. You underwent a biopsy that showed granulomas. We performed multiple tests and determined you do not have cancer. We are not sure what is causing these large lymph nodes. It may due to TB (an infection), but testing is currently pending. You should [MASKED] with the infectious disease and rheumatology doctors to determine what is causing your lymph nodes to be large. You are now ready for discharge to rehab. Please take care, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "D62", "N390", "E871", "E1122", "I2510", "I4891", "E785", "J45909", "K219", "M109", "Z794" ]
[ "R591: Generalized enlarged lymph nodes", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "D62: Acute posthemorrhagic anemia", "F0390: Unspecified dementia without behavioral disturbance", "B1910: Unspecified viral hepatitis B without hepatic coma", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "K922: Gastrointestinal hemorrhage, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z992: Dependence on renal dialysis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "S0102XA: Laceration with foreign body of scalp, initial encounter", "I4891: Unspecified atrial fibrillation", "E876: Hypokalemia", "M542: Cervicalgia", "D631: Anemia in chronic kidney disease", "K6389: Other specified diseases of intestine", "W01190A: Fall on same level from slipping, tripping and stumbling with subsequent striking against furniture, initial encounter", "R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis", "R61: Generalized hyperhidrosis", "R634: Abnormal weight loss", "Y92003: Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "Z87440: Personal history of urinary (tract) infections", "B1920: Unspecified viral hepatitis C without hepatic coma", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "Z794: Long term (current) use of insulin", "M4312: Spondylolisthesis, cervical region", "M810: Age-related osteoporosis without current pathological fracture" ]
10,035,780
29,685,392
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Motrin / lisinopril / metformin / amlodipine Attending: ___. Chief Complaint: Fever and confusion Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year-old ___ woman with PMH significant for ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV co-infection, and recent admission for E. coli urosepsis (___) presenting now with confusion and fever at dialysis. The patient was undergoing scheduled HD when she developed fever and altered mental status and was referred to ___ ED. Most recently, she was admitted to ___ ___ for similar symptoms of lethargy and fever at which time she was found to have E.coli UTI. In the ED, she was febrile to 101.3 with normal vitals. Labs were notable for a WBC 21.8, LFTs with ALT 77 AST 94, and lactate 3.5. UA with many bacteria though negative ___ and nitrites. In the ED, she was given cefepime and vancomycin. Chest x-ray and CT abdomen/pelvis showed no process to explain fever/leukocytosis. On the floor, VS 98.1 132/70 84 16 99%RA. The patient is well-appearing, report slightly running nose and shortness of breath consistent with baseline asthma, but is otherwise without complaints. This morning, states feeling well. Denies dysuria, though has had dysuria with previous UTIs. Denies feeling confused. Denies chills or fever. Still has runny nose and cough, no other concerns. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG ___ - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in ___ - h/o C diff Social History: ___ Family History: She is widowed and she has 7 children, and in apparently good health. Physical Exam: Exam on admission: ================== Vital Signs: afebrile Tc: 98.2, BP 134/72, HR 87, RR 16 98%RA ___: 133 General: Alert, oriented, in no acute distress HEENT: Sclera anicteric, MMM, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, systolic murmur. No rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present GU: No foley Ext: LUE fistula with bruit present. Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Alert and oriented to self and place. States ___ for date. CNII-XII grossly intact. Exam on discharge: =================== Vital Signs: afebrile Tc: 98.0, BP 101-143/50-68 (123/61), HR 71-102 (79), RR 18 98%RA General: Alert, oriented, in no acute distress HEENT: Sclera anicteric, MMM, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, systolic murmur. No rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present GU: No foley Ext: LUE fistula with bruit present. Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact. Deltoids, biceps, triceps ___. Grip strength ___ bilaterally. Pertinent Results: On admission: ============= ___ 06:38PM BLOOD WBC-21.8*# RBC-4.04 Hgb-13.5 Hct-40.0 MCV-99* MCH-33.4* MCHC-33.8 RDW-14.1 RDWSD-51.2* Plt ___ ___ 06:38PM BLOOD Neuts-88.5* Lymphs-3.9* Monos-4.8* Eos-0.0* Baso-0.8 Im ___ AbsNeut-19.30* AbsLymp-0.85* AbsMono-1.05* AbsEos-0.01* AbsBaso-0.17* ___ 06:38PM BLOOD ___ PTT-32.4 ___ ___ 06:38PM BLOOD Glucose-148* UreaN-34* Creat-2.7* Na-136 K-5.0 Cl-92* HCO3-27 AnGap-22* ___ 06:38PM BLOOD ALT-77* AST-94* AlkPhos-180* TotBili-0.4 ___ 06:38PM BLOOD Lipase-60 ___ 06:38PM BLOOD Albumin-4.4 Calcium-9.6 Phos-2.8# Mg-1.9 ___ 07:11PM BLOOD Lactate-3.5* ___ 07:15PM URINE Blood-NEG Nitrite-NEG Protein-300 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 07:15PM URINE RBC-1 WBC-1 Bacteri-MANY Yeast-NONE Epi-0 ___ 07:15PM URINE CastHy-1* Notable labs: ============= ___ 02:32AM BLOOD Lactate-1.2 Blood Culture, Routine ___ x2: NO GROWTH. Blood Culture, Routine ___: pending URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Imaging: ======== - ___ CXR: No acute cardiopulmonary process. - ___ CT A/P W/O CON: 1. Limited exam without intravenous or oral contrast. 2. Equivocal peripancreatic fat-stranding versus partial volume averaging and question of pancreatic calcification versus atherosclerotic calcification. Focal prominence of the main pancreatic duct versus side branch in the tail. Recommend correlation with pancreatic enzymes for pancreatitis and non-emergent MRCP to further evaluate. 3. Unchanged prominence of the CBD to 10 mm, which could be related to cholecystectomy. This can be evaluated with the MRCP at the same time. 4. No diverticulosis. 5. Mild lower lobe bronchiolar inflammation. 6. Thickened left adrenal gland without discrete nodule. - ___ ECG: SR@82, NANI, LVH, peaked T-waves stable from prior, no ischemic changes Labs on discharge: =================== ___ 05:47AM BLOOD WBC-13.7* RBC-3.45* Hgb-11.6 Hct-34.4 MCV-100* MCH-33.6* MCHC-33.7 RDW-14.1 RDWSD-51.3* Plt ___ ___ 05:47AM BLOOD Glucose-124* UreaN-54* Creat-4.2* Na-129* K-4.2 Cl-87* HCO3-27 AnGap-19 ___ 05:47AM BLOOD ALT-59* AST-61* AlkPhos-124* ___ 12:10AM BLOOD Calcium-9.5 Phos-6.8* Mg-2.0 Brief Hospital Course: Ms. ___ is a ___ year-old woman with PMH significant for ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV co-infection, and recent admission for E. coli urosepsis who presented with confusion and fever while at scheduled dialysis. #Fever/Leukocytosis: Patient initially received cefepime. Infectious work-up notable for negative urine culture, negative chest x-ray, and blood cultures negative from ___. Remaining blood cultures are pending. She denied any localizing symptoms including dysuria, abdominal pain, diarrhea. She was empirically treated for UTI with bacteria on UA, see below. She was afebrile during her admission and remained afebrile after discontinuing antibiotics. #UTI: She has a history of recurrent urinary tract infections with more than 3 infections in the past year. Her daughter noted that she was on ciprofloxacin prior to admission; however, previous urine culture sensitivities showed resistance to ciprofloxacin. She was empirically treated for UTI with cefepime and discontinued when urine culture returned negative. She had no fever during stay at ___. #AMS: A&Ox2 to self and place throughout the course of admission. Daughter, who is her primary caretaker, states that this is her baseline. # Cough: Likely viral. Treated symptomatically. # Elevated LFTs: Downtrended throughout the course of admission. On CT abdomen, there was focal prominence of the main pancreatic duct versus side branch in the tail. Not likely pancreatitis with lipase within normal limits. # ESRD on HD: Received dialysis according to her MWF schedule while inpatient. Chronic issues of T2DM, osteoporosis, asthma, gout, and GERD were all stable and continued with home medications. Family stated they would not want rehab or home ___. She has 24-hour supervision at home and therefore, it was determined that she was safe for discharge home. Family also did not want ___. Transitional issues: ==================== [ ] Consider prophylactic antibiotics for recurrent UTI. [ ] Consider outpatient urology for recurrent UTI. [ ] Previous E coli culture and sensitivities showed ciprofloxacin resistance. [ ] On CT, focal prominence of the main pancreatic duct versus side branch in the tail and dilated common biliary duct. Consider non-emergent MRCP to further evaluate. [ ] Daughter, who is primary caretaker, says she has some dementia at baseline. Baseline she is AAO x 2. [ ] new medications: none [ ] patient had very well controlled BG while inpatient, likely can d/c insulin sliding scale as outpatient [ ] consider d/c nifedipine given interaction with metoprolol Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol ___ mg PO BID 4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Furosemide 80 mg PO BID 9. Losartan Potassium 100 mg PO 4X/WEEK (___) 10. Metoprolol Succinate XL 200 mg PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 13. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 14. Montelukast 10 mg PO DAILY 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Omeprazole 20 mg PO BID 17. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 18. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 19. LOPERamide 2 mg PO QID:PRN diarrhea 20. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol ___ mg PO BID 4. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Furosemide 80 mg PO BID 9. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 10. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 11. Losartan Potassium 100 mg PO 4X/WEEK (___) 12. Montelukast 10 mg PO DAILY 13. NIFEdipine CR 90 mg PO DAILY 14. Omeprazole 20 mg PO BID 15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 16. LOPERamide 2 mg PO QID:PRN diarrhea 17. Metoprolol Succinate XL 200 mg PO DAILY 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 20. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: Fever UTI Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Confused - sometimes. Discharge Instructions: Dear Ms. ___, It was a pleasure to take care of you at ___. Why was I here? - You had a fever and were confused when at dialysis. What was done while I was here? - You were treated for a UTI with antibiotics, and it was stopped once bacteria was not found in your urine. What should I do when I get home? - Continue taking your medicines as prescribed. - You do not need to take the antibiotics (ciprofloxacin) prescribed by your primary care doctor on ___. Sincerely, Your ___ team Followup Instructions: ___
[ "R509", "E119", "N2581", "I120", "N186", "B181", "D649", "D72829", "R4182", "R05", "R740", "Z87440", "Z992", "B182", "I2510", "J45909", "M810", "M109", "K219" ]
Allergies: Motrin / lisinopril / metformin / amlodipine Chief Complaint: Fever and confusion Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year-old [MASKED] woman with PMH significant for ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV co-infection, and recent admission for E. coli urosepsis ([MASKED]) presenting now with confusion and fever at dialysis. The patient was undergoing scheduled HD when she developed fever and altered mental status and was referred to [MASKED] ED. Most recently, she was admitted to [MASKED] [MASKED] for similar symptoms of lethargy and fever at which time she was found to have E.coli UTI. In the ED, she was febrile to 101.3 with normal vitals. Labs were notable for a WBC 21.8, LFTs with ALT 77 AST 94, and lactate 3.5. UA with many bacteria though negative [MASKED] and nitrites. In the ED, she was given cefepime and vancomycin. Chest x-ray and CT abdomen/pelvis showed no process to explain fever/leukocytosis. On the floor, VS 98.1 132/70 84 16 99%RA. The patient is well-appearing, report slightly running nose and shortness of breath consistent with baseline asthma, but is otherwise without complaints. This morning, states feeling well. Denies dysuria, though has had dysuria with previous UTIs. Denies feeling confused. Denies chills or fever. Still has runny nose and cough, no other concerns. Past Medical History: - DMII - ESRD on HD MWF, LUE AVG [MASKED] - HTN - osteoarthritis - osteoporosis - HLD - asthma - anemia - HBV - HCV - gout - GERD - s/p lap cholecystectomy in [MASKED] - h/o C diff Social History: [MASKED] Family History: She is widowed and she has 7 children, and in apparently good health. Physical Exam: Exam on admission: ================== Vital Signs: afebrile Tc: 98.2, BP 134/72, HR 87, RR 16 98%RA [MASKED]: 133 General: Alert, oriented, in no acute distress HEENT: Sclera anicteric, MMM, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, systolic murmur. No rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present GU: No foley Ext: LUE fistula with bruit present. Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Alert and oriented to self and place. States [MASKED] for date. CNII-XII grossly intact. Exam on discharge: =================== Vital Signs: afebrile Tc: 98.0, BP 101-143/50-68 (123/61), HR 71-102 (79), RR 18 98%RA General: Alert, oriented, in no acute distress HEENT: Sclera anicteric, MMM, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, systolic murmur. No rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present GU: No foley Ext: LUE fistula with bruit present. Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact. Deltoids, biceps, triceps [MASKED]. Grip strength [MASKED] bilaterally. Pertinent Results: On admission: ============= [MASKED] 06:38PM BLOOD WBC-21.8*# RBC-4.04 Hgb-13.5 Hct-40.0 MCV-99* MCH-33.4* MCHC-33.8 RDW-14.1 RDWSD-51.2* Plt [MASKED] [MASKED] 06:38PM BLOOD Neuts-88.5* Lymphs-3.9* Monos-4.8* Eos-0.0* Baso-0.8 Im [MASKED] AbsNeut-19.30* AbsLymp-0.85* AbsMono-1.05* AbsEos-0.01* AbsBaso-0.17* [MASKED] 06:38PM BLOOD [MASKED] PTT-32.4 [MASKED] [MASKED] 06:38PM BLOOD Glucose-148* UreaN-34* Creat-2.7* Na-136 K-5.0 Cl-92* HCO3-27 AnGap-22* [MASKED] 06:38PM BLOOD ALT-77* AST-94* AlkPhos-180* TotBili-0.4 [MASKED] 06:38PM BLOOD Lipase-60 [MASKED] 06:38PM BLOOD Albumin-4.4 Calcium-9.6 Phos-2.8# Mg-1.9 [MASKED] 07:11PM BLOOD Lactate-3.5* [MASKED] 07:15PM URINE Blood-NEG Nitrite-NEG Protein-300 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 07:15PM URINE RBC-1 WBC-1 Bacteri-MANY Yeast-NONE Epi-0 [MASKED] 07:15PM URINE CastHy-1* Notable labs: ============= [MASKED] 02:32AM BLOOD Lactate-1.2 Blood Culture, Routine [MASKED] x2: NO GROWTH. Blood Culture, Routine [MASKED]: pending URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Imaging: ======== - [MASKED] CXR: No acute cardiopulmonary process. - [MASKED] CT A/P W/O CON: 1. Limited exam without intravenous or oral contrast. 2. Equivocal peripancreatic fat-stranding versus partial volume averaging and question of pancreatic calcification versus atherosclerotic calcification. Focal prominence of the main pancreatic duct versus side branch in the tail. Recommend correlation with pancreatic enzymes for pancreatitis and non-emergent MRCP to further evaluate. 3. Unchanged prominence of the CBD to 10 mm, which could be related to cholecystectomy. This can be evaluated with the MRCP at the same time. 4. No diverticulosis. 5. Mild lower lobe bronchiolar inflammation. 6. Thickened left adrenal gland without discrete nodule. - [MASKED] ECG: SR@82, NANI, LVH, peaked T-waves stable from prior, no ischemic changes Labs on discharge: =================== [MASKED] 05:47AM BLOOD WBC-13.7* RBC-3.45* Hgb-11.6 Hct-34.4 MCV-100* MCH-33.6* MCHC-33.7 RDW-14.1 RDWSD-51.3* Plt [MASKED] [MASKED] 05:47AM BLOOD Glucose-124* UreaN-54* Creat-4.2* Na-129* K-4.2 Cl-87* HCO3-27 AnGap-19 [MASKED] 05:47AM BLOOD ALT-59* AST-61* AlkPhos-124* [MASKED] 12:10AM BLOOD Calcium-9.5 Phos-6.8* Mg-2.0 Brief Hospital Course: Ms. [MASKED] is a [MASKED] year-old woman with PMH significant for ESRD on HD (MWF), DMII, HTN, CAD, HBV/HCV co-infection, and recent admission for E. coli urosepsis who presented with confusion and fever while at scheduled dialysis. #Fever/Leukocytosis: Patient initially received cefepime. Infectious work-up notable for negative urine culture, negative chest x-ray, and blood cultures negative from [MASKED]. Remaining blood cultures are pending. She denied any localizing symptoms including dysuria, abdominal pain, diarrhea. She was empirically treated for UTI with bacteria on UA, see below. She was afebrile during her admission and remained afebrile after discontinuing antibiotics. #UTI: She has a history of recurrent urinary tract infections with more than 3 infections in the past year. Her daughter noted that she was on ciprofloxacin prior to admission; however, previous urine culture sensitivities showed resistance to ciprofloxacin. She was empirically treated for UTI with cefepime and discontinued when urine culture returned negative. She had no fever during stay at [MASKED]. #AMS: A&Ox2 to self and place throughout the course of admission. Daughter, who is her primary caretaker, states that this is her baseline. # Cough: Likely viral. Treated symptomatically. # Elevated LFTs: Downtrended throughout the course of admission. On CT abdomen, there was focal prominence of the main pancreatic duct versus side branch in the tail. Not likely pancreatitis with lipase within normal limits. # ESRD on HD: Received dialysis according to her MWF schedule while inpatient. Chronic issues of T2DM, osteoporosis, asthma, gout, and GERD were all stable and continued with home medications. Family stated they would not want rehab or home [MASKED]. She has 24-hour supervision at home and therefore, it was determined that she was safe for discharge home. Family also did not want [MASKED]. Transitional issues: ==================== [ ] Consider prophylactic antibiotics for recurrent UTI. [ ] Consider outpatient urology for recurrent UTI. [ ] Previous E coli culture and sensitivities showed ciprofloxacin resistance. [ ] On CT, focal prominence of the main pancreatic duct versus side branch in the tail and dilated common biliary duct. Consider non-emergent MRCP to further evaluate. [ ] Daughter, who is primary caretaker, says she has some dementia at baseline. Baseline she is AAO x 2. [ ] new medications: none [ ] patient had very well controlled BG while inpatient, likely can d/c insulin sliding scale as outpatient [ ] consider d/c nifedipine given interaction with metoprolol Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol [MASKED] mg PO BID 4. Artificial Tears [MASKED] DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Furosemide 80 mg PO BID 9. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 10. Metoprolol Succinate XL 200 mg PO DAILY 11. NIFEdipine CR 90 mg PO DAILY 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 13. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 14. Montelukast 10 mg PO DAILY 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Omeprazole 20 mg PO BID 17. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 18. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY 19. LOPERamide 2 mg PO QID:PRN diarrhea 20. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 2. Alendronate Sodium 35 mg PO QWED 3. Allopurinol [MASKED] mg PO BID 4. Artificial Tears [MASKED] DROP BOTH EYES BID:PRN dry eyes 5. Aspirin EC 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY each nares 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. Furosemide 80 mg PO BID 9. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 10. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN pain 11. Losartan Potassium 100 mg PO 4X/WEEK ([MASKED]) 12. Montelukast 10 mg PO DAILY 13. NIFEdipine CR 90 mg PO DAILY 14. Omeprazole 20 mg PO BID 15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral TID 16. LOPERamide 2 mg PO QID:PRN diarrhea 17. Metoprolol Succinate XL 200 mg PO DAILY 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY 20. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY Discharge Disposition: Home Discharge Diagnosis: Fever UTI Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Confused - sometimes. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure to take care of you at [MASKED]. Why was I here? - You had a fever and were confused when at dialysis. What was done while I was here? - You were treated for a UTI with antibiotics, and it was stopped once bacteria was not found in your urine. What should I do when I get home? - Continue taking your medicines as prescribed. - You do not need to take the antibiotics (ciprofloxacin) prescribed by your primary care doctor on [MASKED]. Sincerely, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "E119", "D649", "I2510", "J45909", "M109", "K219" ]
[ "R509: Fever, unspecified", "E119: Type 2 diabetes mellitus without complications", "N2581: Secondary hyperparathyroidism of renal origin", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "B181: Chronic viral hepatitis B without delta-agent", "D649: Anemia, unspecified", "D72829: Elevated white blood cell count, unspecified", "R4182: Altered mental status, unspecified", "R05: Cough", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z87440: Personal history of urinary (tract) infections", "Z992: Dependence on renal dialysis", "B182: Chronic viral hepatitis C", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "J45909: Unspecified asthma, uncomplicated", "M810: Age-related osteoporosis without current pathological fracture", "M109: Gout, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,035,787
29,728,342
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: ___ Aortic valve replacement with 21mm Magna Ease tissue valve, Coronary artery bypass graft x1 (Saphenous vein >Acute Marginal) History of Present Illness: ___ year old male with a known history of aortic stenosis that has been followed by serial echocardiograms through the years. He has felt well through the years until more recently when he noticed mild dyspnea with prolonged activity. His most recent echo from this ___ revealed a normal LVEF and significant aortic stenosis. He was referred for a cardiac catheterization which revealed an ostial 80-90% stenosis of a large RV marginal branch. He was referred for an aortic valve replacement evaluation. Past Medical History: Aortic stenosis Hyperlipidemia Chiari Malformation GERD Ulcerative colitis Hearing loss Bilateral cataract surgery Inguinal hernia repair Social History: ___ Family History: Sister died at the age of ___ from a congenital heart condition. Father had PAD, passed from lung disease at ___. Mother passed from lung cancer at ___. Physical Exam: Admit PE Pulse:60 Resp:18 O2 sat: 100% RA B/P Right:188/79 Left: 178/70 Height: 64 in Weight: 180 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 [x] III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [-] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: P Left: P DP Right: P Left: P ___ Right: P Left: P Radial Right: P Left: P Carotid Bruit: Right: none Left: positive Discharge Examination Vital Signs and Intake/Output: ___ 0343 Temp: 99.1 PO BP: 150/63 HR: 73 RR: 18 O2 sat: 92% O2 delivery: Ra fs 89-131 Date wt (kg) wt (lbs) In Out daily cumulative balance ___ 85.4 kg 188.27 lb ___ ___ 86.6 kg 190.92 lb ___.3 General/Neuro: NAD A/O x3 non-focal Cardiac: RRR Nl S1 S2 Lungs: CTA No resp distress Abd: NBS Soft ND NT Extremities: TRace ___ edema Wounds: Sternal: CDI no erythema or drainage Sternum stable Leg: Left CDI no erythema or drainage Pertinent Results: STUDIES: PA/LAT CXR ___: In comparison with the study of ___, the there are slightly improved lung volumes with decreasing basilar atelectasis and vascular congestion. Cardiac Catheterization: Date: ___ Place: ___ Dominance: Right * Left Main Coronary Artery The LMCA is large in caliber and is overall non obstructive * Left Anterior Descending The LAD appears to have a proximal step down in caliber when compared to the larger caliber of the Left main, possibly mild disease The ___ Diagonal is overall non obstructive * Circumflex The Circumflex is overall non obstructive * Ramus The Ramus has mild luminal irregularities * Right Coronary Artery The RCA is co-dominant There is an ostial 80-90% stenosis of a large RV marginal branch with TIMI II flow The Right PDA is overall non obstructive Cardiac Echocardiogram ___ Atrius: Aortic Root diameter: (2.2-3.7CM) Left Atrium diameter: (2.5-4.0CM) LV septal thickness (IVSd): (0.7-1.1CM) LV diastolic diameter (LVDd): (4.0-5.6CM) LV post wall thickness (LVPWd): (0.7-1.1CM) LV systolic diameter (LVIDs): (2.0-3.8CM) MEASUREMENTS Ao Diam 2.6 cm ___ 3.6 cm IVSd 1.0 cm LVIDd 3.8 cm LVPWd 0.9 cm LVIDs 2.0 cm STRUCTURED FINDINGS This echocardiogram was performed at ___ ___. Referred for evaluation of aortic stenosis. Sinus rhythm. The study was technically adequate. 2D Color and spectral Doppler were performed. The left ventricle size is normal. Left ventricular wall thickness is normal. There are no regional wall motion abnormalities. Overall left ventricular ejection fraction is normal, with an estimated LVEF of 55-60%. Grade I diastolic dysfunction with normal ___ pressure. The left atrium linear dimension is normal. The left atrial volume is mildly increased. The right ventricle is normal in size, thickness and function. TAPSE and RV S' are within normal limits suggesting normal right ventricular free wall systolic function. The right atrium is normal in size. The aortic valve is trileaflet and is moderately thickened. The non coronary cusp appears fixed and moderately calcified. There is trace aortic regurgitation. The peak transvalvular velocity is 4.16 m/sec, with peak/mean pressure gradients of 69/37mmHg , and calculated ___ by continuity equation of 0.7cm2 (using measured LVOT diameter of 2.0 cm, and LVOT velocity of 1.0m/sec); these findings are consistent withprobably moderate aortic stenosis. There is considerable fling in the aortic valve Doppler flow, so the peak gradient varies from low 40's up to high 60's, and therefore aortic valve area varies from 0.7-1.0 cm sq. The mitral valve leaflets are mildly thickened. Mild mitral annular calcification present. Mild mitral regurgitation is present. There is no evidence of mitral stenosis. The tricuspid valve is structurally normal. There is mild tricuspid regurgitation present. PA systolic pressure is normal, with estimated PA systolic of 30mmHg + RA pressure. Pulmonic valve appears structurally and functionally normal. There is no pulmonic stenosis. There is trace pulmonic regurgitation. There is no pericardial effusion. The aortic root, measured at the level of the sinuses of Valsalva, is of normal caliber. Visualized portions of the ascending aorta, transverse and descending thoracic aorta are of normal caliber. The inferior vena cava is normal, with normal respirophasic movement indicating normal right atrial pressure. There is no evidence of a shunt by color Doppler from views imaged. CONCLUSIONS 1. Left ventricular wall thickness is normal. 2. Overall left ventricular ejection fraction is normal, with an estimated LVEF of 55-60%. 3. The aortic valve is trileaflet and is moderately thickened. The non coronary cusp appears fixed and moderately calcified. 4. There is trace aortic regurgitation. 5. There is probably moderate aortic stenosis present. There is considerable variability in the peak gradient/aortic valve area calculation, so there may not be a significant change in the severity of aortic stenosis compared to ___. 6. The mitral valve leaflets are mildly thickened. 7. Mild mitral annular calcification present. 8. Mild mitral regurgitation is present. 9. Visualized portions of the ascending aorta, transverse and descending thoracic aorta are of normal caliber. 10. Compared with the findings of the prior report of ___, more variability in the Dopper gradients of the aortic valve are noted (see above). Carotid US ___: Right ICA 40-59% stenosis. Left ICA 40-59% stenosis. LABS: Admit: ___ 12:08PM BLOOD WBC-9.0 RBC-2.56* Hgb-7.3* Hct-21.6* MCV-84 MCH-28.5 MCHC-33.8 RDW-13.5 RDWSD-41.2 Plt ___ ___ 12:08PM BLOOD ___ PTT-24.3* ___ ___ 01:40PM BLOOD UreaN-15 Creat-0.7 Cl-116* HCO3-23 AnGap-6* ___ 01:00AM BLOOD Glucose-136* UreaN-18 Creat-0.9 Na-141 K-4.9 Cl-107 HCO3-24 AnGap-10 ___ 09:46AM BLOOD ALT-7 AST-35 LD(___)-312* AlkPhos-33* Amylase-27 TotBili-0.3 ___ 09:46AM BLOOD Lipase-9 ___ 09:46AM BLOOD Mg-2.6 ___ 07:52AM BLOOD HEPARIN DEPENDENT ANTIBODIES-PF4 Heparin Antibody 0.07 (range = 0.00 - 0.39) Discharge: ___ 04:50AM BLOOD WBC-6.8 RBC-3.08* Hgb-8.6* Hct-26.8* MCV-87 MCH-27.9 MCHC-32.1 RDW-14.6 RDWSD-47.1* Plt ___ ___ 04:50AM BLOOD Glucose-115* UreaN-29* Creat-1.0 Na-139 K-4.1 Cl-100 HCO3-28 AnGap-11 ___ 09:46AM BLOOD ALT-7 AST-35 LD(LDH)-312* AlkPhos-33* Amylase-27 TotBili-0.3 ___ 04:50AM BLOOD Phos-2.6* Mg-2.3 Brief Hospital Course: Mr ___ was brought to the Operating Room on ___ where he underwent Aortic valve replacement with 21mm Magna Ease tissue valve, CABG x1 (SVG-Acute Marginal). Overall the he tolerated the procedure well although he had traumatic foley placement, with resolving hematuria. See operative report for further details. Post-operatively, he was transferred to the CVICU in stable condition for recovery and invasive monitoring. He had Left pigtail chest tube placed for pneumothorax. Within a few hours he was weaned from sedation, awoke and was extubated without complications. He remained on nitroglycerin for hypertension management. Post operative day one he was started on betablocker and Lasix. He was weaned off nitroglycerin continued to improve and was transitioned to the floor. That evening he developed delirium and medications were adjusted but required seroquel once with progressive resolution. All narcotics were discontinued. Post operative day two due to further thrombocytopenia HITT was sent which was negative and platelet count has ___ trending up most likely cause was related to blood loss and pump. With his anemia he received one unit of packed red blood cells on post operative day two, subsequentl hematocrit has remained stable. Chest tubes were placed on water seal and removed on post operative day two. On post operative day three epicardial wires were removed per protocol and delirium resolved. Physical therapy worked with him on strength and mobility with recommendation for rehab. He continued to progress, lisinopril was added post operative day four for hypertension. In relation to hematuria urine is progressively lightening and hematocrit stable. He should have repeat urine in a month to assess for blood and if still present outpatient follow up with urology. He also was noted for sore throat that is resolving, nothing noted on evaluation and using chloraseptic spray for comfort. He was clinically stable and ready for discharge to rehab at ___ and rehab on post operative day four. Medications on Admission: 1. Ranitidine 150 mg PO BID 2. Simvastatin 40 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. Mesalamine ___ 1600 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H please give atc for 3 days and then change to prn 2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat 3. Docusate Sodium 100 mg PO BID 4. Furosemide 40 mg PO DAILY Duration: 10 Days 5. Lisinopril 5 mg PO DAILY 6. Metoprolol Tartrate 50 mg PO Q8H 7. Pantoprazole 40 mg PO Q24H change back to zantac after 1 month as prior to admission 8. Polyethylene Glycol 17 g PO DAILY 9. Aspirin EC 81 mg PO DAILY 10. Mesalamine ___ 1600 mg PO BID 11. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Aortic stenosis s/p aortic valve replacement Coronary Artery Disease s/p coronary revascularization Hematuria secondary to traumatic foley placement Atrial Fibrillation post op Constipation with history of Ulcerative Colitis Encephalopathy most likely multifactorial Thrombocytopenia Anemia Acute blood loss Deconditioned Pneumothorax Secondary Diagnosis Hyperlipidemia Chiari Malformation GERD Ulcerative colitis Hearing loss Bilateral cataract surgery Inguinal hernia repair Discharge Condition: Alert and oriented x3, non-focal Ambulating with assistance Sternal pain managed with acetaminophen Sternal Incision - healing well, no erythema or drainage Left leg Incision - healing well, no erythema or drainage Edema - trace BLE Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
[ "I350", "G9340", "I4891", "D696", "K5190", "E861", "D62", "I10", "E785", "T8383XA", "I9789", "J95811", "I2510", "J029", "K5900", "R319", "I9581", "Y846", "Y92234", "Y832", "Y92230", "Z87891", "R410", "K219" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [MASKED] Aortic valve replacement with 21mm Magna Ease tissue valve, Coronary artery bypass graft x1 (Saphenous vein >Acute Marginal) History of Present Illness: [MASKED] year old male with a known history of aortic stenosis that has been followed by serial echocardiograms through the years. He has felt well through the years until more recently when he noticed mild dyspnea with prolonged activity. His most recent echo from this [MASKED] revealed a normal LVEF and significant aortic stenosis. He was referred for a cardiac catheterization which revealed an ostial 80-90% stenosis of a large RV marginal branch. He was referred for an aortic valve replacement evaluation. Past Medical History: Aortic stenosis Hyperlipidemia Chiari Malformation GERD Ulcerative colitis Hearing loss Bilateral cataract surgery Inguinal hernia repair Social History: [MASKED] Family History: Sister died at the age of [MASKED] from a congenital heart condition. Father had PAD, passed from lung disease at [MASKED]. Mother passed from lung cancer at [MASKED]. Physical Exam: Admit PE Pulse:60 Resp:18 O2 sat: 100% RA B/P Right:188/79 Left: 178/70 Height: 64 in Weight: 180 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 [x] III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [-] [MASKED] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: P Left: P DP Right: P Left: P [MASKED] Right: P Left: P Radial Right: P Left: P Carotid Bruit: Right: none Left: positive Discharge Examination Vital Signs and Intake/Output: [MASKED] 0343 Temp: 99.1 PO BP: 150/63 HR: 73 RR: 18 O2 sat: 92% O2 delivery: Ra fs 89-131 Date wt (kg) wt (lbs) In Out daily cumulative balance [MASKED] 85.4 kg 188.27 lb [MASKED] [MASKED] 86.6 kg 190.92 lb [MASKED].3 General/Neuro: NAD A/O x3 non-focal Cardiac: RRR Nl S1 S2 Lungs: CTA No resp distress Abd: NBS Soft ND NT Extremities: TRace [MASKED] edema Wounds: Sternal: CDI no erythema or drainage Sternum stable Leg: Left CDI no erythema or drainage Pertinent Results: STUDIES: PA/LAT CXR [MASKED]: In comparison with the study of [MASKED], the there are slightly improved lung volumes with decreasing basilar atelectasis and vascular congestion. Cardiac Catheterization: Date: [MASKED] Place: [MASKED] Dominance: Right * Left Main Coronary Artery The LMCA is large in caliber and is overall non obstructive * Left Anterior Descending The LAD appears to have a proximal step down in caliber when compared to the larger caliber of the Left main, possibly mild disease The [MASKED] Diagonal is overall non obstructive * Circumflex The Circumflex is overall non obstructive * Ramus The Ramus has mild luminal irregularities * Right Coronary Artery The RCA is co-dominant There is an ostial 80-90% stenosis of a large RV marginal branch with TIMI II flow The Right PDA is overall non obstructive Cardiac Echocardiogram [MASKED] Atrius: Aortic Root diameter: (2.2-3.7CM) Left Atrium diameter: (2.5-4.0CM) LV septal thickness (IVSd): (0.7-1.1CM) LV diastolic diameter (LVDd): (4.0-5.6CM) LV post wall thickness (LVPWd): (0.7-1.1CM) LV systolic diameter (LVIDs): (2.0-3.8CM) MEASUREMENTS Ao Diam 2.6 cm [MASKED] 3.6 cm IVSd 1.0 cm LVIDd 3.8 cm LVPWd 0.9 cm LVIDs 2.0 cm STRUCTURED FINDINGS This echocardiogram was performed at [MASKED] [MASKED]. Referred for evaluation of aortic stenosis. Sinus rhythm. The study was technically adequate. 2D Color and spectral Doppler were performed. The left ventricle size is normal. Left ventricular wall thickness is normal. There are no regional wall motion abnormalities. Overall left ventricular ejection fraction is normal, with an estimated LVEF of 55-60%. Grade I diastolic dysfunction with normal [MASKED] pressure. The left atrium linear dimension is normal. The left atrial volume is mildly increased. The right ventricle is normal in size, thickness and function. TAPSE and RV S' are within normal limits suggesting normal right ventricular free wall systolic function. The right atrium is normal in size. The aortic valve is trileaflet and is moderately thickened. The non coronary cusp appears fixed and moderately calcified. There is trace aortic regurgitation. The peak transvalvular velocity is 4.16 m/sec, with peak/mean pressure gradients of 69/37mmHg , and calculated [MASKED] by continuity equation of 0.7cm2 (using measured LVOT diameter of 2.0 cm, and LVOT velocity of 1.0m/sec); these findings are consistent withprobably moderate aortic stenosis. There is considerable fling in the aortic valve Doppler flow, so the peak gradient varies from low 40's up to high 60's, and therefore aortic valve area varies from 0.7-1.0 cm sq. The mitral valve leaflets are mildly thickened. Mild mitral annular calcification present. Mild mitral regurgitation is present. There is no evidence of mitral stenosis. The tricuspid valve is structurally normal. There is mild tricuspid regurgitation present. PA systolic pressure is normal, with estimated PA systolic of 30mmHg + RA pressure. Pulmonic valve appears structurally and functionally normal. There is no pulmonic stenosis. There is trace pulmonic regurgitation. There is no pericardial effusion. The aortic root, measured at the level of the sinuses of Valsalva, is of normal caliber. Visualized portions of the ascending aorta, transverse and descending thoracic aorta are of normal caliber. The inferior vena cava is normal, with normal respirophasic movement indicating normal right atrial pressure. There is no evidence of a shunt by color Doppler from views imaged. CONCLUSIONS 1. Left ventricular wall thickness is normal. 2. Overall left ventricular ejection fraction is normal, with an estimated LVEF of 55-60%. 3. The aortic valve is trileaflet and is moderately thickened. The non coronary cusp appears fixed and moderately calcified. 4. There is trace aortic regurgitation. 5. There is probably moderate aortic stenosis present. There is considerable variability in the peak gradient/aortic valve area calculation, so there may not be a significant change in the severity of aortic stenosis compared to [MASKED]. 6. The mitral valve leaflets are mildly thickened. 7. Mild mitral annular calcification present. 8. Mild mitral regurgitation is present. 9. Visualized portions of the ascending aorta, transverse and descending thoracic aorta are of normal caliber. 10. Compared with the findings of the prior report of [MASKED], more variability in the Dopper gradients of the aortic valve are noted (see above). Carotid US [MASKED]: Right ICA 40-59% stenosis. Left ICA 40-59% stenosis. LABS: Admit: [MASKED] 12:08PM BLOOD WBC-9.0 RBC-2.56* Hgb-7.3* Hct-21.6* MCV-84 MCH-28.5 MCHC-33.8 RDW-13.5 RDWSD-41.2 Plt [MASKED] [MASKED] 12:08PM BLOOD [MASKED] PTT-24.3* [MASKED] [MASKED] 01:40PM BLOOD UreaN-15 Creat-0.7 Cl-116* HCO3-23 AnGap-6* [MASKED] 01:00AM BLOOD Glucose-136* UreaN-18 Creat-0.9 Na-141 K-4.9 Cl-107 HCO3-24 AnGap-10 [MASKED] 09:46AM BLOOD ALT-7 AST-35 LD([MASKED])-312* AlkPhos-33* Amylase-27 TotBili-0.3 [MASKED] 09:46AM BLOOD Lipase-9 [MASKED] 09:46AM BLOOD Mg-2.6 [MASKED] 07:52AM BLOOD HEPARIN DEPENDENT ANTIBODIES-PF4 Heparin Antibody 0.07 (range = 0.00 - 0.39) Discharge: [MASKED] 04:50AM BLOOD WBC-6.8 RBC-3.08* Hgb-8.6* Hct-26.8* MCV-87 MCH-27.9 MCHC-32.1 RDW-14.6 RDWSD-47.1* Plt [MASKED] [MASKED] 04:50AM BLOOD Glucose-115* UreaN-29* Creat-1.0 Na-139 K-4.1 Cl-100 HCO3-28 AnGap-11 [MASKED] 09:46AM BLOOD ALT-7 AST-35 LD(LDH)-312* AlkPhos-33* Amylase-27 TotBili-0.3 [MASKED] 04:50AM BLOOD Phos-2.6* Mg-2.3 Brief Hospital Course: Mr [MASKED] was brought to the Operating Room on [MASKED] where he underwent Aortic valve replacement with 21mm Magna Ease tissue valve, CABG x1 (SVG-Acute Marginal). Overall the he tolerated the procedure well although he had traumatic foley placement, with resolving hematuria. See operative report for further details. Post-operatively, he was transferred to the CVICU in stable condition for recovery and invasive monitoring. He had Left pigtail chest tube placed for pneumothorax. Within a few hours he was weaned from sedation, awoke and was extubated without complications. He remained on nitroglycerin for hypertension management. Post operative day one he was started on betablocker and Lasix. He was weaned off nitroglycerin continued to improve and was transitioned to the floor. That evening he developed delirium and medications were adjusted but required seroquel once with progressive resolution. All narcotics were discontinued. Post operative day two due to further thrombocytopenia HITT was sent which was negative and platelet count has [MASKED] trending up most likely cause was related to blood loss and pump. With his anemia he received one unit of packed red blood cells on post operative day two, subsequentl hematocrit has remained stable. Chest tubes were placed on water seal and removed on post operative day two. On post operative day three epicardial wires were removed per protocol and delirium resolved. Physical therapy worked with him on strength and mobility with recommendation for rehab. He continued to progress, lisinopril was added post operative day four for hypertension. In relation to hematuria urine is progressively lightening and hematocrit stable. He should have repeat urine in a month to assess for blood and if still present outpatient follow up with urology. He also was noted for sore throat that is resolving, nothing noted on evaluation and using chloraseptic spray for comfort. He was clinically stable and ready for discharge to rehab at [MASKED] and rehab on post operative day four. Medications on Admission: 1. Ranitidine 150 mg PO BID 2. Simvastatin 40 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. Mesalamine [MASKED] 1600 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H please give atc for 3 days and then change to prn 2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat 3. Docusate Sodium 100 mg PO BID 4. Furosemide 40 mg PO DAILY Duration: 10 Days 5. Lisinopril 5 mg PO DAILY 6. Metoprolol Tartrate 50 mg PO Q8H 7. Pantoprazole 40 mg PO Q24H change back to zantac after 1 month as prior to admission 8. Polyethylene Glycol 17 g PO DAILY 9. Aspirin EC 81 mg PO DAILY 10. Mesalamine [MASKED] 1600 mg PO BID 11. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Aortic stenosis s/p aortic valve replacement Coronary Artery Disease s/p coronary revascularization Hematuria secondary to traumatic foley placement Atrial Fibrillation post op Constipation with history of Ulcerative Colitis Encephalopathy most likely multifactorial Thrombocytopenia Anemia Acute blood loss Deconditioned Pneumothorax Secondary Diagnosis Hyperlipidemia Chiari Malformation GERD Ulcerative colitis Hearing loss Bilateral cataract surgery Inguinal hernia repair Discharge Condition: Alert and oriented x3, non-focal Ambulating with assistance Sternal pain managed with acetaminophen Sternal Incision - healing well, no erythema or drainage Left leg Incision - healing well, no erythema or drainage Edema - trace BLE Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
[]
[ "I4891", "D696", "D62", "I10", "E785", "I2510", "K5900", "Y92230", "Z87891", "K219" ]
[ "I350: Nonrheumatic aortic (valve) stenosis", "G9340: Encephalopathy, unspecified", "I4891: Unspecified atrial fibrillation", "D696: Thrombocytopenia, unspecified", "K5190: Ulcerative colitis, unspecified, without complications", "E861: Hypovolemia", "D62: Acute posthemorrhagic anemia", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "T8383XA: Hemorrhage due to genitourinary prosthetic devices, implants and grafts, initial encounter", "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "J95811: Postprocedural pneumothorax", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "J029: Acute pharyngitis, unspecified", "K5900: Constipation, unspecified", "R319: Hematuria, unspecified", "I9581: Postprocedural hypotension", "Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "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", "Z87891: Personal history of nicotine dependence", "R410: Disorientation, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,035,791
20,113,280
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Compazine / doxycycline / Phenergan Attending: ___ Chief Complaint: n/v, eval cholelithiasis Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms ___ is a pleasant ___ yo F with HLD, hypothyroidism, HTN, n/v/abd pain since ___, found to have biliary dilation and CBD stone, admitted for ERCP to eval for choledocholithiasis. Pt tells me that the abd pain has been intermittent, ___ at its worst, however sometime she is without any pain at all. No diarrhea/constipation/SOB/CP. Last episode of pain was in ___. EUS showed soft tissue mass in distal CBD within the ampulla (mural nodule vs ampullary folds). No stones were found, brushings were taken. The procedure was uncomplicated. Currently, pt endorses nausea but is otherwise asx. She tells me that just prior to coming into the hospital she was asx. Denies pain currently Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. 10 pt ros otherwise negative. Past Medical History: (per chart, confirmed with pt): HTN HLD hypothyroidism cholecystecomy appendectomy hysterectomy Social History: ___ Family History: (per chart, confirmed with pt): HTN in dad Physical ___: ADMISSION EXAM: Constitutional: Alert, oriented, no acute distress, falling asleep during history/exam EYES: Sclera anicteric, EOMI, PERRL ENMT: MMM, oropharynx clear, normal hearing, normal nares Neck: Supple, JVP not elevated, no LAD CV: irregular rate, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused, no CCE NEURO: aaox3 CNII-XII and strength grossly intact SKIN: no rashes or lesions DISCHARGE EXAM: Constitutional: Alert, oriented, no acute distress, falling asleep during history/exam EYES: Sclera anicteric, EOMI, PERRL ENMT: MMM, oropharynx clear, normal hearing, normal nares Neck: Supple, JVP not elevated, no LAD CV: irregular rate, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused, no CCE NEURO: aaox3 CNII-XII and strength grossly intact SKIN: no rashes or lesions Pertinent Results: Upper EUS: EUS was performed using a linear echoendoscope at ___ MHz frequency. The head and uncinate pancreas were imaged from the duodenal bulb and the second / third duodenum. The body and tail were imaged from the gastric body and fundus. Pancreas parenchyma: The pancreatic parenchyma was homogenous, with a normal “salt and pepper” appearance. Pancreatic duct: The pancreas was normal in size, echotexture and contour. No intra-ductal stones were noted. No dilated side-branches were noted. Bile duct: The bile duct was imaged at the level of the porta-hepatis, head of the pancreas and ampulla. The CBD was dilated with a maximum diameter of 12 mm. No intrinsic stones or sludge were noted. The bile duct and the pancreatic duct were imaged within the ampulla. In the intra-ampullary portion of the CBD, a 5mm soft tissue lesion was seen. Differential diagnosis include ampullary fold vs malignant tumor. Ampulla: The ampulla appeared normal both endoscopically and sonographically. ERCP w/Spincterotomy Impression: •The scout film was normal. The major papilla was normal. •The CBD was successfully cannulated using a Clevercut sphincterotome preloaded with 0.025in guidewire. •Contrast injection showed a dilated CBD but no filling defect. •A biliary sphincterotomy was successfully performed. There was no post-sphincterotomy bleeding. •The CBD was swep multiple times using a balloon. Small amount of sludge was successfully removed. There was no protrusion of a tissue mass at the ampulla during the balloon sweeps. •A brushing was obtained from the distal CBD and sent for cytology. •There was excellent bile and contrast drainage at the end of the procedure. •The PD was not cannulated. Minimal injection was made. I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good. EKG: sinus with PACs, infrolateral q waves Brief Hospital Course: Pleasant ___ yo F with HLD, hypothyroidism, HTN, n/v/abd pain since ___, found to have biliary dilation and CBD stone, admitted for ERCP to eval for choledocholithiasis. # Biliar dilation s/p ERCP: no stone identified on EGD, however sludge present, and was removed. Pt tolerated the procedure well with no abdominal pain post-procedure. Post-procedural LFT's were downtrending and pt was tolerating a regular diet on discharge. # Hyponatremia: pt's Na decreased from 134 to 128 with continuing IVF's. Possibly component of ?SIADH given worsening with IVF's? Her home HCTZ was felt to also be contributing so was held on discharge until pt follows-up with PCP> # abnl ekg: sinus with PACS, pt also noted to have q waves on EKG, would recommend outpt risk stratification with stress test. # HTN: Held HCTZ on discharge per above. Restarted home ACE-i, amlodipine # HLD: cont statin # Hypothyroidism: cont levothyroxine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Enalapril Maleate 10 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Levothyroxine Sodium 125 mcg PO DAILY 6. Ondansetron 4 mg PO Frequency is Unknown 7. Potassium Chloride Dose is Unknown PO Frequency is Unknown 8. Aspirin 81 mg PO DAILY 9. Vitamin D 1000 UNIT PO Frequency is Unknown Discharge Medications: 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Potassium Chloride 60 mEq PO DAILY Hold for K > 3. Vitamin D 1000 UNIT PO DAILY 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Enalapril Maleate 10 mg PO DAILY 8. Levothyroxine Sodium 125 mcg PO DAILY 9. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until You speak with your PCP since your sodium was found to be low Discharge Disposition: Home Discharge Diagnosis: Biliary obstruction d/t soft tissue mass in distal CBD (mural nodule vs. ampullary fold) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came in with abdominal pain which was thought to be due to a stone in your bile duct. You underwent a procedure called an ERCP to relieve the obstruction and they found that there was a nodule or a fold of your bile outlet that was causing the obstruction. A sample was taken for biopsy. Your abdominal pain improved post-procedure. Please return if you have worsening abdominal pain, nausea, vomiting, fevers, chills, or jaundice. It was a pleasure taking care of you at ___ ___. Followup Instructions: ___
[ "K831", "K838", "R932", "E871", "R9431", "D72829", "I10", "E785", "E039" ]
Allergies: Compazine / doxycycline / Phenergan Chief Complaint: n/v, eval cholelithiasis Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms [MASKED] is a pleasant [MASKED] yo F with HLD, hypothyroidism, HTN, n/v/abd pain since [MASKED], found to have biliary dilation and CBD stone, admitted for ERCP to eval for choledocholithiasis. Pt tells me that the abd pain has been intermittent, [MASKED] at its worst, however sometime she is without any pain at all. No diarrhea/constipation/SOB/CP. Last episode of pain was in [MASKED]. EUS showed soft tissue mass in distal CBD within the ampulla (mural nodule vs ampullary folds). No stones were found, brushings were taken. The procedure was uncomplicated. Currently, pt endorses nausea but is otherwise asx. She tells me that just prior to coming into the hospital she was asx. Denies pain currently Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. 10 pt ros otherwise negative. Past Medical History: (per chart, confirmed with pt): HTN HLD hypothyroidism cholecystecomy appendectomy hysterectomy Social History: [MASKED] Family History: (per chart, confirmed with pt): HTN in dad Physical [MASKED]: ADMISSION EXAM: Constitutional: Alert, oriented, no acute distress, falling asleep during history/exam EYES: Sclera anicteric, EOMI, PERRL ENMT: MMM, oropharynx clear, normal hearing, normal nares Neck: Supple, JVP not elevated, no LAD CV: irregular rate, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused, no CCE NEURO: aaox3 CNII-XII and strength grossly intact SKIN: no rashes or lesions DISCHARGE EXAM: Constitutional: Alert, oriented, no acute distress, falling asleep during history/exam EYES: Sclera anicteric, EOMI, PERRL ENMT: MMM, oropharynx clear, normal hearing, normal nares Neck: Supple, JVP not elevated, no LAD CV: irregular rate, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused, no CCE NEURO: aaox3 CNII-XII and strength grossly intact SKIN: no rashes or lesions Pertinent Results: Upper EUS: EUS was performed using a linear echoendoscope at [MASKED] MHz frequency. The head and uncinate pancreas were imaged from the duodenal bulb and the second / third duodenum. The body and tail were imaged from the gastric body and fundus. Pancreas parenchyma: The pancreatic parenchyma was homogenous, with a normal “salt and pepper” appearance. Pancreatic duct: The pancreas was normal in size, echotexture and contour. No intra-ductal stones were noted. No dilated side-branches were noted. Bile duct: The bile duct was imaged at the level of the porta-hepatis, head of the pancreas and ampulla. The CBD was dilated with a maximum diameter of 12 mm. No intrinsic stones or sludge were noted. The bile duct and the pancreatic duct were imaged within the ampulla. In the intra-ampullary portion of the CBD, a 5mm soft tissue lesion was seen. Differential diagnosis include ampullary fold vs malignant tumor. Ampulla: The ampulla appeared normal both endoscopically and sonographically. ERCP w/Spincterotomy Impression: •The scout film was normal. The major papilla was normal. •The CBD was successfully cannulated using a Clevercut sphincterotome preloaded with 0.025in guidewire. •Contrast injection showed a dilated CBD but no filling defect. •A biliary sphincterotomy was successfully performed. There was no post-sphincterotomy bleeding. •The CBD was swep multiple times using a balloon. Small amount of sludge was successfully removed. There was no protrusion of a tissue mass at the ampulla during the balloon sweeps. •A brushing was obtained from the distal CBD and sent for cytology. •There was excellent bile and contrast drainage at the end of the procedure. •The PD was not cannulated. Minimal injection was made. I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good. EKG: sinus with PACs, infrolateral q waves Brief Hospital Course: Pleasant [MASKED] yo F with HLD, hypothyroidism, HTN, n/v/abd pain since [MASKED], found to have biliary dilation and CBD stone, admitted for ERCP to eval for choledocholithiasis. # Biliar dilation s/p ERCP: no stone identified on EGD, however sludge present, and was removed. Pt tolerated the procedure well with no abdominal pain post-procedure. Post-procedural LFT's were downtrending and pt was tolerating a regular diet on discharge. # Hyponatremia: pt's Na decreased from 134 to 128 with continuing IVF's. Possibly component of ?SIADH given worsening with IVF's? Her home HCTZ was felt to also be contributing so was held on discharge until pt follows-up with PCP> # abnl ekg: sinus with PACS, pt also noted to have q waves on EKG, would recommend outpt risk stratification with stress test. # HTN: Held HCTZ on discharge per above. Restarted home ACE-i, amlodipine # HLD: cont statin # Hypothyroidism: cont levothyroxine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Enalapril Maleate 10 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Levothyroxine Sodium 125 mcg PO DAILY 6. Ondansetron 4 mg PO Frequency is Unknown 7. Potassium Chloride Dose is Unknown PO Frequency is Unknown 8. Aspirin 81 mg PO DAILY 9. Vitamin D 1000 UNIT PO Frequency is Unknown Discharge Medications: 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Potassium Chloride 60 mEq PO DAILY Hold for K > 3. Vitamin D 1000 UNIT PO DAILY 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Enalapril Maleate 10 mg PO DAILY 8. Levothyroxine Sodium 125 mcg PO DAILY 9. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until You speak with your PCP since your sodium was found to be low Discharge Disposition: Home Discharge Diagnosis: Biliary obstruction d/t soft tissue mass in distal CBD (mural nodule vs. ampullary fold) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came in with abdominal pain which was thought to be due to a stone in your bile duct. You underwent a procedure called an ERCP to relieve the obstruction and they found that there was a nodule or a fold of your bile outlet that was causing the obstruction. A sample was taken for biopsy. Your abdominal pain improved post-procedure. Please return if you have worsening abdominal pain, nausea, vomiting, fevers, chills, or jaundice. It was a pleasure taking care of you at [MASKED] [MASKED]. Followup Instructions: [MASKED]
[]
[ "E871", "I10", "E785", "E039" ]
[ "K831: Obstruction of bile duct", "K838: Other specified diseases of biliary tract", "R932: Abnormal findings on diagnostic imaging of liver and biliary tract", "E871: Hypo-osmolality and hyponatremia", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "D72829: Elevated white blood cell count, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified" ]
10,035,844
27,129,365
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission Labs ------------------ ___ 01:22PM BLOOD WBC-11.5* RBC-4.96 Hgb-15.1 Hct-47.0* MCV-95 MCH-30.4 MCHC-32.1 RDW-13.4 RDWSD-47.3* Plt ___ ___ 01:22PM BLOOD Neuts-84.1* Lymphs-10.4* Monos-4.3* Eos-0.1* Baso-0.6 Im ___ AbsNeut-9.68* AbsLymp-1.20 AbsMono-0.49 AbsEos-0.01* AbsBaso-0.07 ___ 01:22PM BLOOD Plt ___ ___ 01:22PM BLOOD Glucose-263* UreaN-17 Creat-0.9 Na-134* K-5.5* Cl-102 HCO3-21* AnGap-11 ___ 01:22PM BLOOD CK(CPK)-216* ___ 06:01AM BLOOD ALT-27 AST-45* AlkPhos-144* TotBili-0.8 ___ 01:22PM BLOOD cTropnT-<0.01 ___ 07:12AM BLOOD CK-MB-3 cTropnT-0.01 ___ 07:12AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.3 Mg-2.0 Cholest-155 ___ 07:57AM BLOOD %HbA1c-7.1* eAG-157* ___ 07:12AM BLOOD HDL-34* CHOL/HD-4.6 ___ 06:01AM BLOOD Cortsol-16.5 ___ 01:22PM BLOOD TSH-2.2 ___ 01:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG Discharge Labs ------------------- ___ 09:10AM BLOOD WBC-8.0 RBC-4.74 Hgb-14.5 Hct-45.3* MCV-96 MCH-30.6 MCHC-32.0 RDW-13.2 RDWSD-46.6* Plt ___ ___ 09:10AM BLOOD Plt ___ ___ 09:10AM BLOOD Glucose-231* UreaN-12 Creat-0.8 Na-139 K-4.4 Cl-100 HCO3-24 AnGap-15 ___ 09:10AM BLOOD ALT-30 AST-43* ___ 09:10AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.7 Imaging ------------------ CTA HEAD AND NECK IMPRESSION: 1. Head CT: Images degraded by motion artifact. Within this confine: No definite acute territorial infarct, intracranial hemorrhage, mass or mass effect. 2. Head CTA: Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm. Mild atherosclerotic calcifications of the bilateral carotid siphons. 3. Neck CTA: Images degraded by motion artifact. Within these confines: Linear filling defect within the proximal right internal carotid artery (3:157) is felt to reflect artifact related to patient motion. There is approximately 20% stenosis of the left proximal internal carotid artery by NASCET criteria. Otherwise, patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion,or dissection. CAROTID U/S IMPRESSION: Right ICA <40% stenosis. Left ICA <40% stenosis. MRI IMPRESSION: 1. No acute intracranial abnormality. No evidence of acute or subacute infarct. 2. Mild nonspecific white matter signal changes most likely reflecting chronic small vessel disease in this age group Brief Hospital Course: ___ is a ___ female with a history of hypertension, diabetes on insulin who presented as a transfer from ___ with hypoglycemia secondary to overinsulinization found to have post-hypoglycemic tonic-clonic seizure complicated by ___ paralysis with normal neurologic imaging and mental status returning back to baseline. Her insulin regimen was adjusted by the ___ diabetes team with education provided by the diabetes educator. TRANSITIONAL ISSUES: ==================== [] Ensure ___ follow up, patient given contact information [] Would benefit from Dexcom glucose monitor [] Neuro follow up with seizure clinics [] Needs a Basqimi (intransal glucagon) prescription upon follow up ACUTE ISSUES: ============= #Hypoglycemic Seizure #Left common carotid artery calcification Patient presented to ___ with a tonic-clonic seizure that was likely precipitated by a hypoglycemic episode with residual right-sided hemiparesis secondary to a postictal state precipitated by an overly aggressive home insulin sliding scale. Work-up for her seizure was unremarkable with no signs of infectious, toxic or Metabolic processes. Neurological imaging with an CTA of the head and MRI was also unremarkable. She had no further episodes of seizures while she was admitted here. She will need follow up in the ___ seizure clinic for a routine outpatient sleep deprived extended EEG as an outpatient. #T2DM with repeated hypoglycemia Her home insulin regimen consisted of 50 units of Lantus in the AM followed by 'carb counting' resulting in ___ units of Novolog which was an overly aggressive insulin regimen. Her A1c during this admission was 7.1 She was evaluated by the ___ team and transition to a simpler insulin regimen of lantus 35u qAM with sliding scale humalog with meals. She also met with the diabetes nurse educator for further education. CHRONIC ISSUES: =============== #Hypothyroidism Her TSH level was 2.2. Continued home levothyroxine 275mcg daily. #Depression Continued her home sertraline 100mg daily #HTN Continued her home lisinopril #Hyperlipidemia Continued her home simvastatin. CORE MEASURES ============= #CODE: full confirmed #CONTACT: ___, husband. ___: ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Sertraline 100 mg PO DAILY 2. Simvastatin 20 mg PO QPM 3. Lisinopril 20 mg PO DAILY 4. Glargine 50 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Levothyroxine Sodium 275 mcg PO DAILY Discharge Medications: 1. Baqsimi (glucagon) 3 mg/actuation nasal PRN hypoglycemia RX *glucagon [Baqsimi] 3 mg/actuation 1 spray nasal PRN Disp #*3 Spray Refills:*0 2. Glargine 35 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. Levothyroxine Sodium 275 mcg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Sertraline 100 mg PO DAILY 6. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary ========== Hypoglycemic Seizure Insulin depending diabetes mellitus Secondary ========== Hypothyroidism Depression Hypertension Hyperlipedmia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you during your admission to ___. Below you will find information regarding your stay. WHY WAS I ADMITTED TO THE HOSPITAL? -You were admitted to the hospital because you had a seizure due to low blood sugars. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -While you are in the hospital you received a number of imaging diagnostic test to evaluate for causes of your seizure. These tests all came back normal. Additionally, you also met with the diabetes doctors as ___ as diabetes educator to work on a more stable insulin regimen. WHAT SHOULD I DO WHEN I GO HOME? -Take your medications as prescribed and attend your follow up appointments as scheduled. -Please call ___ on ___ and request a "hospital transition appointment" within ___s a Dietician appointment on the same day. Thank you for letting us be a part of your care! Your ___ Care Team Followup Instructions: ___
[ "E11649", "E039", "G8384", "R569", "E785", "I6522", "I2510", "F329", "F1290", "Z794", "Z885", "Z882" ]
Allergies: oxycodone Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission Labs ------------------ [MASKED] 01:22PM BLOOD WBC-11.5* RBC-4.96 Hgb-15.1 Hct-47.0* MCV-95 MCH-30.4 MCHC-32.1 RDW-13.4 RDWSD-47.3* Plt [MASKED] [MASKED] 01:22PM BLOOD Neuts-84.1* Lymphs-10.4* Monos-4.3* Eos-0.1* Baso-0.6 Im [MASKED] AbsNeut-9.68* AbsLymp-1.20 AbsMono-0.49 AbsEos-0.01* AbsBaso-0.07 [MASKED] 01:22PM BLOOD Plt [MASKED] [MASKED] 01:22PM BLOOD Glucose-263* UreaN-17 Creat-0.9 Na-134* K-5.5* Cl-102 HCO3-21* AnGap-11 [MASKED] 01:22PM BLOOD CK(CPK)-216* [MASKED] 06:01AM BLOOD ALT-27 AST-45* AlkPhos-144* TotBili-0.8 [MASKED] 01:22PM BLOOD cTropnT-<0.01 [MASKED] 07:12AM BLOOD CK-MB-3 cTropnT-0.01 [MASKED] 07:12AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.3 Mg-2.0 Cholest-155 [MASKED] 07:57AM BLOOD %HbA1c-7.1* eAG-157* [MASKED] 07:12AM BLOOD HDL-34* CHOL/HD-4.6 [MASKED] 06:01AM BLOOD Cortsol-16.5 [MASKED] 01:22PM BLOOD TSH-2.2 [MASKED] 01:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG Discharge Labs ------------------- [MASKED] 09:10AM BLOOD WBC-8.0 RBC-4.74 Hgb-14.5 Hct-45.3* MCV-96 MCH-30.6 MCHC-32.0 RDW-13.2 RDWSD-46.6* Plt [MASKED] [MASKED] 09:10AM BLOOD Plt [MASKED] [MASKED] 09:10AM BLOOD Glucose-231* UreaN-12 Creat-0.8 Na-139 K-4.4 Cl-100 HCO3-24 AnGap-15 [MASKED] 09:10AM BLOOD ALT-30 AST-43* [MASKED] 09:10AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.7 Imaging ------------------ CTA HEAD AND NECK IMPRESSION: 1. Head CT: Images degraded by motion artifact. Within this confine: No definite acute territorial infarct, intracranial hemorrhage, mass or mass effect. 2. Head CTA: Patent circle of [MASKED] without evidence of stenosis,occlusion,or aneurysm. Mild atherosclerotic calcifications of the bilateral carotid siphons. 3. Neck CTA: Images degraded by motion artifact. Within these confines: Linear filling defect within the proximal right internal carotid artery (3:157) is felt to reflect artifact related to patient motion. There is approximately 20% stenosis of the left proximal internal carotid artery by NASCET criteria. Otherwise, patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion,or dissection. CAROTID U/S IMPRESSION: Right ICA <40% stenosis. Left ICA <40% stenosis. MRI IMPRESSION: 1. No acute intracranial abnormality. No evidence of acute or subacute infarct. 2. Mild nonspecific white matter signal changes most likely reflecting chronic small vessel disease in this age group Brief Hospital Course: [MASKED] is a [MASKED] female with a history of hypertension, diabetes on insulin who presented as a transfer from [MASKED] with hypoglycemia secondary to overinsulinization found to have post-hypoglycemic tonic-clonic seizure complicated by [MASKED] paralysis with normal neurologic imaging and mental status returning back to baseline. Her insulin regimen was adjusted by the [MASKED] diabetes team with education provided by the diabetes educator. TRANSITIONAL ISSUES: ==================== [] Ensure [MASKED] follow up, patient given contact information [] Would benefit from Dexcom glucose monitor [] Neuro follow up with seizure clinics [] Needs a Basqimi (intransal glucagon) prescription upon follow up ACUTE ISSUES: ============= #Hypoglycemic Seizure #Left common carotid artery calcification Patient presented to [MASKED] with a tonic-clonic seizure that was likely precipitated by a hypoglycemic episode with residual right-sided hemiparesis secondary to a postictal state precipitated by an overly aggressive home insulin sliding scale. Work-up for her seizure was unremarkable with no signs of infectious, toxic or Metabolic processes. Neurological imaging with an CTA of the head and MRI was also unremarkable. She had no further episodes of seizures while she was admitted here. She will need follow up in the [MASKED] seizure clinic for a routine outpatient sleep deprived extended EEG as an outpatient. #T2DM with repeated hypoglycemia Her home insulin regimen consisted of 50 units of Lantus in the AM followed by 'carb counting' resulting in [MASKED] units of Novolog which was an overly aggressive insulin regimen. Her A1c during this admission was 7.1 She was evaluated by the [MASKED] team and transition to a simpler insulin regimen of lantus 35u qAM with sliding scale humalog with meals. She also met with the diabetes nurse educator for further education. CHRONIC ISSUES: =============== #Hypothyroidism Her TSH level was 2.2. Continued home levothyroxine 275mcg daily. #Depression Continued her home sertraline 100mg daily #HTN Continued her home lisinopril #Hyperlipidemia Continued her home simvastatin. CORE MEASURES ============= #CODE: full confirmed #CONTACT: [MASKED], husband. [MASKED]: [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Sertraline 100 mg PO DAILY 2. Simvastatin 20 mg PO QPM 3. Lisinopril 20 mg PO DAILY 4. Glargine 50 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Levothyroxine Sodium 275 mcg PO DAILY Discharge Medications: 1. Baqsimi (glucagon) 3 mg/actuation nasal PRN hypoglycemia RX *glucagon [Baqsimi] 3 mg/actuation 1 spray nasal PRN Disp #*3 Spray Refills:*0 2. Glargine 35 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. Levothyroxine Sodium 275 mcg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Sertraline 100 mg PO DAILY 6. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary ========== Hypoglycemic Seizure Insulin depending diabetes mellitus Secondary ========== Hypothyroidism Depression Hypertension Hyperlipedmia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you during your admission to [MASKED]. Below you will find information regarding your stay. WHY WAS I ADMITTED TO THE HOSPITAL? -You were admitted to the hospital because you had a seizure due to low blood sugars. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -While you are in the hospital you received a number of imaging diagnostic test to evaluate for causes of your seizure. These tests all came back normal. Additionally, you also met with the diabetes doctors as [MASKED] as diabetes educator to work on a more stable insulin regimen. WHAT SHOULD I DO WHEN I GO HOME? -Take your medications as prescribed and attend your follow up appointments as scheduled. -Please call [MASKED] on [MASKED] and request a "hospital transition appointment" within s a Dietician appointment on the same day. Thank you for letting us be a part of your care! Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "E039", "E785", "I2510", "F329", "Z794" ]
[ "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E039: Hypothyroidism, unspecified", "G8384: Todd's paralysis (postepileptic)", "R569: Unspecified convulsions", "E785: Hyperlipidemia, unspecified", "I6522: Occlusion and stenosis of left carotid artery", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F329: Major depressive disorder, single episode, unspecified", "F1290: Cannabis use, unspecified, uncomplicated", "Z794: Long term (current) use of insulin", "Z885: Allergy status to narcotic agent", "Z882: Allergy status to sulfonamides" ]
10,036,086
22,023,413
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___ Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: Coronary Anatomy Right dominant, heart rotated to the left. LM: No significant disease. LAD: Proximal 40% smooth disease. Mid vessel 90% stenosis after large diag. LCx: Luminal irregularities. RCA: Luminal irregularities. 60% ostial PDA lesion. Interventional Details We proceeded with PCI of the mid LAD. XBLAD 3.5 guide. Vessel wired with a Runthrough wire. Angioplasty of the vessel followed by placement of a 3.0 x 18 mm Xience DES, post dilated with a 3.5 and 3.75 NC balloon at high pressure. TIMI III flow, 0% residual. Impressions: Successful PCI of severe mid LAD stenosis with single DES. Recommendations ASA for life, clopidogrel 75 daily x 3 months minimum History of Present Illness: Mr. ___ is a ___ year old male with PMH notable for HIV on HAART therapy, T2IDDM, HTN, HLD, obesity, CKD who presents with left arm pain. He was in his usual state of health until ___ when he was on the train when he noted severe dull left arm pain. These symptoms lasted for approx. 5 minutes and improved. Over the next few hours, he noted intermittent dull left arm pain that felt very similar to that same episode. He then presented to his PCP who referred him to the ED. Trops negative. Nuclear stress test completed on ___ showed reversible perfusion defect in the LAD territory. Since being here he has had intermittent arm pain that can range in severity from a 2 to an 8. Episodes of severe pain have been between 5 to 30 minutes. He slept in a recliner last night as he feels his pain is less when sitting upright. At baseline, he is typically very sedentary as he had been unemployed for 8 months. In ___, pt. began a new job and has been walking approximately 1.3 miles a day. When he goes a certain distance, he feels fatigued and short of breath which causes him to stop. Additionally, when he goes up a flight a steps, he feels very short of breath and can only do one flight at a time. He denies a history of chest, arm, jaw, or back pain, lightheadedness, dizziness, pre-syncope, syncope, worsening of his chronic ___ edema, orthopnea, PND, or palpitations. In the ED, pt. received crestor, losartan, fenofibrate, HAART therapy, Tylenol, and insulin. Past Medical History: PMHx/PSHx: 1. HIV (VL ___, CD4 490 in ___ on antiretroviral therapy 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in ___ secondary to salmonella abscess. 7. Type 2 diabetes mellitus on insulin 8. Morbid obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. Social History: ___ Family History: nc Physical Exam: Physical Exam: Gen: Alert, no acute distress, sitting comfortably in recliner Neuro: Oriented x 3, speech clear, appropriate and comprehensible, Follows commands appropriately, MAE, mood and affect appropriate CV: Regular rate/rhythm Chest: Lungs clear bilaterally, diminished at bases, breathing non-labored ABD: Soft, non-tender, +bs Extr: BLE warm/well-perfused, ___ pulses Skin: Warm and dry Pertinent Results: ___ 05:00AM BLOOD WBC-8.8 RBC-4.93 Hgb-14.9 Hct-47.3 MCV-96 MCH-30.2 MCHC-31.5* RDW-17.3* RDWSD-59.3* Plt ___ ___ 05:50PM BLOOD WBC-9.4 RBC-5.39# Hgb-16.1# Hct-51.2*# MCV-95 MCH-29.9 MCHC-31.4* RDW-17.3* RDWSD-58.6* Plt ___ ___ 05:50PM BLOOD Neuts-62.6 ___ Monos-9.3 Eos-1.2 Baso-0.5 Im ___ AbsNeut-5.89 AbsLymp-2.43 AbsMono-0.87* AbsEos-0.11 AbsBaso-0.05 ___ 05:00AM BLOOD Plt ___ ___ 05:00AM BLOOD ___ PTT-34.3 ___ ___ 09:39PM BLOOD PTT-31.1 ___ 12:45PM BLOOD ___ PTT-28.7 ___ ___ 05:50PM BLOOD Plt ___ ___ 05:00AM BLOOD Glucose-135* UreaN-26* Creat-1.3* Na-141 K-4.6 Cl-102 HCO3-27 AnGap-17 ___ 05:50PM BLOOD Glucose-126* UreaN-27* Creat-1.4* Na-142 K-4.8 Cl-99 HCO3-29 AnGap-19 ___ 11:35AM BLOOD cTropnT-<0.01 ___ 12:45PM BLOOD cTropnT-<0.01 ___ 12:00AM BLOOD cTropnT-<0.01 ___ 05:50PM BLOOD cTropnT-<0.01 ___ 05:50PM BLOOD proBNP-118 Brief Hospital Course: Mr. ___ is a ___ year old man with a PMH notable for HIV on HAART therapy, T2IDDM, hypertension, hyperlipidemia, obesity, CKD who presented to the ED with left arm pain relieved with nitroglycerin. He underwent a stress test, which was notable for reversible ischemia in the LAD territory. He was started on heparin and nitro gtts pre-cath and underwent a cardiac catheterization on ___ and was found to have a severe mid LAD stenosis and one DES was placed via a right radial approach. his access site is clean without bleeding or hematoma. His CSM is normal. His left arm pain never resolved and continues despite coronary revascularization. He will be referred to his PCP to have outpatient work-up for other non-cardiac cause. He was started on ASA, Plavix and increased his dose of Crestor. He will follow-up with Dr. ___ long term cardiology care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 50 mg PO DAILY 2. Fish Oil (Omega 3) ___ mg PO BID 3. Fenofibrate 134 mg PO DAILY 4. rilpivirine 25 mg oral DAILY 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q48H 6. RiTONAvir 100 mg PO DAILY 7. Rosuvastatin Calcium 20 mg PO QPM 8. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 9. Glargine 60 Units Breakfast 10. Multivitamins 1 TAB PO DAILY 11. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Darunavir 800 mg PO DAILY 4. Glargine 60 Units Breakfast 5. Rosuvastatin Calcium 40 mg PO QPM 6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q48H 8. Fenofibrate 134 mg PO DAILY 9. Fish Oil (Omega 3) ___ mg PO BID 10. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 11. Losartan Potassium 50 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. rilpivirine 25 mg oral DAILY 14. RiTONAvir 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: CAD s/p DES to mid LAD Discharge Condition: Mr. ___ is a ___ year old man with a PMH notable for HIV on HAART therapy, T2IDDM, hypertension, hyperlipidemia, obesity, CKD who presented to the ED with left arm pain relieved with nitroglycerin. He underwent a stress test, which was notable for reversible ischemia in the LAD territory. He was started on heparin and nitro gtts and which were stopped after his cardiac catheterization. He is now s/p cardiac catheterization and DES to LAD: # Angina: fairly constant left arm discomfort since arrival to ___ on ___, worst was ___, currently ___, states has not been ___ since his arrival. Now s/p cardiac catheterization with PCI of severe mid LAD stenosis with ___ 1: -NTG gtt stopped post-cath -Heparin gtt stopped post-cath -ASA 81mg po daily lifelong -Start Plavix 75mg daily x minimum 3 months -Referral to cardiac rehab upon discharge -Follow-up with Dr. ___ for ___ cardiologist per patient request. # DM -continue Lantus -(takes victoza at home; may resume upon discharge, non-formulary here) monitor ___, ISS PRN -carb consistent diet # Hypertension: BP stable 120s/70s -Losartan held for cath (cr 1.4, now 1.3) -___ resume post discharge # Hyperlipidemia -Increase Crestor to 40 mg -cont Fenofibrate # CKD stage III GFR 51 Creat 1.4 -pre and post IV hydration -Holding Losartan for procedure; may resume upon discharge -Renal function labs on ___ #. HIV -cont home med regimen Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ with left arm pain and were worked up for a cardiac source. You had an abnormal stress test followed by a cardiac catheterization. You were found to have a blockage in your left anterior descending artery and a drug coated stent was placed to improve blood flow to the heart. You will take Aspirin 81mg daily for life and Plavix 75mg daily. These will prevent a clot from forming in your stent. Do not stop taking either of these unless your cardiologist instructs you to do so. Stopping either of these will put you at risk for a life threatening heart attack. We also recommend that you consider attending a cardiac rehab program. A referral has been provided with your discharge paperwork. Care of your right wrist access site will be provided in your discharge instructions. We are providing you with a lab slip to get your kidney function tests checked on ___. We will request that the results be sent to your PCP. Your arm pain has not resolved despite your improved blood flow to the heart muscle. We recommend that you follow-up with your PCP to be worked up outpatient for other non-cardiac related sources. It has been a pleasure caring for you at ___! Followup Instructions: ___
[ "I25110", "B20", "I1310", "B181", "Z6842", "Z862", "E119", "Z794", "N183", "R9439", "Z8619", "Z9081", "E6601", "E785", "J45909", "M23203", "Z22322", "Q248", "G4733", "Z8546", "Z923", "Z87442", "Z96652" ]
Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Chief Complaint: Left arm pain Major Surgical or Invasive Procedure: Coronary Anatomy Right dominant, heart rotated to the left. LM: No significant disease. LAD: Proximal 40% smooth disease. Mid vessel 90% stenosis after large diag. LCx: Luminal irregularities. RCA: Luminal irregularities. 60% ostial PDA lesion. Interventional Details We proceeded with PCI of the mid LAD. XBLAD 3.5 guide. Vessel wired with a Runthrough wire. Angioplasty of the vessel followed by placement of a 3.0 x 18 mm Xience DES, post dilated with a 3.5 and 3.75 NC balloon at high pressure. TIMI III flow, 0% residual. Impressions: Successful PCI of severe mid LAD stenosis with single DES. Recommendations ASA for life, clopidogrel 75 daily x 3 months minimum History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with PMH notable for HIV on HAART therapy, T2IDDM, HTN, HLD, obesity, CKD who presents with left arm pain. He was in his usual state of health until [MASKED] when he was on the train when he noted severe dull left arm pain. These symptoms lasted for approx. 5 minutes and improved. Over the next few hours, he noted intermittent dull left arm pain that felt very similar to that same episode. He then presented to his PCP who referred him to the ED. Trops negative. Nuclear stress test completed on [MASKED] showed reversible perfusion defect in the LAD territory. Since being here he has had intermittent arm pain that can range in severity from a 2 to an 8. Episodes of severe pain have been between 5 to 30 minutes. He slept in a recliner last night as he feels his pain is less when sitting upright. At baseline, he is typically very sedentary as he had been unemployed for 8 months. In [MASKED], pt. began a new job and has been walking approximately 1.3 miles a day. When he goes a certain distance, he feels fatigued and short of breath which causes him to stop. Additionally, when he goes up a flight a steps, he feels very short of breath and can only do one flight at a time. He denies a history of chest, arm, jaw, or back pain, lightheadedness, dizziness, pre-syncope, syncope, worsening of his chronic [MASKED] edema, orthopnea, PND, or palpitations. In the ED, pt. received crestor, losartan, fenofibrate, HAART therapy, Tylenol, and insulin. Past Medical History: PMHx/PSHx: 1. HIV (VL [MASKED], CD4 490 in [MASKED] on antiretroviral therapy 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in [MASKED] secondary to salmonella abscess. 7. Type 2 diabetes mellitus on insulin 8. Morbid obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. Social History: [MASKED] Family History: nc Physical Exam: Physical Exam: Gen: Alert, no acute distress, sitting comfortably in recliner Neuro: Oriented x 3, speech clear, appropriate and comprehensible, Follows commands appropriately, MAE, mood and affect appropriate CV: Regular rate/rhythm Chest: Lungs clear bilaterally, diminished at bases, breathing non-labored ABD: Soft, non-tender, +bs Extr: BLE warm/well-perfused, [MASKED] pulses Skin: Warm and dry Pertinent Results: [MASKED] 05:00AM BLOOD WBC-8.8 RBC-4.93 Hgb-14.9 Hct-47.3 MCV-96 MCH-30.2 MCHC-31.5* RDW-17.3* RDWSD-59.3* Plt [MASKED] [MASKED] 05:50PM BLOOD WBC-9.4 RBC-5.39# Hgb-16.1# Hct-51.2*# MCV-95 MCH-29.9 MCHC-31.4* RDW-17.3* RDWSD-58.6* Plt [MASKED] [MASKED] 05:50PM BLOOD Neuts-62.6 [MASKED] Monos-9.3 Eos-1.2 Baso-0.5 Im [MASKED] AbsNeut-5.89 AbsLymp-2.43 AbsMono-0.87* AbsEos-0.11 AbsBaso-0.05 [MASKED] 05:00AM BLOOD Plt [MASKED] [MASKED] 05:00AM BLOOD [MASKED] PTT-34.3 [MASKED] [MASKED] 09:39PM BLOOD PTT-31.1 [MASKED] 12:45PM BLOOD [MASKED] PTT-28.7 [MASKED] [MASKED] 05:50PM BLOOD Plt [MASKED] [MASKED] 05:00AM BLOOD Glucose-135* UreaN-26* Creat-1.3* Na-141 K-4.6 Cl-102 HCO3-27 AnGap-17 [MASKED] 05:50PM BLOOD Glucose-126* UreaN-27* Creat-1.4* Na-142 K-4.8 Cl-99 HCO3-29 AnGap-19 [MASKED] 11:35AM BLOOD cTropnT-<0.01 [MASKED] 12:45PM BLOOD cTropnT-<0.01 [MASKED] 12:00AM BLOOD cTropnT-<0.01 [MASKED] 05:50PM BLOOD cTropnT-<0.01 [MASKED] 05:50PM BLOOD proBNP-118 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with a PMH notable for HIV on HAART therapy, T2IDDM, hypertension, hyperlipidemia, obesity, CKD who presented to the ED with left arm pain relieved with nitroglycerin. He underwent a stress test, which was notable for reversible ischemia in the LAD territory. He was started on heparin and nitro gtts pre-cath and underwent a cardiac catheterization on [MASKED] and was found to have a severe mid LAD stenosis and one DES was placed via a right radial approach. his access site is clean without bleeding or hematoma. His CSM is normal. His left arm pain never resolved and continues despite coronary revascularization. He will be referred to his PCP to have outpatient work-up for other non-cardiac cause. He was started on ASA, Plavix and increased his dose of Crestor. He will follow-up with Dr. [MASKED] long term cardiology care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 50 mg PO DAILY 2. Fish Oil (Omega 3) [MASKED] mg PO BID 3. Fenofibrate 134 mg PO DAILY 4. rilpivirine 25 mg oral DAILY 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q48H 6. RiTONAvir 100 mg PO DAILY 7. Rosuvastatin Calcium 20 mg PO QPM 8. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 9. Glargine 60 Units Breakfast 10. Multivitamins 1 TAB PO DAILY 11. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Darunavir 800 mg PO DAILY 4. Glargine 60 Units Breakfast 5. Rosuvastatin Calcium 40 mg PO QPM 6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q48H 8. Fenofibrate 134 mg PO DAILY 9. Fish Oil (Omega 3) [MASKED] mg PO BID 10. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 11. Losartan Potassium 50 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. rilpivirine 25 mg oral DAILY 14. RiTONAvir 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: CAD s/p DES to mid LAD Discharge Condition: Mr. [MASKED] is a [MASKED] year old man with a PMH notable for HIV on HAART therapy, T2IDDM, hypertension, hyperlipidemia, obesity, CKD who presented to the ED with left arm pain relieved with nitroglycerin. He underwent a stress test, which was notable for reversible ischemia in the LAD territory. He was started on heparin and nitro gtts and which were stopped after his cardiac catheterization. He is now s/p cardiac catheterization and DES to LAD: # Angina: fairly constant left arm discomfort since arrival to [MASKED] on [MASKED], worst was [MASKED], currently [MASKED], states has not been [MASKED] since his arrival. Now s/p cardiac catheterization with PCI of severe mid LAD stenosis with [MASKED] 1: -NTG gtt stopped post-cath -Heparin gtt stopped post-cath -ASA 81mg po daily lifelong -Start Plavix 75mg daily x minimum 3 months -Referral to cardiac rehab upon discharge -Follow-up with Dr. [MASKED] for [MASKED] cardiologist per patient request. # DM -continue Lantus -(takes victoza at home; may resume upon discharge, non-formulary here) monitor [MASKED], ISS PRN -carb consistent diet # Hypertension: BP stable 120s/70s -Losartan held for cath (cr 1.4, now 1.3) -[MASKED] resume post discharge # Hyperlipidemia -Increase Crestor to 40 mg -cont Fenofibrate # CKD stage III GFR 51 Creat 1.4 -pre and post IV hydration -Holding Losartan for procedure; may resume upon discharge -Renal function labs on [MASKED] #. HIV -cont home med regimen Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [MASKED] with left arm pain and were worked up for a cardiac source. You had an abnormal stress test followed by a cardiac catheterization. You were found to have a blockage in your left anterior descending artery and a drug coated stent was placed to improve blood flow to the heart. You will take Aspirin 81mg daily for life and Plavix 75mg daily. These will prevent a clot from forming in your stent. Do not stop taking either of these unless your cardiologist instructs you to do so. Stopping either of these will put you at risk for a life threatening heart attack. We also recommend that you consider attending a cardiac rehab program. A referral has been provided with your discharge paperwork. Care of your right wrist access site will be provided in your discharge instructions. We are providing you with a lab slip to get your kidney function tests checked on [MASKED]. We will request that the results be sent to your PCP. Your arm pain has not resolved despite your improved blood flow to the heart muscle. We recommend that you follow-up with your PCP to be worked up outpatient for other non-cardiac related sources. It has been a pleasure caring for you at [MASKED]! Followup Instructions: [MASKED]
[]
[ "E119", "Z794", "E785", "J45909", "G4733" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "B20: Human immunodeficiency virus [HIV] disease", "I1310: Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "B181: Chronic viral hepatitis B without delta-agent", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "Z862: Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "N183: Chronic kidney disease, stage 3 (moderate)", "R9439: Abnormal result of other cardiovascular function study", "Z8619: Personal history of other infectious and parasitic diseases", "Z9081: Acquired absence of spleen", "E6601: Morbid (severe) obesity due to excess calories", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "M23203: Derangement of unspecified medial meniscus due to old tear or injury, right knee", "Z22322: Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus", "Q248: Other specified congenital malformations of heart", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8546: Personal history of malignant neoplasm of prostate", "Z923: Personal history of irradiation", "Z87442: Personal history of urinary calculi", "Z96652: Presence of left artificial knee joint" ]
10,036,086
24,186,608
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: ___ catheter insertion ___ filter placement ___ with duodenal ulcer clipping History of Present Illness: Mr. ___ is a ___ man with a history of CAD s/p DES to LAD (___), HIV on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p splenectomy (___), and prior hepatitis B infection who was admitted with a submassive PE and AF with RVR on ___ until ___ at ___. He is now presenting with dyspnea in the setting of being off anticoagulation since ___ in the setting of GI and RP bleeding. Of note patient was recently admitted with submassive PE on ___. MASCOT was consulted and he was treated and discharged on warfarin with a lovenox bridge. During that admission, he also had a TEE/DCCV for new AF with RVR and started on amiodarone PO. After discharge on ___ patient was doing well until ___ when he developed severe abdominal pain and was admitted to ___ with GI and RP bleeding. After admission to the floor, his BP dropped to SBP ___, for which he required norepinephrine and 4 units pRBCs. Patient was then discharged to rehab on ___ off of all anticoagulation. He was doing well until ___ when he developed acute shortness of breath with mild activity getting around and new swelling in both his legs and his right arm. He had no chest pain, palpitations, lightheadedness,dizziness, or syncope. Given these symptoms he was sent from rehab to ___ where he was found to be hypoxemic and hypotensive to SBP ___. A CT was performed showing a saddle PE, for which he was started on heparin and transferred to ___. Past Medical History: PMHx/PSHx: 1. HIV (VL <20, CD4 500s in ___ on antiretroviral therapy 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in ___ secondary to salmonella abscess. 7. Type 2 diabetes mellitus on insulin 8. Morbid obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. 14. Submassive PE/DVT in ___ 15. Retroperitoneal venous bleed in ___ 16. Saddle PE/DVT in ___ 17. Paroxysmal atrial fibrillation with h/o RVR Social History: ___ Family History: nc Physical Exam: Admission Physical Examination: =============================== VS: T 96.9, BP 126/72, HR 98, Resp rate 28 O2Sa 91% on 6L NC GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP not elevated. CARDIAC: RRR no m/r/g LUNGS: CTAB no r/r/w ABDOMEN: Soft, NT, ND, +BS, scattered bruising. EXTREMITIES: Bilateral leg edema R>L SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. Discharge Physical Examination: ================================ VS: 24 HR Data (last updated ___ @ 509) Temp: 97.5 (Tm 97.5), BP: 126/52 (115-126/52-62), HR: 71 (71-76), RR: 18, O2 sat: 98% (93-98), O2 delivery: 2.5L (2L NC-3L), Wt: 552.47 lb/250.6 kg Fluid Balance (last updated ___ @ 538) Last 8 hours Total cumulative 1206ml IN: Total 1256ml, PO Amt 400ml, IV Amt Infused 856ml OUT: Total 50ml, Urine Amt 50ml Last 24 hours Total cumulative 1206ml IN: Total 1256ml, PO Amt 400ml, IV Amt Infused 856ml OUT: Total 50ml, Urine Amt 50ml (Multiple missed voids) GEN: morbidly obese woman lying in bed in NAD HEENT: NC/AT. PERRLA, EOMI, MMM. NECK: supple CV: RRR, no murmurs PULM: CTAB no increased WOB ABD: obese, soft, NT, ND, +BS EXTR: WWP. No clubbing, cyanosis, or peripheral edema. SKIN: no significant lesions or rashes. PULSE: distal pulses palpable and symmetric. NEURO: AOx3, grossly intact. Pertinent Results: Admission Labs: =============== ___ 05:03PM TYPE-ART PO2-64* PCO2-43 PH-7.40 TOTAL CO2-28 BASE XS-0 ___ 04:44PM HGB-10.0* HCT-33.9* ___ 04:44PM PTT-60.9* ___ 04:44PM ___ ___ 12:35PM TYPE-ART PO2-116* PCO2-58* PH-7.29* TOTAL CO2-29 BASE XS-0 ___ 12:00PM HGB-9.7* HCT-33.5* ___ 12:00PM ___ ___ 10:17AM TYPE-ART PO2-149* PCO2-58* PH-7.27* TOTAL CO2-28 BASE XS--1 ___ 10:01AM WBC-9.1 RBC-3.03* HGB-9.8* HCT-33.4* MCV-110* MCH-32.3* MCHC-29.3* RDW-19.1* RDWSD-75.8* ___ 10:01AM ___ PTT-47.1* ___ ___ 10:01AM ___ ___ 08:26AM TYPE-ART PO2-61* PCO2-51* PH-7.32* TOTAL CO2-27 BASE XS-0 ___ 08:26AM LACTATE-1.1 ___ 06:58AM TYPE-ART PO2-103 PCO2-56* PH-7.25* TOTAL CO2-26 BASE XS--3 ___ 06:58AM LACTATE-1.2 ___ 06:51AM GLUCOSE-227* UREA N-39* CREAT-1.3* SODIUM-141 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14 ___ 06:51AM ALT(SGPT)-20 AST(SGOT)-26 LD(LDH)-720* ALK PHOS-67 TOT BILI-1.0 ___ 06:51AM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-5.3* MAGNESIUM-1.8 ___ 06:51AM WBC-9.5 RBC-3.26* HGB-10.4* HCT-35.9* MCV-110* MCH-31.9 MCHC-29.0* RDW-19.1* RDWSD-76.0* ___ 06:51AM ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+* POLYCHROM-1+* ECHINO-1+* RBCM-SLIDE REVI ___ 06:51AM PLT SMR-NORMAL PLT COUNT-272 ___ 06:51AM ___ PTT-55.9* ___ ___ 03:00AM %HbA1c-7.1* eAG-157* ___ 02:36AM ___ PTT-56.6* ___ ___ 02:22AM ___ PO2-30* PCO2-51* PH-7.36 TOTAL CO2-30 BASE XS-0 ___ 02:22AM LACTATE-1.1 ___ 02:22AM O2 SAT-50 ___ 12:37AM VoidSpec-SPECIMEN S ___ 11:51PM GLUCOSE-167* UREA N-41* CREAT-1.2 SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11 ___ 11:51PM estGFR-Using this ___ 11:51PM cTropnT-0.21* proBNP-5167* ___ 11:51PM WBC-9.9 RBC-3.32* HGB-10.7* HCT-36.3* MCV-109* MCH-32.2* MCHC-29.5* RDW-18.9* RDWSD-73.7* ___ 11:51PM NEUTS-70.8 LYMPHS-17.5* MONOS-9.0 EOS-0.4* BASOS-0.3 NUC RBCS-3.2* IM ___ AbsNeut-6.98* AbsLymp-1.73 AbsMono-0.89* AbsEos-0.04 AbsBaso-0.03 ___ 11:51PM PLT COUNT-292 ___ 11:51PM ___ PTT-76.6* ___ Pertinent Labs: ================== ___ 03:00AM BLOOD %HbA1c-7.1* eAG-157* ___ 05:29AM BLOOD VitB___ Folate-9 Pertinent Studies: ================== CXR: ___ FINDINGS: - Lung volumes are low bilaterally. There has been interval placement of a right chest port with tip overlying the cavoatrial junction. Streaky linear bibasilar opacities likely represent atelectasis. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is likely mildly enlarged although this is likely exaggerated by low lung volumes and the AP technique. No acute osseous abnormalities are identified. IMPRESSION: 1. Interval placement of a right chest port with tip overlying the cavoatrial junction. No pneumothorax. 2. Redemonstration hypoinflated lungs with lower lobe volume loss. ___ Pulmonary Arteriogram COMPARISON: CTA Chest ___ from outside facility. TECHNIQUE: Dr. ___ and Dr. ___ Interventional ___ and Dr. ___, Interventional Radiology fellow performed the procedure. ANESTHESIA: Mac sedation was provided by anesthesia. MEDICATIONS: A total of 8 mg of tPA were infused during the procedure. CONTRAST: 60 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 21.7 minutes, 1122 mGy PROCEDURE: 1. Right IJ central venous access under ultrasound guidance. 2. Left pulmonary arteriogram. 3. Left pulmonary artery chemical thrombolysis. 4. Lysis catheter placement in the left lower lobe pulmonary artery. 5. Right pulmonary arteriogram. 6. Right pulmonary artery mechanical and chemical thrombolysis. 7. Repeat right pulmonary arteriogram. 8. Lysis catheter placement in the right lower lobe pulmonary artery. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The neck and both groins were prepped and draped in the usual sterile fashion. Preliminary ultrasound images of the right IJ were stored. The overlying skin was anesthetized with 1% lidocaine solution. A 21 gauge needle was advanced into the right IJ under ultrasound guidance. A microwire was advanced through the needle into the ___. A small skin ___ was made at the needle insertion site. The needle was exchanged for a micropuncture access sheath. The wire and inner dilator were removed ___ wire was advanced into the ___. The micro sheath was then exchanged for a 6 ___ sheath. The inner dilator and ___ wire were then removed. A 5 ___ C2 Cobra glide catheter and Glidewire were then advanced through the sheath and used to navigate into the left pulmonary artery. The wire was removed. At this point, the catheter was used to measure pulmonary artery pressures (the left mean pulmonary artery pressure was 51). Contrast was injected to confirm positioning. A digital was retracted left pulmonary arteriogram was performed, demonstrating large filling defect in the proximal pulmonary artery and a paucity of lower lobe pulmonary artery branches. At this point, the patient's hemodynamic status began to decline. 2 mg of diluted tPA were injected directly into the proximal thrombus. A ___ wire was then advanced through the Cobra catheter, which was subsequently exchanged for a 6 cm EKOS infusion catheter. A 21 gauge needle was advanced into the right IJ at a separate access site under ultrasound guidance. A microwire was advanced through the needle into the ___. A small skin ___ was made at the needle insertion site. The needle was exchanged for a micropuncture access sheath. The wire and inner dilator were removed ___ wire was advanced into the ___. The micro sheath was then exchanged for a 6 ___ sheath. The Cobra catheter was advanced through the new sheath and navigated into the right pulmonary artery with a Glidewire. Glidewire was removed. Contrast was injected to confirm positioning. A digitally subtracted right pulmonary arteriogram was performed, demonstrating proximal thrombus and near complete occlusion of the right lung sparing only 2 segments in the right upper lobe. 2 mg of dilute tPA were infused directly into the thrombus. A ___ wire was advanced through the Cobra catheter. The Cobra catheter was exchanged for a Omni flush catheter. The Omni Flush catheter was used to perform mechanical thrombectomy as an additional 4 mg of tPA were infused. The ___ wire was injected advanced through the Omni Flush catheter. The Omni Flush catheter was then removed. The 6 ___ sheath was exchanged for an 8 ___ sheath. A penumbra aspiration catheter was advanced over the ___ wire and into the right pulmonary artery. The aspiration catheter was used for thrombectomy transiently. Shortly after initiation of thrombectomy, the patient's hemodynamic status significantly improved. The aspiration catheter was then exchanged over a ___ wire for the Omni Flush catheter. A repeat digitally subtracted right pulmonary arteriogram was performed demonstrating improved flow the right lung. The ___ wire was then advanced through the Omni Flush catheter and positioned in the right lung base. The Omni Flush catheter was then exchanged for a 12 cm EKOS infusion catheter. Contrast was injected through both EKOS catheters to confirm positioning. The coast catheters were then assembled unattached to respective devices. Both sheaths and infusion catheters were secured to the skin with 0 silk suture. A sterile dressing was applied. The patient tolerated the procedure well. There were no immediate post-procedure complications. The patient was transferred to the ICU in stable condition. FINDINGS: - Pulmonary arteriograms demonstrated extensive thrombosis bilaterally. - Local tPA was infused (total of 8 mg). - Post thrombolysis/thrombectomy arteriogram showed improvement in pulmonary arterial flow. - Successful placement of bilateral pulmonary arterial EKOS lysis catheters. IMPRESSION: - Successful pulmonary arterial thrombus debulking. - Successful placement of bilateral pulmonary arterial EKOS lysis catheters. TTE ___ CONCLUSION: There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional left ventricular systolic function. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 55-60%. Moderately dilated right ventricular cavity with moderate global free wall hypokinesis. There is abnormal interventricular septal motion c/w right ventricular pressure overload. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The tricuspid valve leaflets are mildly thickened. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Dilated right ventricle with moderate global RV systolic dysfunction. Moderate pulmonary hypertension. ___ IVC Filter Placement Final Report INDICATION: ___ year old man with DVT and history of bleeding from anticoagulation// IVC filter placement COMPARISON: Lower extremity venous duplex dated ___ TECHNIQUE: Dr. ___ Interventional ___, performed the procedure. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1% lidocaine CONTRAST: 25 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 4.7, 484 mGy PROCEDURE: 1. IVC venogram. 2. Infrarenal Denali IVC filter deployment. 3. Post-filter placement venogram. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. the right neck was prepped and draped in the usual sterile fashion. An Amplatz wire was placed through the existing 8 ___ sheath. The sheath was removed over the wire and a new 8 ___ sheath was placed. The Amplatz wire was passed down into the distal IVC and left iliac vein. Over the wire, a straight flush catheter was placed. A inferior vena cava venogram was performed. Based on the results of the venogram, detailed below, a decision was made to place a Denali filter. The catheter and sheath were removed over the wire and the sheath of a Denali filter was advanced over the wire into the IVC past the take-off of the renal vessels. An Denali vena cava filter was advanced over the wire until the cranial tip was at the level of the inferior margin of the lower renal vein. The sheath was then withdrawn until the filter was deployed. The wire and loading device were then removed through the sheath and a repeat contrast injection was performed, confirming appropriate filter positioning. The final image was stored on PACS. The sheath was removed and pressure was held for 5 minutes,at which point hemostasis was achieved. A sterile dressing was applied. The patient tolerated the procedure well and there were no immediate post procedure complications. FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal Denali IVC filter. ___ CXR Portable FINDINGS: - There is no evidence of pneumoperitoneum, though detection is severely limited given patient positioning. Lung volumes are low bilaterally. No focal consolidation is seen. Blunting of the left costophrenic angle is unchanged and likely secondary to pericardial fat as demonstrated on CT from ___. The right internal jugular central line has been removed. IMPRESSION: - No evidence of pneumoperitoneum, though detection severely limited by patient positioning and portable technique. ___ EGD 1) Normal mucosa in the whole esophagus 2) Normal mucosa in the whole stomach 3) Oozing was noted upon entry into the duodenal bulb and duodenal sweep. A single cratered 8mm ulcer was found in the duodenal sweep. A visible vessel suggested recent bleeding. 2ml epinephrine was successfully applied for hemostasis. One endoclip was successfully applied for the purpose of hemostasis. ___ CXR for PICC Placement TECHNIQUE: Dr. ___ radiology attending) performed the procedure. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None CONTRAST: 0 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 1.1 minutes, 5.2 mGy PROCEDURE: 1. Replacement of right PICC. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing PICC line was aspirated and flushed and a Nitinol guidewire was introduced into the superior vena cava (SVC). A peel-away sheath was then placed over a guidewire. The guidewire was then advanced into the superior vena cava. A double lumen PIC line measuring 42 cm in length was then placed through the peel-away sheath with its tip positioned in the distal SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. Existing right arm approach PICC with tip in the axillary vein replaced with a new double lumen PIC line with tip in the distal SVC. IMPRESSION: Successful placement of a 42 cm right arm approach double lumen PowerPICC with tip in the distal SVC. The line is ready to use. Discharge Labs: =============== ___ 05:41AM BLOOD WBC-7.7 RBC-2.51* Hgb-8.4* Hct-28.7* MCV-114* MCH-33.5* MCHC-29.3* RDW-24.0* RDWSD-96.6* Plt ___ ___ 05:41AM BLOOD ___ PTT-24.8* ___ ___ 06:01AM BLOOD Glucose-137* UreaN-31* Creat-1.2 Na-142 K-4.2 Cl-99 HCO3-31 AnGap-12 ___ 06:01AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1 ___ 05:29AM BLOOD ALT-22 AST-20 LD(LDH)-551* AlkPhos-45 TotBili-0.5 Brief Hospital Course: Summary: ========= Mr. ___ is a ___ man with a history of CAD s/p DES to LAD (___), HIV on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p splenectomy (___), and prior hepatitis B infection who was recently admitted with a submassive PE from ___ until ___ at ___. He now represents with a saddle PE on CT with hypoxemia and hypotension after a recent episode of retroperitoneal hemorrhage leading to hemorrhagic shock and withholding of all anticoagulation since ___. #CORONARIES: s/p DES to LAD (___) #PUMP: LVEF 55-60% (___) #RHYTHM: Sinus TRANSITIONAL ISSUES: ==================== Follow Ups: [] PLEASE ENSURE PATIENT KEEPS HIS F/U ___ ON ___ [] ___ will set up a clinic appointment to assess for IVC filter removal in ___ months. Medications: [] Patient started on Warfarin for treatment of massive PE, INR GOAL: 1.8-2.4 given severe RP and GI bleeds on anticoagulation. Bridge with enoxaparin 120 mg BID for INR < 1.8. [] Patient will need long-term management of anticoagulation with Warfarin, PCP ___ aware. [] Discharged on PPI BID given GI bleed on anticoagulation. Discontinue PO PPI in 8 weeks (___). [] Glargine 60u at home, discharged on 50u given lower requirements during hospitalization. Increase back prn. Issues: ***For Rehab*** [] Please monitor the patient's weight and attempt to uptitrate diuresis as needed to achieve his dry weight of 274lbs. ***For Cardiology*** [] PO amiodarone started I/s/o difficult to control AF w/ RVR. Please re-evaluate its need moving forward. [] Repeat TTE in 1 month to eval interval change from prior, define EF, ensure not newly reduced ***For PCP*** [] Given unprovoked PE, ensure age appropriate malignancy screening has been done. if unremarkable, consider hypercoagulability w/u. [] Mildly nodular contour seen on abdominal imaging. Consider outpatient Fibroscan and possibly hepatology referral. Pt is high risk for NASH Data: * Discharge Hb 8.4; no need to recheck if not having melena. * DRY WT: ~274 lbs. Last pre-discharge 281.08lbs, bed weight (on ___. CODE STATUS: FULL ACUTE ISSUES: ============= #Massive PULMONARY EMBOLISM #Acute on chronic hypoxic respiratory failure Patient recently admitted for submassive PE and discharged on ___ with warfarin and a lovenox bridge. Presented later that month to ___ and was found to have GI bleeding as well as a large RP bleed and the decision was made to stop his anticoagulation. He was discharged to rehab and represented ___ with dyspnea found to have a mass PE initially requiring pressor support. Immediately after arriving on the floor patient was taken to ___ suite where two EKOS catheters were placed for tPA administration. During procedure local tPA boluses were administered to the clot and a catheter was used break up the clot. The patient was started on a heparin drip. EKOS catheters were removed later that day. Transthoracic echo showed a dilated right ventricle associated with dysfunction. Patient also had moderate pulmonary hypertension. Given his edematous appearance, the patient was diuresed with IV Lasix and eventually transitioned to PO Lasix 20mg daily. On ___, patient had a IVC filter placed successfully. The patient was continued on a heparin drip, and converted to warfarin. His INR goal was determined to be 1.8-2.4 given high risk of major bleed as well as high risk of life-threatening clot. On discharge INR was 1.8. #UGIB on AC #S/p Clipping of duodenal ulcer The patient was started on warfarin ___. Overnight on ___, the patient had multiple melanotic stools, with associated hemoglobin drop from 8.7 to 7. The patient received 2 units of packed red blood cells with good response 9.1. He was taken to endoscopy by gastroenterology, and had a duodenal ulcer clipped with appropriate hemostasis. On discharge he was having soft brown BMs. He will be continued on a PPI on discharge for 8 weeks. Discharge hemoglobin was 8.4. #ATRIAL FIBRILLATION W/ RVR Had new onset afib with RVR during previous hospitalization to submassive PE. Had DCCV ___, successful, remained in sinus at time of discharge. Anticoagulation as above. His home metoprolol was held in the setting of acute pulmonary embolus associated with right ventricular dysfunction. His amiodarone was adjusted to 200 mg twice daily, as he had already been appropriately loaded with amiodarone on his prior hospitalization. on discharge we continued him home metoprolol succinate #CORONARY ARTERY DISEASE s/p DES to LAD (___). Mild troponin elevation likely reflective of right heart strain from acute PE. He was chest pain-free throughout the hospitalization. He was continued on his home rosuvastatin and losartan. His metoprolol was held during the admission in the setting of severe RV systolic dysfunction as well as the UGIB. It was able to restarted on discharge. #Acute on Chronic HFpEF The patient had increased volume on examination with a TTE showing an LV EF of 55-60. He was volume overloaded on examination and required Lasix 20 IV which had good effect. We converted him to po Lasix regimen and would like his facility to continue to monitor the patients weight with a plan to have him lose another ___ pounds from his admission to the facility. He should have daily weights at the facility. CHRONIC ISSUES: =============== #HIV Most recent VL undetectable. CD4 of 500. Continue the patient on his home darunavir/cobicistat and Odefsey. #HYPERLIPIDEMIA Continued Fenofibrate 145 mg PO DAILY in addition to statin (both home meds) #DIABETES: Held PO meds and home liraglutide (as it was nonformulary), placed on 40u glargine qAM (60u at home) as well as insulin sliding scale instead in the setting of acute illness. On discharge uptitrated glargine to 50u. #RADIOGRAPHIC LIVER ABNORMALITY Mild nodular contour of the liver raises concern for cirrhosis. Consider outpatient Fibroscan and possibly hepatology referral. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Fenofibrate 145 mg PO DAILY 3. Rosuvastatin Calcium 40 mg PO QPM 4. Glargine 60 Units Breakfast 5. liraglutide 1.8 mg subcutaneous DAILY 6. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 7. Amiodarone 200 mg PO TID 8. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY Duration: 14 Days 2. Aspirin 81 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Pantoprazole 40 mg PO Q12H 5. ___ MD to order daily dose PO DAILY16 6. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days 7. Amiodarone 200 mg PO DAILY 8. Glargine 50 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 9. Fenofibrate 145 mg PO DAILY 10. liraglutide 1.8 mg subcutaneous DAILY 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 13. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY 14. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: ================== 1) Massive Pulmonary Embolism 2) Upper GI Bleeding s/p duodenal ulcer clipping 3) Acute on chronic hypoxic respiratory 4) Afib with RVR 5) Coronary Artery Disease . 6) Acute on Chronic Heart Failure with Preserved Ejection Fraction Secondary Diagnosis: ==================== 1) HIV 2) Hyperlipidemia 3) Diabetes Mellitus 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: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? -You were admitted to the hospital because you had blood clots in your lungs WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? -We gave you medications to break up the clots –We started you on a blood thinning medication –Unfortunately you had a small gastrointestinal bleed, which was fixed by our gastroenterologist. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? -Take all of your medications as prescribed (listed below), especially your warfarin -Your goal INR is 1.8-2.4 -Follow up with your doctors as listed below -Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs. -___ medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at ___! We wish you all the best! - Your ___ Care Team Followup Instructions: ___
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Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [MASKED] catheter insertion [MASKED] filter placement [MASKED] with duodenal ulcer clipping History of Present Illness: Mr. [MASKED] is a [MASKED] man with a history of CAD s/p DES to LAD ([MASKED]), HIV on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p splenectomy ([MASKED]), and prior hepatitis B infection who was admitted with a submassive PE and AF with RVR on [MASKED] until [MASKED] at [MASKED]. He is now presenting with dyspnea in the setting of being off anticoagulation since [MASKED] in the setting of GI and RP bleeding. Of note patient was recently admitted with submassive PE on [MASKED]. MASCOT was consulted and he was treated and discharged on warfarin with a lovenox bridge. During that admission, he also had a TEE/DCCV for new AF with RVR and started on amiodarone PO. After discharge on [MASKED] patient was doing well until [MASKED] when he developed severe abdominal pain and was admitted to [MASKED] with GI and RP bleeding. After admission to the floor, his BP dropped to SBP [MASKED], for which he required norepinephrine and 4 units pRBCs. Patient was then discharged to rehab on [MASKED] off of all anticoagulation. He was doing well until [MASKED] when he developed acute shortness of breath with mild activity getting around and new swelling in both his legs and his right arm. He had no chest pain, palpitations, lightheadedness,dizziness, or syncope. Given these symptoms he was sent from rehab to [MASKED] where he was found to be hypoxemic and hypotensive to SBP [MASKED]. A CT was performed showing a saddle PE, for which he was started on heparin and transferred to [MASKED]. Past Medical History: PMHx/PSHx: 1. HIV (VL <20, CD4 500s in [MASKED] on antiretroviral therapy 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in [MASKED] secondary to salmonella abscess. 7. Type 2 diabetes mellitus on insulin 8. Morbid obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. 14. Submassive PE/DVT in [MASKED] 15. Retroperitoneal venous bleed in [MASKED] 16. Saddle PE/DVT in [MASKED] 17. Paroxysmal atrial fibrillation with h/o RVR Social History: [MASKED] Family History: nc Physical Exam: Admission Physical Examination: =============================== VS: T 96.9, BP 126/72, HR 98, Resp rate 28 O2Sa 91% on 6L NC GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP not elevated. CARDIAC: RRR no m/r/g LUNGS: CTAB no r/r/w ABDOMEN: Soft, NT, ND, +BS, scattered bruising. EXTREMITIES: Bilateral leg edema R>L SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. Discharge Physical Examination: ================================ VS: 24 HR Data (last updated [MASKED] @ 509) Temp: 97.5 (Tm 97.5), BP: 126/52 (115-126/52-62), HR: 71 (71-76), RR: 18, O2 sat: 98% (93-98), O2 delivery: 2.5L (2L NC-3L), Wt: 552.47 lb/250.6 kg Fluid Balance (last updated [MASKED] @ 538) Last 8 hours Total cumulative 1206ml IN: Total 1256ml, PO Amt 400ml, IV Amt Infused 856ml OUT: Total 50ml, Urine Amt 50ml Last 24 hours Total cumulative 1206ml IN: Total 1256ml, PO Amt 400ml, IV Amt Infused 856ml OUT: Total 50ml, Urine Amt 50ml (Multiple missed voids) GEN: morbidly obese woman lying in bed in NAD HEENT: NC/AT. PERRLA, EOMI, MMM. NECK: supple CV: RRR, no murmurs PULM: CTAB no increased WOB ABD: obese, soft, NT, ND, +BS EXTR: WWP. No clubbing, cyanosis, or peripheral edema. SKIN: no significant lesions or rashes. PULSE: distal pulses palpable and symmetric. NEURO: AOx3, grossly intact. Pertinent Results: Admission Labs: =============== [MASKED] 05:03PM TYPE-ART PO2-64* PCO2-43 PH-7.40 TOTAL CO2-28 BASE XS-0 [MASKED] 04:44PM HGB-10.0* HCT-33.9* [MASKED] 04:44PM PTT-60.9* [MASKED] 04:44PM [MASKED] [MASKED] 12:35PM TYPE-ART PO2-116* PCO2-58* PH-7.29* TOTAL CO2-29 BASE XS-0 [MASKED] 12:00PM HGB-9.7* HCT-33.5* [MASKED] 12:00PM [MASKED] [MASKED] 10:17AM TYPE-ART PO2-149* PCO2-58* PH-7.27* TOTAL CO2-28 BASE XS--1 [MASKED] 10:01AM WBC-9.1 RBC-3.03* HGB-9.8* HCT-33.4* MCV-110* MCH-32.3* MCHC-29.3* RDW-19.1* RDWSD-75.8* [MASKED] 10:01AM [MASKED] PTT-47.1* [MASKED] [MASKED] 10:01AM [MASKED] [MASKED] 08:26AM TYPE-ART PO2-61* PCO2-51* PH-7.32* TOTAL CO2-27 BASE XS-0 [MASKED] 08:26AM LACTATE-1.1 [MASKED] 06:58AM TYPE-ART PO2-103 PCO2-56* PH-7.25* TOTAL CO2-26 BASE XS--3 [MASKED] 06:58AM LACTATE-1.2 [MASKED] 06:51AM GLUCOSE-227* UREA N-39* CREAT-1.3* SODIUM-141 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14 [MASKED] 06:51AM ALT(SGPT)-20 AST(SGOT)-26 LD(LDH)-720* ALK PHOS-67 TOT BILI-1.0 [MASKED] 06:51AM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-5.3* MAGNESIUM-1.8 [MASKED] 06:51AM WBC-9.5 RBC-3.26* HGB-10.4* HCT-35.9* MCV-110* MCH-31.9 MCHC-29.0* RDW-19.1* RDWSD-76.0* [MASKED] 06:51AM ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+* POLYCHROM-1+* ECHINO-1+* RBCM-SLIDE REVI [MASKED] 06:51AM PLT SMR-NORMAL PLT COUNT-272 [MASKED] 06:51AM [MASKED] PTT-55.9* [MASKED] [MASKED] 03:00AM %HbA1c-7.1* eAG-157* [MASKED] 02:36AM [MASKED] PTT-56.6* [MASKED] [MASKED] 02:22AM [MASKED] PO2-30* PCO2-51* PH-7.36 TOTAL CO2-30 BASE XS-0 [MASKED] 02:22AM LACTATE-1.1 [MASKED] 02:22AM O2 SAT-50 [MASKED] 12:37AM VoidSpec-SPECIMEN S [MASKED] 11:51PM GLUCOSE-167* UREA N-41* CREAT-1.2 SODIUM-141 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11 [MASKED] 11:51PM estGFR-Using this [MASKED] 11:51PM cTropnT-0.21* proBNP-5167* [MASKED] 11:51PM WBC-9.9 RBC-3.32* HGB-10.7* HCT-36.3* MCV-109* MCH-32.2* MCHC-29.5* RDW-18.9* RDWSD-73.7* [MASKED] 11:51PM NEUTS-70.8 LYMPHS-17.5* MONOS-9.0 EOS-0.4* BASOS-0.3 NUC RBCS-3.2* IM [MASKED] AbsNeut-6.98* AbsLymp-1.73 AbsMono-0.89* AbsEos-0.04 AbsBaso-0.03 [MASKED] 11:51PM PLT COUNT-292 [MASKED] 11:51PM [MASKED] PTT-76.6* [MASKED] Pertinent Labs: ================== [MASKED] 03:00AM BLOOD %HbA1c-7.1* eAG-157* [MASKED] 05:29AM BLOOD VitB Folate-9 Pertinent Studies: ================== CXR: [MASKED] FINDINGS: - Lung volumes are low bilaterally. There has been interval placement of a right chest port with tip overlying the cavoatrial junction. Streaky linear bibasilar opacities likely represent atelectasis. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is likely mildly enlarged although this is likely exaggerated by low lung volumes and the AP technique. No acute osseous abnormalities are identified. IMPRESSION: 1. Interval placement of a right chest port with tip overlying the cavoatrial junction. No pneumothorax. 2. Redemonstration hypoinflated lungs with lower lobe volume loss. [MASKED] Pulmonary Arteriogram COMPARISON: CTA Chest [MASKED] from outside facility. TECHNIQUE: Dr. [MASKED] and Dr. [MASKED] Interventional [MASKED] and Dr. [MASKED], Interventional Radiology fellow performed the procedure. ANESTHESIA: Mac sedation was provided by anesthesia. MEDICATIONS: A total of 8 mg of tPA were infused during the procedure. CONTRAST: 60 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 21.7 minutes, 1122 mGy PROCEDURE: 1. Right IJ central venous access under ultrasound guidance. 2. Left pulmonary arteriogram. 3. Left pulmonary artery chemical thrombolysis. 4. Lysis catheter placement in the left lower lobe pulmonary artery. 5. Right pulmonary arteriogram. 6. Right pulmonary artery mechanical and chemical thrombolysis. 7. Repeat right pulmonary arteriogram. 8. Lysis catheter placement in the right lower lobe pulmonary artery. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per [MASKED] protocol. The neck and both groins were prepped and draped in the usual sterile fashion. Preliminary ultrasound images of the right IJ were stored. The overlying skin was anesthetized with 1% lidocaine solution. A 21 gauge needle was advanced into the right IJ under ultrasound guidance. A microwire was advanced through the needle into the [MASKED]. A small skin [MASKED] was made at the needle insertion site. The needle was exchanged for a micropuncture access sheath. The wire and inner dilator were removed [MASKED] wire was advanced into the [MASKED]. The micro sheath was then exchanged for a 6 [MASKED] sheath. The inner dilator and [MASKED] wire were then removed. A 5 [MASKED] C2 Cobra glide catheter and Glidewire were then advanced through the sheath and used to navigate into the left pulmonary artery. The wire was removed. At this point, the catheter was used to measure pulmonary artery pressures (the left mean pulmonary artery pressure was 51). Contrast was injected to confirm positioning. A digital was retracted left pulmonary arteriogram was performed, demonstrating large filling defect in the proximal pulmonary artery and a paucity of lower lobe pulmonary artery branches. At this point, the patient's hemodynamic status began to decline. 2 mg of diluted tPA were injected directly into the proximal thrombus. A [MASKED] wire was then advanced through the Cobra catheter, which was subsequently exchanged for a 6 cm EKOS infusion catheter. A 21 gauge needle was advanced into the right IJ at a separate access site under ultrasound guidance. A microwire was advanced through the needle into the [MASKED]. A small skin [MASKED] was made at the needle insertion site. The needle was exchanged for a micropuncture access sheath. The wire and inner dilator were removed [MASKED] wire was advanced into the [MASKED]. The micro sheath was then exchanged for a 6 [MASKED] sheath. The Cobra catheter was advanced through the new sheath and navigated into the right pulmonary artery with a Glidewire. Glidewire was removed. Contrast was injected to confirm positioning. A digitally subtracted right pulmonary arteriogram was performed, demonstrating proximal thrombus and near complete occlusion of the right lung sparing only 2 segments in the right upper lobe. 2 mg of dilute tPA were infused directly into the thrombus. A [MASKED] wire was advanced through the Cobra catheter. The Cobra catheter was exchanged for a Omni flush catheter. The Omni Flush catheter was used to perform mechanical thrombectomy as an additional 4 mg of tPA were infused. The [MASKED] wire was injected advanced through the Omni Flush catheter. The Omni Flush catheter was then removed. The 6 [MASKED] sheath was exchanged for an 8 [MASKED] sheath. A penumbra aspiration catheter was advanced over the [MASKED] wire and into the right pulmonary artery. The aspiration catheter was used for thrombectomy transiently. Shortly after initiation of thrombectomy, the patient's hemodynamic status significantly improved. The aspiration catheter was then exchanged over a [MASKED] wire for the Omni Flush catheter. A repeat digitally subtracted right pulmonary arteriogram was performed demonstrating improved flow the right lung. The [MASKED] wire was then advanced through the Omni Flush catheter and positioned in the right lung base. The Omni Flush catheter was then exchanged for a 12 cm EKOS infusion catheter. Contrast was injected through both EKOS catheters to confirm positioning. The coast catheters were then assembled unattached to respective devices. Both sheaths and infusion catheters were secured to the skin with 0 silk suture. A sterile dressing was applied. The patient tolerated the procedure well. There were no immediate post-procedure complications. The patient was transferred to the ICU in stable condition. FINDINGS: - Pulmonary arteriograms demonstrated extensive thrombosis bilaterally. - Local tPA was infused (total of 8 mg). - Post thrombolysis/thrombectomy arteriogram showed improvement in pulmonary arterial flow. - Successful placement of bilateral pulmonary arterial EKOS lysis catheters. IMPRESSION: - Successful pulmonary arterial thrombus debulking. - Successful placement of bilateral pulmonary arterial EKOS lysis catheters. TTE [MASKED] CONCLUSION: There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional left ventricular systolic function. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 55-60%. Moderately dilated right ventricular cavity with moderate global free wall hypokinesis. There is abnormal interventricular septal motion c/w right ventricular pressure overload. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The tricuspid valve leaflets are mildly thickened. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Dilated right ventricle with moderate global RV systolic dysfunction. Moderate pulmonary hypertension. [MASKED] IVC Filter Placement Final Report INDICATION: [MASKED] year old man with DVT and history of bleeding from anticoagulation// IVC filter placement COMPARISON: Lower extremity venous duplex dated [MASKED] TECHNIQUE: Dr. [MASKED] Interventional [MASKED], performed the procedure. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: 1% lidocaine CONTRAST: 25 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 4.7, 484 mGy PROCEDURE: 1. IVC venogram. 2. Infrarenal Denali IVC filter deployment. 3. Post-filter placement venogram. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per [MASKED] protocol. the right neck was prepped and draped in the usual sterile fashion. An Amplatz wire was placed through the existing 8 [MASKED] sheath. The sheath was removed over the wire and a new 8 [MASKED] sheath was placed. The Amplatz wire was passed down into the distal IVC and left iliac vein. Over the wire, a straight flush catheter was placed. A inferior vena cava venogram was performed. Based on the results of the venogram, detailed below, a decision was made to place a Denali filter. The catheter and sheath were removed over the wire and the sheath of a Denali filter was advanced over the wire into the IVC past the take-off of the renal vessels. An Denali vena cava filter was advanced over the wire until the cranial tip was at the level of the inferior margin of the lower renal vein. The sheath was then withdrawn until the filter was deployed. The wire and loading device were then removed through the sheath and a repeat contrast injection was performed, confirming appropriate filter positioning. The final image was stored on PACS. The sheath was removed and pressure was held for 5 minutes,at which point hemostasis was achieved. A sterile dressing was applied. The patient tolerated the procedure well and there were no immediate post procedure complications. FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal Denali IVC filter. [MASKED] CXR Portable FINDINGS: - There is no evidence of pneumoperitoneum, though detection is severely limited given patient positioning. Lung volumes are low bilaterally. No focal consolidation is seen. Blunting of the left costophrenic angle is unchanged and likely secondary to pericardial fat as demonstrated on CT from [MASKED]. The right internal jugular central line has been removed. IMPRESSION: - No evidence of pneumoperitoneum, though detection severely limited by patient positioning and portable technique. [MASKED] EGD 1) Normal mucosa in the whole esophagus 2) Normal mucosa in the whole stomach 3) Oozing was noted upon entry into the duodenal bulb and duodenal sweep. A single cratered 8mm ulcer was found in the duodenal sweep. A visible vessel suggested recent bleeding. 2ml epinephrine was successfully applied for hemostasis. One endoclip was successfully applied for the purpose of hemostasis. [MASKED] CXR for PICC Placement TECHNIQUE: Dr. [MASKED] radiology attending) performed the procedure. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None CONTRAST: 0 ml of Optiray contrast FLUOROSCOPY TIME AND DOSE: 1.1 minutes, 5.2 mGy PROCEDURE: 1. Replacement of right PICC. PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing PICC line was aspirated and flushed and a Nitinol guidewire was introduced into the superior vena cava (SVC). A peel-away sheath was then placed over a guidewire. The guidewire was then advanced into the superior vena cava. A double lumen PIC line measuring 42 cm in length was then placed through the peel-away sheath with its tip positioned in the distal SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. FINDINGS: 1. Existing right arm approach PICC with tip in the axillary vein replaced with a new double lumen PIC line with tip in the distal SVC. IMPRESSION: Successful placement of a 42 cm right arm approach double lumen PowerPICC with tip in the distal SVC. The line is ready to use. Discharge Labs: =============== [MASKED] 05:41AM BLOOD WBC-7.7 RBC-2.51* Hgb-8.4* Hct-28.7* MCV-114* MCH-33.5* MCHC-29.3* RDW-24.0* RDWSD-96.6* Plt [MASKED] [MASKED] 05:41AM BLOOD [MASKED] PTT-24.8* [MASKED] [MASKED] 06:01AM BLOOD Glucose-137* UreaN-31* Creat-1.2 Na-142 K-4.2 Cl-99 HCO3-31 AnGap-12 [MASKED] 06:01AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1 [MASKED] 05:29AM BLOOD ALT-22 AST-20 LD(LDH)-551* AlkPhos-45 TotBili-0.5 Brief Hospital Course: Summary: ========= Mr. [MASKED] is a [MASKED] man with a history of CAD s/p DES to LAD ([MASKED]), HIV on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p splenectomy ([MASKED]), and prior hepatitis B infection who was recently admitted with a submassive PE from [MASKED] until [MASKED] at [MASKED]. He now represents with a saddle PE on CT with hypoxemia and hypotension after a recent episode of retroperitoneal hemorrhage leading to hemorrhagic shock and withholding of all anticoagulation since [MASKED]. #CORONARIES: s/p DES to LAD ([MASKED]) #PUMP: LVEF 55-60% ([MASKED]) #RHYTHM: Sinus TRANSITIONAL ISSUES: ==================== Follow Ups: [] PLEASE ENSURE PATIENT KEEPS HIS F/U [MASKED] ON [MASKED] [] [MASKED] will set up a clinic appointment to assess for IVC filter removal in [MASKED] months. Medications: [] Patient started on Warfarin for treatment of massive PE, INR GOAL: 1.8-2.4 given severe RP and GI bleeds on anticoagulation. Bridge with enoxaparin 120 mg BID for INR < 1.8. [] Patient will need long-term management of anticoagulation with Warfarin, PCP [MASKED] aware. [] Discharged on PPI BID given GI bleed on anticoagulation. Discontinue PO PPI in 8 weeks ([MASKED]). [] Glargine 60u at home, discharged on 50u given lower requirements during hospitalization. Increase back prn. Issues: ***For Rehab*** [] Please monitor the patient's weight and attempt to uptitrate diuresis as needed to achieve his dry weight of 274lbs. ***For Cardiology*** [] PO amiodarone started I/s/o difficult to control AF w/ RVR. Please re-evaluate its need moving forward. [] Repeat TTE in 1 month to eval interval change from prior, define EF, ensure not newly reduced ***For PCP*** [] Given unprovoked PE, ensure age appropriate malignancy screening has been done. if unremarkable, consider hypercoagulability w/u. [] Mildly nodular contour seen on abdominal imaging. Consider outpatient Fibroscan and possibly hepatology referral. Pt is high risk for NASH Data: * Discharge Hb 8.4; no need to recheck if not having melena. * DRY WT: ~274 lbs. Last pre-discharge 281.08lbs, bed weight (on [MASKED]. CODE STATUS: FULL ACUTE ISSUES: ============= #Massive PULMONARY EMBOLISM #Acute on chronic hypoxic respiratory failure Patient recently admitted for submassive PE and discharged on [MASKED] with warfarin and a lovenox bridge. Presented later that month to [MASKED] and was found to have GI bleeding as well as a large RP bleed and the decision was made to stop his anticoagulation. He was discharged to rehab and represented [MASKED] with dyspnea found to have a mass PE initially requiring pressor support. Immediately after arriving on the floor patient was taken to [MASKED] suite where two EKOS catheters were placed for tPA administration. During procedure local tPA boluses were administered to the clot and a catheter was used break up the clot. The patient was started on a heparin drip. EKOS catheters were removed later that day. Transthoracic echo showed a dilated right ventricle associated with dysfunction. Patient also had moderate pulmonary hypertension. Given his edematous appearance, the patient was diuresed with IV Lasix and eventually transitioned to PO Lasix 20mg daily. On [MASKED], patient had a IVC filter placed successfully. The patient was continued on a heparin drip, and converted to warfarin. His INR goal was determined to be 1.8-2.4 given high risk of major bleed as well as high risk of life-threatening clot. On discharge INR was 1.8. #UGIB on AC #S/p Clipping of duodenal ulcer The patient was started on warfarin [MASKED]. Overnight on [MASKED], the patient had multiple melanotic stools, with associated hemoglobin drop from 8.7 to 7. The patient received 2 units of packed red blood cells with good response 9.1. He was taken to endoscopy by gastroenterology, and had a duodenal ulcer clipped with appropriate hemostasis. On discharge he was having soft brown BMs. He will be continued on a PPI on discharge for 8 weeks. Discharge hemoglobin was 8.4. #ATRIAL FIBRILLATION W/ RVR Had new onset afib with RVR during previous hospitalization to submassive PE. Had DCCV [MASKED], successful, remained in sinus at time of discharge. Anticoagulation as above. His home metoprolol was held in the setting of acute pulmonary embolus associated with right ventricular dysfunction. His amiodarone was adjusted to 200 mg twice daily, as he had already been appropriately loaded with amiodarone on his prior hospitalization. on discharge we continued him home metoprolol succinate #CORONARY ARTERY DISEASE s/p DES to LAD ([MASKED]). Mild troponin elevation likely reflective of right heart strain from acute PE. He was chest pain-free throughout the hospitalization. He was continued on his home rosuvastatin and losartan. His metoprolol was held during the admission in the setting of severe RV systolic dysfunction as well as the UGIB. It was able to restarted on discharge. #Acute on Chronic HFpEF The patient had increased volume on examination with a TTE showing an LV EF of 55-60. He was volume overloaded on examination and required Lasix 20 IV which had good effect. We converted him to po Lasix regimen and would like his facility to continue to monitor the patients weight with a plan to have him lose another [MASKED] pounds from his admission to the facility. He should have daily weights at the facility. CHRONIC ISSUES: =============== #HIV Most recent VL undetectable. CD4 of 500. Continue the patient on his home darunavir/cobicistat and Odefsey. #HYPERLIPIDEMIA Continued Fenofibrate 145 mg PO DAILY in addition to statin (both home meds) #DIABETES: Held PO meds and home liraglutide (as it was nonformulary), placed on 40u glargine qAM (60u at home) as well as insulin sliding scale instead in the setting of acute illness. On discharge uptitrated glargine to 50u. #RADIOGRAPHIC LIVER ABNORMALITY Mild nodular contour of the liver raises concern for cirrhosis. Consider outpatient Fibroscan and possibly hepatology referral. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Fenofibrate 145 mg PO DAILY 3. Rosuvastatin Calcium 40 mg PO QPM 4. Glargine 60 Units Breakfast 5. liraglutide 1.8 mg subcutaneous DAILY 6. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 7. Amiodarone 200 mg PO TID 8. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY Discharge Medications: 1. Ascorbic Acid [MASKED] mg PO DAILY Duration: 14 Days 2. Aspirin 81 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Pantoprazole 40 mg PO Q12H 5. [MASKED] MD to order daily dose PO DAILY16 6. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days 7. Amiodarone 200 mg PO DAILY 8. Glargine 50 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 9. Fenofibrate 145 mg PO DAILY 10. liraglutide 1.8 mg subcutaneous DAILY 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 13. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY 14. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: ================== 1) Massive Pulmonary Embolism 2) Upper GI Bleeding s/p duodenal ulcer clipping 3) Acute on chronic hypoxic respiratory 4) Afib with RVR 5) Coronary Artery Disease . 6) Acute on Chronic Heart Failure with Preserved Ejection Fraction Secondary Diagnosis: ==================== 1) HIV 2) Hyperlipidemia 3) Diabetes Mellitus 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: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. [MASKED], WHY WERE YOU ADMITTED TO THE HOSPITAL? -You were admitted to the hospital because you had blood clots in your lungs WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? -We gave you medications to break up the clots –We started you on a blood thinning medication –Unfortunately you had a small gastrointestinal bleed, which was fixed by our gastroenterologist. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? -Take all of your medications as prescribed (listed below), especially your warfarin -Your goal INR is 1.8-2.4 -Follow up with your doctors as listed below -Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs. -[MASKED] medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at [MASKED]! We wish you all the best! - Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I130", "D62", "E1122", "I480", "I2510", "E785", "G4733", "Z955", "Z86718", "Z7901", "Z794" ]
[ "I2692: Saddle embolus of pulmonary artery without acute cor pulmonale", "J9621: Acute and chronic respiratory failure with hypoxia", "I5033: Acute on chronic diastolic (congestive) heart failure", "K264: Chronic or unspecified duodenal ulcer with hemorrhage", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "D62: Acute posthemorrhagic anemia", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "I480: Paroxysmal atrial fibrillation", "I2720: Pulmonary hypertension, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "Z21: Asymptomatic human immunodeficiency virus [HIV] infection status", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R932: Abnormal findings on diagnostic imaging of liver and biliary tract", "Z955: Presence of coronary angioplasty implant and graft", "Z86711: Personal history of pulmonary embolism", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "Z8546: Personal history of malignant neoplasm of prostate" ]
10,036,086
25,086,233
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Attending: ___ Chief Complaint: PE Major Surgical or Invasive Procedure: TEE/DCCV ___ History of Present Illness: ___ y/o male with hx of HIV on HAART therapy, prostate cancer s/p brachytherapy, T2IDDM, HTN, HLD, obesity, CKD, presents w tachycardia and dyspnea on exertion. Patient went to PCP today for bilateral lower ext edema but was found to have a a heart rate of 130s so sent here. He states that for the past few weeks he has had progressive dyspnea with exertion and b/l swelling. No history of blood clot. No chest pain. no fevers. no abdominal pain, n/v, cough or congestion. has had increased erythema over the left lower ext medial mal with pain progressively worsening. In the ED, initial vitals were: HR 132 BP 152/88 RR 18 O2 95 - Exam notable for: RLE swelling, erythema over bilat malls abrasions over the anterior shin. full ROM of all joint. - Labs notable for: 134 100 40 AGap=11 ------------<295 9.1 23 1.5 Repeat whole K: 4.5 proBNP: 843 Trop-T: 0.04 Lactate:3.1-->3.5 - Imaging was notable for: CTA 1. Pulmonary emboli extending from the distal right main pulmonary artery to segmental level in right upper and middle lobes and subsegmental level in right lower lobe. No left-sided pulmonary emboli. Difficult to exclude right heart strain. Echocardiogram would further assess. 2. No focal consolidation. 3. Mild nodular contour of the liver raise concern for cirrhosis. Correlation with liver function test is recommended for further evaluation. 4. Status post splenectomy. ___ on right There is non-occlusive deep vein thrombus of a right posterior tibial vein. - Patient was given: ___ ___ 13:41 IV Piperacillin-Tazobactam ___ 13:41 IVF NS ___ 14:52 IV Vancomycin 1500mg ___ 17:33 IV Heparin 6500 UNIT ___ ___ 18:41 IVF NS ___ Started Upon arrival to the ICU, patient reports feeling fine without sx. Review of systems was negative except as detailed above. Past Medical History: PMHx/PSHx: 1. HIV (VL ___, CD4 490 in ___ on antiretroviral therapy 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in ___ secondary to salmonella abscess. 7. Type 2 diabetes mellitus on insulin 8. Morbid obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. Social History: ___ Family History: nc Physical Exam: ADMISSION EXAM: =============== GENERAL: well-appearing sitting in bed with no distress HEENT: NCAT CARDIAC: RRR, no mgr. PULMONARY: Lungs clear to auscultation b/l. No wheezing. CHEST: no tenderness to palpation ABDOMEN: soft and non-distended. Non-tender to palpation. EXTREMITIES: RLE swelling, erythema over bilat malleoli w abrasions over the anterior shin. full ROM of all joints. SKIN: Abrasions over the anterior shin. NEURO: A&Ox3. Motor and sensory exam grossly normal. DISCHARGE EXAM: =============== GENERAL: Well appearing male in no acute distress. Comfortable. HEENT: NCAT. EOMI. MMM. CARDIAC: Rapid rate, regular rhythm. Distant heart sounds. No appreciable murmurs. PULMONARY: Clear to auscultation bilaterally. Breathing comfortably on nasal cannula. ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly. EXTREMITIES: Warm, well perfused, 1+ ___ on R>L. Right leg with multiple healing ulcers. Diffuse erythema around right ankle, tender, warm, no clear border between erythema and normal skin. NEURO: AAOx3. CNII-XII grossly intact. Moving all four extremities with purpose. Pertinent Results: ADMISSION LABS: =============== ___ 01:32PM BLOOD WBC-11.8* RBC-4.78 Hgb-15.8 Hct-47.6 MCV-100* MCH-33.1* MCHC-33.2 RDW-15.3 RDWSD-56.4* Plt ___ ___ 01:32PM BLOOD Neuts-78.8* Lymphs-11.6* Monos-7.4 Eos-0.1* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-9.27* AbsLymp-1.37 AbsMono-0.87* AbsEos-0.01* AbsBaso-0.02 ___ 01:32PM BLOOD ___ PTT-22.6* ___ ___ 01:32PM BLOOD Plt ___ ___ 01:32PM BLOOD Glucose-295* UreaN-40* Creat-1.5* Na-134* K-9.1* Cl-100 HCO3-23 AnGap-11 ___ 01:32PM BLOOD ALT-<5 AST-168* AlkPhos-41 TotBili-0.5 ___ 01:32PM BLOOD proBNP-843* ___ 01:32PM BLOOD cTropnT-0.04* ___ 01:32PM BLOOD Albumin-3.4* Calcium-9.4 Phos-4.1 Mg-2.1 ___ 04:58AM BLOOD PSA-<0.03 ___ 11:13PM BLOOD ___ Temp-36.8 pO2-60* pCO2-39 pH-7.43 calTCO2-27 Base XS-1 Intubat-NOT INTUBA ___ 01:51PM BLOOD Lactate-3.1* ___ 03:00PM BLOOD LMWH-1.01 DISCHARGE LABS: =============== ___ 06:51AM BLOOD WBC-10.1* RBC-4.32* Hgb-14.2 Hct-44.2 MCV-102* MCH-32.9* MCHC-32.1 RDW-15.6* RDWSD-59.1* Plt ___ ___ 06:51AM BLOOD Glucose-151* UreaN-42* Creat-1.2 Na-147 K-4.9 Cl-107 HCO3-25 AnGap-15 ___ 04:58AM BLOOD AST-20 AlkPhos-53 TotBili-0.4 ___ 06:51AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.3 PERTINENT STUDIES: ================== TEE ___ 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. The interatrial septum is dynamic, but not frankly aneurysmal. There is no evidence for an atrial septal defect by 2D/color Doppler though evaluation was limited by tachycardia and limited images obtained. Overall left ventricular systolic function is at least mildly depressed with beat-to-beat variability in the left ventricular contractility due to the irregular rhythm. The right ventricle has moderate global free wall hypokinesis. There are simple atheroma in the descending aorta to from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No abscess is seen. There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is mild to moderate [___] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is tricuspid regurgitation present (could not be qualified). IMPRESSION: No vegetations or intracardiac thrombus seen. Mild global biventricular systolic dysfunction. Mild to moderate mitral regurgitation. CTA Chest ___ IMPRESSION: 1. Pulmonary emboli extending from the distal right main pulmonary artery to segmental level in right upper and middle lobes and subsegmental level in right lower lobe. No left-sided pulmonary emboli. Difficult to exclude right heart strain. Echocardiogram would further assess. 2. No focal consolidation. 3. Mild nodular contour of the liver raise concern for cirrhosis. Correlation with liver function test is recommended for further evaluation. 4. Status post splenectomy. U/S of ___ ___ IMPRESSION: Non-occlusive deep vein thrombus of one right posterior tibial vein. Brief Hospital Course: ___ man with history of CAD s/p DES to LAD (___), HIV on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p splenectomy (___), and prior hepatitis B infection admitted w/ submassive PE and AF w/ RVR. ACUTE ISSUES ============ # SUBMASSIVE PULMONARY EMBOLISM # RIGHT LOWER EXTREMITY DVT Notable for TTE with evidence of right heart strain as well as mild troponin elevation. Never hypotensive, initiated on heparin gtt upon arrival, quickly weaned to RA. Appears unprovoked at this time: no signs of active malignancy, immobilization (although obese, not active), operations, or family history. Transitioned to warfarin, discharged on ___ bridge. # ATRIAL FIBRILLATION W/ RVR No prior records of Afib. Likely provoked ___ PE. Had rates difficult to control despite escalating doses of metoprolol and initiation of PO amiodarone. Hence, he had TEE and DCCV ___, successful, remained in sinus at time of discharge. Anticoagulation as above. Restarted on home dose metop succinate 25mg daily after DCCV, continued on PO amiodarone. # Acute on Chronic HFpEF: TTE this admission w/ poor image quality, noted depressed systolic function but could not determine EF. If EF was decreased, likely rate related I/s/o Afib w/ RVR. Mildly volume overloaded on exam initially, responded well to low dose IV diuresis, did not require PO diuretic at time of discharge. # RLE Cellulitis: noted upon arrival, nonpurulent, started on cephalexin for ___ORONARY ARTERY DISEASE s/p DES to LAD (___). Mild troponin elevation likely reflective of right heart strain from acute PE. Chest pain free. Continued ASA, statin, ___, and BB as above. D/c'd Plavix given initiation of AC, and > ___ year since stent placement. # RADIOGRAPHIC LIVER ABNORMALITY Mild nodular contour of the liver raises concern for cirrhosis. Consider. outpatient Fibroscan and possibly hepatology referral. CORE MEASURES: ================================= # HIV Most recent VL undetectable. CD4 of 500. Continued home HAART regimen (Darunavir 800 mg PO QHS, Cobicistat 150 mg PO QHS, Odefsey 200-25-25 mg oral QHS) # HYPERLIPIDEMIA: Fenofibrate 145 mg PO DAILY in addition to statin (both home meds) # DIABETES: held PO meds, placed on insulin sliding scale. TRANSITIONAL ISSUES =================== [] given unprovoked PE, ensure age appropriate malignancy screening has been done. if unremarkable, consider hypercoagulability w/u. [] currently on lovenox bridge until warfarin therapeutic. Increased warfarin dose to 10mg daily on day of discharge. Will need close monitoring and titration of warfarin dose, d/c lovenox when INR > 2. [] ___ of Hearts monitor at time of discharge [] PO amiodarone started I/s/o difficult to control AF w/ RVR. Please re-evaluate its need moving forward. [] cephalexin for RLE cellulitis for 7 day course. Please re-evaluate leg. pt diabetic and high risk for PVD, consider noninvasive flow studies. [] repeat TTE in several weeks to eval interval change from prior, define EF, ensure not newly reduced [] monitor for signs of increased volume, start diuretic as necessary [] outpatient Fibroscan and possibly hepatology referral given liver appearance on imaging, high risk for NASH [] on ASA/Plavix upon arrival for DES in ___. Given > ___ year, and placed on warfarin, d/c'd Plavix use. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fenofibrate 145 mg PO DAILY 2. Rosuvastatin Calcium 40 mg PO QPM 3. Losartan Potassium 50 mg PO DAILY 4. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID 5. Clopidogrel 75 mg PO DAILY 6. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 7. Darunavir 800 mg PO DAILY 8. Cobicistat 150 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO TID 2. Cephalexin 500 mg PO Q6H Duration: 4 Days 3. Enoxaparin Sodium 120 mg SC BID 4. Warfarin 10 mg PO DAILY16 5. Glargine 60 Units Breakfast 6. Aspirin 81 mg PO DAILY 7. Cobicistat 150 mg PO DAILY 8. Darunavir 800 mg PO DAILY 9. Fenofibrate 145 mg PO DAILY 10. Losartan Potassium 50 mg PO DAILY 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 13. Rosuvastatin Calcium 40 mg PO QPM 14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID 15.Outpatient Lab Work Please obtain an INR ___ ICD-9 Code: ___ Contact: ___ Phone: ___ Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Pulmonary Embolism Right Lower Extremity Deep Vein Thrombosis Atrial Fibrillation with rapid ventricular response Acute on Chronic Heart Failure with preserved ejection fraction SECONDARY DIAGNOSIS =================== Coronary Artery Disease HIV Diabetes Mellitus II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___! WHY WERE YOU ADMITTED ===================== You were admitted after we found blood clots in your lungs and legs. You were also in an abnormal heart rhythm. WHAT DID WE DO FOR YOU HERE =========================== We started you on blood thinners for the clots. We then shocked your heart back into a normal rhythm. WHAT DO YOU NEED TO DO WHEN YOU LEAVE ===================================== - It is really important that you take your blood thinner (warfarin) as prescribed. You need to have regular blood checks to make sure the blood thinner is at a good level (INR between 2 and 3). - You need to see a cardiologist (heart doctor) after you leave the hospital. - You were discharged on an event monitor that will record your heart rhythm if it is triggered. If you feel palpitations, trigger the monitor so your cardiologist can see if your heart goes back into an abnormal rhythm. - Please weigh yourself every morning. If your weight increases by more than 3lbs in one day or 5 lbs in one week, please call your cardiologist to consider adding a medicine that will keep the extra fluid out of your body. We wish you the best of health, Your ___ Care Team Followup Instructions: ___
[ "I2699", "I5033", "I82441", "E872", "I4892", "L03115", "I2510", "Z955", "Z21", "E6601", "I4891", "G4733", "Z96652", "E8881", "Z8546", "N183", "E785", "J45909", "E1121" ]
Allergies: Erythromycin Base / Biaxin / Ciprofloxacin Chief Complaint: PE Major Surgical or Invasive Procedure: TEE/DCCV [MASKED] History of Present Illness: [MASKED] y/o male with hx of HIV on HAART therapy, prostate cancer s/p brachytherapy, T2IDDM, HTN, HLD, obesity, CKD, presents w tachycardia and dyspnea on exertion. Patient went to PCP today for bilateral lower ext edema but was found to have a a heart rate of 130s so sent here. He states that for the past few weeks he has had progressive dyspnea with exertion and b/l swelling. No history of blood clot. No chest pain. no fevers. no abdominal pain, n/v, cough or congestion. has had increased erythema over the left lower ext medial mal with pain progressively worsening. In the ED, initial vitals were: HR 132 BP 152/88 RR 18 O2 95 - Exam notable for: RLE swelling, erythema over bilat malls abrasions over the anterior shin. full ROM of all joint. - Labs notable for: 134 100 40 AGap=11 ------------<295 9.1 23 1.5 Repeat whole K: 4.5 proBNP: 843 Trop-T: 0.04 Lactate:3.1-->3.5 - Imaging was notable for: CTA 1. Pulmonary emboli extending from the distal right main pulmonary artery to segmental level in right upper and middle lobes and subsegmental level in right lower lobe. No left-sided pulmonary emboli. Difficult to exclude right heart strain. Echocardiogram would further assess. 2. No focal consolidation. 3. Mild nodular contour of the liver raise concern for cirrhosis. Correlation with liver function test is recommended for further evaluation. 4. Status post splenectomy. [MASKED] on right There is non-occlusive deep vein thrombus of a right posterior tibial vein. - Patient was given: [MASKED] [MASKED] 13:41 IV Piperacillin-Tazobactam [MASKED] 13:41 IVF NS [MASKED] 14:52 IV Vancomycin 1500mg [MASKED] 17:33 IV Heparin 6500 UNIT [MASKED] [MASKED] 18:41 IVF NS [MASKED] Started Upon arrival to the ICU, patient reports feeling fine without sx. Review of systems was negative except as detailed above. Past Medical History: PMHx/PSHx: 1. HIV (VL [MASKED], CD4 490 in [MASKED] on antiretroviral therapy 2. Prior hepatitis B. 3. Status post septic shock requiring Xigris with Strep viridans bacteremia. 4. Acute kidney injury and CVVH in the setting of severe sepsis. 5. Chronic kidney disease, stage III. 6. History of splenic abscess status post splenectomy in [MASKED] secondary to salmonella abscess. 7. Type 2 diabetes mellitus on insulin 8. Morbid obesity. 9. Hyperlipidemia. 10. Asthma. 11. Right medial meniscus tear. 12. History of severe bronchitis. 13. History of MRSA colonization. Social History: [MASKED] Family History: nc Physical Exam: ADMISSION EXAM: =============== GENERAL: well-appearing sitting in bed with no distress HEENT: NCAT CARDIAC: RRR, no mgr. PULMONARY: Lungs clear to auscultation b/l. No wheezing. CHEST: no tenderness to palpation ABDOMEN: soft and non-distended. Non-tender to palpation. EXTREMITIES: RLE swelling, erythema over bilat malleoli w abrasions over the anterior shin. full ROM of all joints. SKIN: Abrasions over the anterior shin. NEURO: A&Ox3. Motor and sensory exam grossly normal. DISCHARGE EXAM: =============== GENERAL: Well appearing male in no acute distress. Comfortable. HEENT: NCAT. EOMI. MMM. CARDIAC: Rapid rate, regular rhythm. Distant heart sounds. No appreciable murmurs. PULMONARY: Clear to auscultation bilaterally. Breathing comfortably on nasal cannula. ABDOMEN: Soft, non-tender, non-distended. No hepatosplenomegaly. EXTREMITIES: Warm, well perfused, 1+ [MASKED] on R>L. Right leg with multiple healing ulcers. Diffuse erythema around right ankle, tender, warm, no clear border between erythema and normal skin. NEURO: AAOx3. CNII-XII grossly intact. Moving all four extremities with purpose. Pertinent Results: ADMISSION LABS: =============== [MASKED] 01:32PM BLOOD WBC-11.8* RBC-4.78 Hgb-15.8 Hct-47.6 MCV-100* MCH-33.1* MCHC-33.2 RDW-15.3 RDWSD-56.4* Plt [MASKED] [MASKED] 01:32PM BLOOD Neuts-78.8* Lymphs-11.6* Monos-7.4 Eos-0.1* Baso-0.2 NRBC-0.2* Im [MASKED] AbsNeut-9.27* AbsLymp-1.37 AbsMono-0.87* AbsEos-0.01* AbsBaso-0.02 [MASKED] 01:32PM BLOOD [MASKED] PTT-22.6* [MASKED] [MASKED] 01:32PM BLOOD Plt [MASKED] [MASKED] 01:32PM BLOOD Glucose-295* UreaN-40* Creat-1.5* Na-134* K-9.1* Cl-100 HCO3-23 AnGap-11 [MASKED] 01:32PM BLOOD ALT-<5 AST-168* AlkPhos-41 TotBili-0.5 [MASKED] 01:32PM BLOOD proBNP-843* [MASKED] 01:32PM BLOOD cTropnT-0.04* [MASKED] 01:32PM BLOOD Albumin-3.4* Calcium-9.4 Phos-4.1 Mg-2.1 [MASKED] 04:58AM BLOOD PSA-<0.03 [MASKED] 11:13PM BLOOD [MASKED] Temp-36.8 pO2-60* pCO2-39 pH-7.43 calTCO2-27 Base XS-1 Intubat-NOT INTUBA [MASKED] 01:51PM BLOOD Lactate-3.1* [MASKED] 03:00PM BLOOD LMWH-1.01 DISCHARGE LABS: =============== [MASKED] 06:51AM BLOOD WBC-10.1* RBC-4.32* Hgb-14.2 Hct-44.2 MCV-102* MCH-32.9* MCHC-32.1 RDW-15.6* RDWSD-59.1* Plt [MASKED] [MASKED] 06:51AM BLOOD Glucose-151* UreaN-42* Creat-1.2 Na-147 K-4.9 Cl-107 HCO3-25 AnGap-15 [MASKED] 04:58AM BLOOD AST-20 AlkPhos-53 TotBili-0.4 [MASKED] 06:51AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.3 PERTINENT STUDIES: ================== TEE [MASKED] 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. The interatrial septum is dynamic, but not frankly aneurysmal. There is no evidence for an atrial septal defect by 2D/color Doppler though evaluation was limited by tachycardia and limited images obtained. Overall left ventricular systolic function is at least mildly depressed with beat-to-beat variability in the left ventricular contractility due to the irregular rhythm. The right ventricle has moderate global free wall hypokinesis. There are simple atheroma in the descending aorta to from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No abscess is seen. There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is mild to moderate [[MASKED]] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is tricuspid regurgitation present (could not be qualified). IMPRESSION: No vegetations or intracardiac thrombus seen. Mild global biventricular systolic dysfunction. Mild to moderate mitral regurgitation. CTA Chest [MASKED] IMPRESSION: 1. Pulmonary emboli extending from the distal right main pulmonary artery to segmental level in right upper and middle lobes and subsegmental level in right lower lobe. No left-sided pulmonary emboli. Difficult to exclude right heart strain. Echocardiogram would further assess. 2. No focal consolidation. 3. Mild nodular contour of the liver raise concern for cirrhosis. Correlation with liver function test is recommended for further evaluation. 4. Status post splenectomy. U/S of [MASKED] [MASKED] IMPRESSION: Non-occlusive deep vein thrombus of one right posterior tibial vein. Brief Hospital Course: [MASKED] man with history of CAD s/p DES to LAD ([MASKED]), HIV on HAART, HTN, HLD, diabetes, prostate cancer s/p brachytherapy, CKD, salmonella splenic abscess s/p splenectomy ([MASKED]), and prior hepatitis B infection admitted w/ submassive PE and AF w/ RVR. ACUTE ISSUES ============ # SUBMASSIVE PULMONARY EMBOLISM # RIGHT LOWER EXTREMITY DVT Notable for TTE with evidence of right heart strain as well as mild troponin elevation. Never hypotensive, initiated on heparin gtt upon arrival, quickly weaned to RA. Appears unprovoked at this time: no signs of active malignancy, immobilization (although obese, not active), operations, or family history. Transitioned to warfarin, discharged on [MASKED] bridge. # ATRIAL FIBRILLATION W/ RVR No prior records of Afib. Likely provoked [MASKED] PE. Had rates difficult to control despite escalating doses of metoprolol and initiation of PO amiodarone. Hence, he had TEE and DCCV [MASKED], successful, remained in sinus at time of discharge. Anticoagulation as above. Restarted on home dose metop succinate 25mg daily after DCCV, continued on PO amiodarone. # Acute on Chronic HFpEF: TTE this admission w/ poor image quality, noted depressed systolic function but could not determine EF. If EF was decreased, likely rate related I/s/o Afib w/ RVR. Mildly volume overloaded on exam initially, responded well to low dose IV diuresis, did not require PO diuretic at time of discharge. # RLE Cellulitis: noted upon arrival, nonpurulent, started on cephalexin for ORONARY ARTERY DISEASE s/p DES to LAD ([MASKED]). Mild troponin elevation likely reflective of right heart strain from acute PE. Chest pain free. Continued ASA, statin, [MASKED], and BB as above. D/c'd Plavix given initiation of AC, and > [MASKED] year since stent placement. # RADIOGRAPHIC LIVER ABNORMALITY Mild nodular contour of the liver raises concern for cirrhosis. Consider. outpatient Fibroscan and possibly hepatology referral. CORE MEASURES: ================================= # HIV Most recent VL undetectable. CD4 of 500. Continued home HAART regimen (Darunavir 800 mg PO QHS, Cobicistat 150 mg PO QHS, Odefsey 200-25-25 mg oral QHS) # HYPERLIPIDEMIA: Fenofibrate 145 mg PO DAILY in addition to statin (both home meds) # DIABETES: held PO meds, placed on insulin sliding scale. TRANSITIONAL ISSUES =================== [] given unprovoked PE, ensure age appropriate malignancy screening has been done. if unremarkable, consider hypercoagulability w/u. [] currently on lovenox bridge until warfarin therapeutic. Increased warfarin dose to 10mg daily on day of discharge. Will need close monitoring and titration of warfarin dose, d/c lovenox when INR > 2. [] [MASKED] of Hearts monitor at time of discharge [] PO amiodarone started I/s/o difficult to control AF w/ RVR. Please re-evaluate its need moving forward. [] cephalexin for RLE cellulitis for 7 day course. Please re-evaluate leg. pt diabetic and high risk for PVD, consider noninvasive flow studies. [] repeat TTE in several weeks to eval interval change from prior, define EF, ensure not newly reduced [] monitor for signs of increased volume, start diuretic as necessary [] outpatient Fibroscan and possibly hepatology referral given liver appearance on imaging, high risk for NASH [] on ASA/Plavix upon arrival for DES in [MASKED]. Given > [MASKED] year, and placed on warfarin, d/c'd Plavix use. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fenofibrate 145 mg PO DAILY 2. Rosuvastatin Calcium 40 mg PO QPM 3. Losartan Potassium 50 mg PO DAILY 4. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID 5. Clopidogrel 75 mg PO DAILY 6. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 7. Darunavir 800 mg PO DAILY 8. Cobicistat 150 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO TID 2. Cephalexin 500 mg PO Q6H Duration: 4 Days 3. Enoxaparin Sodium 120 mg SC BID 4. Warfarin 10 mg PO DAILY16 5. Glargine 60 Units Breakfast 6. Aspirin 81 mg PO DAILY 7. Cobicistat 150 mg PO DAILY 8. Darunavir 800 mg PO DAILY 9. Fenofibrate 145 mg PO DAILY 10. Losartan Potassium 50 mg PO DAILY 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Odefsey (emtricitab-rilpivir-tenofo ala) 200-25-25 mg oral DAILY 13. Rosuvastatin Calcium 40 mg PO QPM 14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID 15.Outpatient Lab Work Please obtain an INR [MASKED] ICD-9 Code: [MASKED] Contact: [MASKED] Phone: [MASKED] Fax: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Pulmonary Embolism Right Lower Extremity Deep Vein Thrombosis Atrial Fibrillation with rapid ventricular response Acute on Chronic Heart Failure with preserved ejection fraction SECONDARY DIAGNOSIS =================== Coronary Artery Disease HIV Diabetes Mellitus II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED]! WHY WERE YOU ADMITTED ===================== You were admitted after we found blood clots in your lungs and legs. You were also in an abnormal heart rhythm. WHAT DID WE DO FOR YOU HERE =========================== We started you on blood thinners for the clots. We then shocked your heart back into a normal rhythm. WHAT DO YOU NEED TO DO WHEN YOU LEAVE ===================================== - It is really important that you take your blood thinner (warfarin) as prescribed. You need to have regular blood checks to make sure the blood thinner is at a good level (INR between 2 and 3). - You need to see a cardiologist (heart doctor) after you leave the hospital. - You were discharged on an event monitor that will record your heart rhythm if it is triggered. If you feel palpitations, trigger the monitor so your cardiologist can see if your heart goes back into an abnormal rhythm. - Please weigh yourself every morning. If your weight increases by more than 3lbs in one day or 5 lbs in one week, please call your cardiologist to consider adding a medicine that will keep the extra fluid out of your body. We wish you the best of health, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "E872", "I2510", "Z955", "I4891", "G4733", "E785", "J45909" ]
[ "I2699: Other pulmonary embolism without acute cor pulmonale", "I5033: Acute on chronic diastolic (congestive) heart failure", "I82441: Acute embolism and thrombosis of right tibial vein", "E872: Acidosis", "I4892: Unspecified atrial flutter", "L03115: Cellulitis of right lower limb", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z21: Asymptomatic human immunodeficiency virus [HIV] infection status", "E6601: Morbid (severe) obesity due to excess calories", "I4891: Unspecified atrial fibrillation", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z96652: Presence of left artificial knee joint", "E8881: Metabolic syndrome", "Z8546: Personal history of malignant neoplasm of prostate", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "E1121: Type 2 diabetes mellitus with diabetic nephropathy" ]
10,036,821
20,948,493
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Percocet / Ativan / latex Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o Hodgkin disease (Dx ___, s/p ABVD x6), newly diagnosed gastric cancer (cT3N2M0 Stage III, Her-2 neg) currently C1D7 ___ chemotherapy. He was referred in from home today due to acute onset of severe abdominal pain starting this morning sometime before lunch. States he ate breakfast and had a bowel movement without any difficulty then pain later came on spontaneously. He describes it as generalized abdominal pain and "muscle cramping ". Currently ___ however was more severe when he initially presented to ED and he received total of 1.5 mg Dilaudid with some relief but notes that when it wears off the pain does return. Denies any bony or joint pain. Denies nausea, vomiting, diarrhea. He was taking Zofran regularly after his chemo cycle and did have some mild constipation but does not feel this is the cause of his current pain. Has not had any difficulty eating or drinking and does still have appetite. In the ED he also underwent abdominal CT which did not show any acute pathology. REVIEW OF SYSTEMS: No fevers, night sweats, or weight loss. Appetite is good. No chest pain, shortness of breath, or cough. No abdominal pain, nausea/vomiting, or diarrhea. No urinary symptoms. No headaches, vision changes, or focal numbness/weakness. No bone or back pain. A comprehensive 14-point review of systems was otherwise negative. Past Medical History: Hodgkin Lymphoma: Mixed cellularity Hodgkin's Disease with mediastinal mass diagnosed ___. PET shows disease limited to chest. No B symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy negative for involvement by HD. ABVD x6. Treated by Dr ___, ___. Gastric Cancer: - ___: presented with reflux symptoms - ___: EGD showed an 8-10 cm mass in the body and fundus of the stomach. - ___: CT Torso showed no distant disease, but there remains a question of the etiology of several omental nodules and non-regional lymph nodes. - ___: EUS staging showed 4 suspicious lymph nodes, T3N2 disease. Gastric biopsy showed signet ring adenocarcinoma, HER-2 negative (IHC 1+). Biopsy of a gastrohepatic lymph node was positive. - ___ - C1D1 ___ ___ + leucovorin, docetaxel, oxaliplatin) + neulasta PMH/PSH: Peripheral neuropathy BPH possible prostate nodule DVT while on chemotherapy, treated with Lovenox for 3 months ? interstitial lung disease following bleomycin treatment chronic lower back pain s/p b/l IHR as a child ___ years old) s/p R knee arthroscopy Social History: ___ Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer Cancers in the family: no others known Physical Exam: ___ 2149 Temp: 98.5 PO BP: 132/79 HR: 78 RR: 18 O2 sat: 95% O2 delivery: RA General appearance: Generally well appearing, comfortable appearing and in no acute distress. Head, eyes, ears, nose, and throat: Pupils round and equally reactive to light. Oropharynx clear with moist mucous membranes. Lymph: No palpable cervical or supraclavicular lymphadenopathy. Cardiovascular: Regular rate and rhythm, S1, S2, no audible murmurs. Respiratory: Lungs clear to auscultation bilaterally. Abdomen: Bowel sounds present, soft, nondistended. No palpable hepatosplenomegaly. Trivial tenderness to deep palpation in the RUQ and RLQ. Extremities: Warm, without edema. Neurologic: Alert and oriented. Grossly normal strength, coordination, and gait. ___ strength in lower extremities. Intact and symmetric fine touch sensation on abdominal wall and in lower extremities. 2+ and symmetric patellar reflexes. Skin: No rashes. Pertinent Results: LABS: ___ 03:42AM BLOOD WBC-9.3 RBC-4.89 Hgb-11.8* Hct-36.5* MCV-75* MCH-24.1* MCHC-32.3 RDW-17.0* RDWSD-45.1 Plt ___ ___ 03:42AM BLOOD Neuts-60 Bands-6* ___ Monos-9 Eos-1 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-6.14* AbsLymp-2.05 AbsMono-0.84* AbsEos-0.09 AbsBaso-0.00* ___ 03:42AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-3+* Polychr-NORMAL ___ 03:42AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-138 K-4.1 Cl-98 HCO3-29 AnGap-11 ___ 03:42AM BLOOD ALT-27 AST-15 AlkPhos-92 TotBili-0.5 ___ 03:42AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7 ___ 04:12PM BLOOD Lactate-1.2 CT ABDOMEN/PELVIS W/ CONTRAST: 1. No pneumoperitoneum. 2. Upper abdominal lymphadenopathy is again seen, with some unchanged in size, some with interval decrease in size, and interval development of central necrosis in 1 lymph node. Haziness of the left omentum is again seen. CXR No evidence of acute thoracic process. No free subdiaphragmatic free air. Brief Hospital Course: ___ w/ Hodgkin disease (Dx ___, s/p ABVD x6), newly diagnosed gastric cancer (T3N2M0 Stage III, Her-2 neg; C1D7 ___ on admission) who was admitted with acute-onset abdominal pain. Exam by surgery and by the admitting and discharging medicine physicians was unremarkable for any abdominal or neurological pathology to explain the symptoms. His CT showed only known pathology. LFTs and lipase also normal. He is far enough out from his chemo that we cannot invoke oxaliplatin toxicity, and he did not have bone pain consistent with a Neulasta side effect. His pain was initially ___ intensity, but subsided over about 12 hours and by the time of discharge he was fairly comfortable, although still intermittently requiring oral opiate analgesics. At discharge his PPI was empirically doubled to twice daily dosing and he was given a seven day supply of oral dilaudid to use as needed. He was instructed to return should his symptoms evolve or worsen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Dexamethasone 4 mg PO Q12H 3. Prochlorperazine 10 mg PO Q6H:PRN nausea 4. Omeprazole 20 mg PO DAILY 5. Tamsulosin 0.4 mg PO DAILY Discharge Medications: 1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*42 Tablet Refills:*0 2. Omeprazole 20 mg PO BID RX *omeprazole 20 mg 1 capsule(s) by mouth BIDAC Disp #*60 Capsule Refills:*0 3. Dexamethasone 4 mg PO Q12H 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Tamsulosin 0.4 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Gastric cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with sudden-onset of severe abdominal pain. We remain unsure what caused this, but your CT scan, labs, and exam were all very reassuring. We are doubling your omeprazole to twice daily in case the pain is from some sort of irritation in the stomach. We are also giving you dilaudid pills that you can take as needed if the pain continues. If the pain keeps coming back in severe episodes, or worsens progressively, please return to the ED for consideration of further workup. With any more minor issues, or if you aren't sure whether you should come in, call the ___ clinic at ___ and ask to speak to one of the nurses. Followup Instructions: ___
[ "R109", "C169", "Z8571", "C772", "G629", "N400", "Z86718", "M545", "G8929", "Z801", "Z8042" ]
Allergies: Percocet / Ativan / latex Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with h/o Hodgkin disease (Dx [MASKED], s/p ABVD x6), newly diagnosed gastric cancer (cT3N2M0 Stage III, Her-2 neg) currently C1D7 [MASKED] chemotherapy. He was referred in from home today due to acute onset of severe abdominal pain starting this morning sometime before lunch. States he ate breakfast and had a bowel movement without any difficulty then pain later came on spontaneously. He describes it as generalized abdominal pain and "muscle cramping ". Currently [MASKED] however was more severe when he initially presented to ED and he received total of 1.5 mg Dilaudid with some relief but notes that when it wears off the pain does return. Denies any bony or joint pain. Denies nausea, vomiting, diarrhea. He was taking Zofran regularly after his chemo cycle and did have some mild constipation but does not feel this is the cause of his current pain. Has not had any difficulty eating or drinking and does still have appetite. In the ED he also underwent abdominal CT which did not show any acute pathology. REVIEW OF SYSTEMS: No fevers, night sweats, or weight loss. Appetite is good. No chest pain, shortness of breath, or cough. No abdominal pain, nausea/vomiting, or diarrhea. No urinary symptoms. No headaches, vision changes, or focal numbness/weakness. No bone or back pain. A comprehensive 14-point review of systems was otherwise negative. Past Medical History: Hodgkin Lymphoma: Mixed cellularity Hodgkin's Disease with mediastinal mass diagnosed [MASKED]. PET shows disease limited to chest. No B symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy negative for involvement by HD. ABVD x6. Treated by Dr [MASKED], [MASKED]. Gastric Cancer: - [MASKED]: presented with reflux symptoms - [MASKED]: EGD showed an 8-10 cm mass in the body and fundus of the stomach. - [MASKED]: CT Torso showed no distant disease, but there remains a question of the etiology of several omental nodules and non-regional lymph nodes. - [MASKED]: EUS staging showed 4 suspicious lymph nodes, T3N2 disease. Gastric biopsy showed signet ring adenocarcinoma, HER-2 negative (IHC 1+). Biopsy of a gastrohepatic lymph node was positive. - [MASKED] - C1D1 [MASKED] [MASKED] + leucovorin, docetaxel, oxaliplatin) + neulasta PMH/PSH: Peripheral neuropathy BPH possible prostate nodule DVT while on chemotherapy, treated with Lovenox for 3 months ? interstitial lung disease following bleomycin treatment chronic lower back pain s/p b/l IHR as a child [MASKED] years old) s/p R knee arthroscopy Social History: [MASKED] Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer Cancers in the family: no others known Physical Exam: [MASKED] 2149 Temp: 98.5 PO BP: 132/79 HR: 78 RR: 18 O2 sat: 95% O2 delivery: RA General appearance: Generally well appearing, comfortable appearing and in no acute distress. Head, eyes, ears, nose, and throat: Pupils round and equally reactive to light. Oropharynx clear with moist mucous membranes. Lymph: No palpable cervical or supraclavicular lymphadenopathy. Cardiovascular: Regular rate and rhythm, S1, S2, no audible murmurs. Respiratory: Lungs clear to auscultation bilaterally. Abdomen: Bowel sounds present, soft, nondistended. No palpable hepatosplenomegaly. Trivial tenderness to deep palpation in the RUQ and RLQ. Extremities: Warm, without edema. Neurologic: Alert and oriented. Grossly normal strength, coordination, and gait. [MASKED] strength in lower extremities. Intact and symmetric fine touch sensation on abdominal wall and in lower extremities. 2+ and symmetric patellar reflexes. Skin: No rashes. Pertinent Results: LABS: [MASKED] 03:42AM BLOOD WBC-9.3 RBC-4.89 Hgb-11.8* Hct-36.5* MCV-75* MCH-24.1* MCHC-32.3 RDW-17.0* RDWSD-45.1 Plt [MASKED] [MASKED] 03:42AM BLOOD Neuts-60 Bands-6* [MASKED] Monos-9 Eos-1 Baso-0 [MASKED] Metas-2* Myelos-0 AbsNeut-6.14* AbsLymp-2.05 AbsMono-0.84* AbsEos-0.09 AbsBaso-0.00* [MASKED] 03:42AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-3+* Polychr-NORMAL [MASKED] 03:42AM BLOOD Glucose-81 UreaN-13 Creat-0.9 Na-138 K-4.1 Cl-98 HCO3-29 AnGap-11 [MASKED] 03:42AM BLOOD ALT-27 AST-15 AlkPhos-92 TotBili-0.5 [MASKED] 03:42AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7 [MASKED] 04:12PM BLOOD Lactate-1.2 CT ABDOMEN/PELVIS W/ CONTRAST: 1. No pneumoperitoneum. 2. Upper abdominal lymphadenopathy is again seen, with some unchanged in size, some with interval decrease in size, and interval development of central necrosis in 1 lymph node. Haziness of the left omentum is again seen. CXR No evidence of acute thoracic process. No free subdiaphragmatic free air. Brief Hospital Course: [MASKED] w/ Hodgkin disease (Dx [MASKED], s/p ABVD x6), newly diagnosed gastric cancer (T3N2M0 Stage III, Her-2 neg; C1D7 [MASKED] on admission) who was admitted with acute-onset abdominal pain. Exam by surgery and by the admitting and discharging medicine physicians was unremarkable for any abdominal or neurological pathology to explain the symptoms. His CT showed only known pathology. LFTs and lipase also normal. He is far enough out from his chemo that we cannot invoke oxaliplatin toxicity, and he did not have bone pain consistent with a Neulasta side effect. His pain was initially [MASKED] intensity, but subsided over about 12 hours and by the time of discharge he was fairly comfortable, although still intermittently requiring oral opiate analgesics. At discharge his PPI was empirically doubled to twice daily dosing and he was given a seven day supply of oral dilaudid to use as needed. He was instructed to return should his symptoms evolve or worsen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Dexamethasone 4 mg PO Q12H 3. Prochlorperazine 10 mg PO Q6H:PRN nausea 4. Omeprazole 20 mg PO DAILY 5. Tamsulosin 0.4 mg PO DAILY Discharge Medications: 1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*42 Tablet Refills:*0 2. Omeprazole 20 mg PO BID RX *omeprazole 20 mg 1 capsule(s) by mouth BIDAC Disp #*60 Capsule Refills:*0 3. Dexamethasone 4 mg PO Q12H 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Tamsulosin 0.4 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Gastric cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with sudden-onset of severe abdominal pain. We remain unsure what caused this, but your CT scan, labs, and exam were all very reassuring. We are doubling your omeprazole to twice daily in case the pain is from some sort of irritation in the stomach. We are also giving you dilaudid pills that you can take as needed if the pain continues. If the pain keeps coming back in severe episodes, or worsens progressively, please return to the ED for consideration of further workup. With any more minor issues, or if you aren't sure whether you should come in, call the [MASKED] clinic at [MASKED] and ask to speak to one of the nurses. Followup Instructions: [MASKED]
[]
[ "N400", "Z86718", "G8929" ]
[ "R109: Unspecified abdominal pain", "C169: Malignant neoplasm of stomach, unspecified", "Z8571: Personal history of Hodgkin lymphoma", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "G629: Polyneuropathy, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z86718: Personal history of other venous thrombosis and embolism", "M545: Low back pain", "G8929: Other chronic pain", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "Z8042: Family history of malignant neoplasm of prostate" ]
10,036,821
26,036,824
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Percocet / Ativan / latex Attending: ___. Chief Complaint: gastric cancer Major Surgical or Invasive Procedure: robotic gastrectomy with esopho-jejunostomy History of Present Illness: ___ with Hx Hodgkins disease s/p ABVD x 6 and interstitial lung disease, presenting for surgical follow-up s/p neoadjuvant therapy for gastric cancer. He has cT3N2M0 gastric cancer, signet ring type, Her2 neg, of the body and fundus of the stomach (proximal extent 1 cm from GEJ.) He completed 4 cycles of neoadjuvant ___ therapy last week. There are no plans for radiation. His oncologist is Dr. ___. His last CT scan in ___ showed improvement in the gastrohepatic nodes and no sign of metastasis. He has overall done very well except for peripheral neuropathy of his fingers and toes as well as occasional dizziness. He is eating more now (taste of food is improving) without nausea or vomiting. Diarrhea is improving. He weighed 184 lbs before chemo and now weighs 174 lbs. Past Medical History: Hodgkin Lymphoma: Mixed cellularity Hodgkin's Disease with mediastinal mass diagnosed ___. PET shows disease limited to chest. No B symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy negative for involvement by HD. ABVD x6. Treated by Dr ___, ___. Gastric Cancer: - ___: presented with reflux symptoms - ___: EGD showed an 8-10 cm mass in the body and fundus of the stomach. - ___: CT Torso showed no distant disease, but there remains a question of the etiology of several omental nodules and non-regional lymph nodes. - ___: EUS staging showed 4 suspicious lymph nodes, T3N2 disease. Gastric biopsy showed signet ring adenocarcinoma, HER-2 negative (IHC 1+). Biopsy of a gastrohepatic lymph node was positive. - ___ - C1D1 ___ ___ + leucovorin, docetaxel, oxaliplatin) + neulasta PMH/PSH: Peripheral neuropathy BPH possible prostate nodule DVT while on chemotherapy, treated with Lovenox for 3 months ? interstitial lung disease following bleomycin treatment chronic lower back pain s/p b/l IHR as a child ___ years old) s/p R knee arthroscopy Social History: ___ Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer Cancers in the family: no others known Physical Exam: Preop: GEN: NAD HEENT: NCAT, EOMI, anicteric CV: RRR, no murmurs PULM: clear, no respiratory distress BACK: no vertebral tenderness, no CVAT ABD: soft, NT, ND, no mass, no hernia; well-healed laparoscopic scars, old scars from stab wounds also well-healed EXT: warm, no edema, +numbness at tips of fingers and toes, +nail changes, no tenderness, 2+ B/L ___ NEURO: A&Ox3, no focal neurologic deficits Post op: GEN: Well appearing, no acute distress HEENT: NCAT, EOMI, sclera anicteric CV: HDS PULM: No signs of respiratory distress. ABD: soft, non-distended, nontender, J tube sutured in place without erythema or leaking. Drain in place with minimal yellow/ purulent output EXT: Warm, well-perfused NEURO: A&Ox3, no focal neurologic deficits Pertinent Results: ___ 04:16AM BLOOD WBC-5.3 RBC-3.38* Hgb-8.0* Hct-25.2* MCV-75* MCH-23.7* MCHC-31.7* RDW-20.5* RDWSD-54.6* Plt ___ ___ 07:39AM BLOOD Neuts-80.4* Lymphs-13.9* Monos-4.6* Eos-0.4* Baso-0.1 Im ___ AbsNeut-7.30* AbsLymp-1.26 AbsMono-0.42 AbsEos-0.04 AbsBaso-0.01 ___ 04:16AM BLOOD Plt ___ ___ 04:16AM BLOOD Glucose-101* UreaN-7 Creat-0.8 Na-139 K-4.7 Cl-104 HCO3-26 AnGap-9* ___ 04:16AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.2 ___ 04:02AM BLOOD calTIBC-163* VitB12-984* Ferritn-687* TRF-125* Brief Hospital Course: Mr. ___ was admitted to the hospital on ___ after robotic total gastrectomy with esopho-jejunostomy with j tube palcement. This procedure was down without complication and he tolerated it well. He was transferred from the pacu to the floor with an NJ tube in place and a PCA for pain control. He was initially NPO with NJ left in place until post op day 4 when a UGI swallow study was done which confirmed that there was no leak at the anastomosis. He was then slowly progressed to a soft mechanical diet which he tolerated for a short period of time before developing intolerance to solid foods due to epigastric pain. This intolerance coincided with a change in his surgical drain at the anastomosis which became more purulent. This led to a CT scan which showed a fluid collection at the EJ anastomosis, which was being drained by the ___ drain. He was started on IV cipro/ flagyl and his J tube was utilized for tube feeds which he tolerated well. His progression was slowed by his J tube becoming clogged and he was without nutrition for a short time while he awaited replacement. He had an interval scan on ___ which showed a small persistent fluid collection wo his drian was left in place despite minimal output, and he was transitioned to PO cipro flagyl which he will take until ___. Despite this resolving fluid collection he still had significant pain with solid foods so was kept on liquid. During this admission he also developed a episode of severe right knee pain which was tapped by both rheumatology and orthopedics and found to be pseudogout. This resolved with itra-articular steroid injections successfully. Throughout his prolonged stay he was seen by ___ who recommended disposition to a rehab given his deconditioning. During this hospitalization, the he 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 during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating his home tube feeds at a goal rate of 70cc, as well as diet liquids per oral, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged to acute rehab per pT recs. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. 1 capsule(s) by mouth twice a day RANITIDINE HCL - ranitidine 150 mg capsule. 1 capsule(s) by mouth twice a day TAMSULOSIN [FLOMAX] - Flomax 0.4 mg capsule. 1 capsule(s) by mouth am daily - (Prescribed by Other Provider) Discharge Medications: Active Medications ___ Enoxaparin Sodium 80 mg SC Q 12 hrs LOPERamide 2 mg PO/NG Q12H:PRN loose stool Ciprofloxacin HCl 500 mg PO/NG Q12H Multivitamins W/minerals Chewable 1 TAB PO/NG DAILY MetroNIDAZOLE 500 mg PO/NG TID OxyCODONE (Immediate Release) ___ mg PO/NG Q4H:PRN Pain Simethicone 40-80 mg PO/NG QID:PRN GAS PAIN Tamsulosin 0.8 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: gastric cancer s/p gastrectomy Malnutrition Abdominal abscess Deep Venous Thrombosis Discharge Condition: good Discharge Instructions: Please call your surgeon or return to the Emergency Department if you develop a fever greater than ___ F, shaking chills, chest pain, difficulty breathing, pain with breathing, cough, a rapid heartbeat, dizziness, severe abdominal pain, pain unrelieved by your pain medication, a change in the nature or severity of your pain, severe nausea, vomiting, abdominal bloating, severe diarrhea, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness, swelling from your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment; please refer to your work book for detailed instructions. Do not self- advance your diet and avoid drinking with a straw or chewing gum. To avoid dehydration, remember to sip small amounts of fluid frequently throughout the day to reach a goal of approximately ___ mL per day. Please note the following signs of dehydration: dry mouth, rapid heartbeat, feeling dizzy or faint, dark colored urine, infrequent urination. Medication Instructions: Please refer to the medication list provided with your discharge paperwork for detailed instruction regarding your home and newly prescribed medications. Some of the new medications you will be taking include: 1. Pain medication: You will receive a prescription for liquid oxycodone, an opioid pain medication. This medication will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. You may also take acetaminophen (Tylenol) for pain management; do not exceed 4000 mg per 24 hour period. 2. Constipation: This is a common side effect of opioid pain medication. If you experience constipation, please reduce or eliminate opioid pain medication. You may trial 2 ounces of light prune juice and/or a stool softener (i.e. crushed docusate sodium tablets), twice daily until you resume a normal bowel pattern. Please stop taking this medication if you develop loose stools. Please do not begin taking laxatives including until you have discussed it with your nurse or surgeon. 3. Antacids: You will be taking famotidine tablets, 20 mg twice daily, for one month. This medicine reduces stomach acid production. Please crush. 4. You must not use NSAIDS (non-steroidal anti-inflammatory drugs). Examples include, but are not limited to Aleve, Arthrotec, aspirin, Bufferin, diclofenac, Ecotrin, etodolac, ibuprofen, Indocin, indomethacin, Feldene, ketorolac, meclofenamate, meloxicam, Midol, Motrin, nambumetone, Naprosyn, Naproxen, Nuprin, oxaprozin, Piroxicam, Relafen, Toradol and Voltaren. These agents may cause bleeding and ulcers in your digestive system. If you are unclear whether a medication is considered an NSAID, please ask call your nurse or ask your pharmacist. 5. Vitamins/ minerals: You may resume a chewable multivitamin, however, please discuss when to resume additional vitamin and mineral supplements with your bariatric dietitian. Activity: You should continue walking frequently throughout the day right after surgery; you may climb stairs. You may resume moderate exercise at your discretion, but avoid performing abdominal exercises or lifting items greater than10 to 15 pounds for six weeks. Wound Care: You may remove any remaining gauze from over your incisions. You will have thin paper strips (Steri-Strips) over your incision; please, remove any remaining Steri-Strip seven to 10 days after surgery. You may shower 48 hours following your surgery; avoid scrubbing your incisions and gently pat them dry. Avoid tub baths or swimming until cleared by your surgeon. If there is clear drainage from your incisions, cover with clean, dry gauze. Please call the doctor if you have increased pain, swelling, redness, cloudy, bloody or foul smelling drainage from the incision sites. Avoid direct sun exposure to the incision area for up to 24 months. Do not use any ointments on the incision unless you were told otherwise. Followup Instructions: ___
[ "C162", "E46", "L02211", "K9413", "I824Z2", "C161", "G629", "N400", "G8929", "M545", "M11261", "R1013", "R1031", "Z8571", "Z86718" ]
Allergies: Percocet / Ativan / latex Chief Complaint: gastric cancer Major Surgical or Invasive Procedure: robotic gastrectomy with esopho-jejunostomy History of Present Illness: [MASKED] with Hx Hodgkins disease s/p ABVD x 6 and interstitial lung disease, presenting for surgical follow-up s/p neoadjuvant therapy for gastric cancer. He has cT3N2M0 gastric cancer, signet ring type, Her2 neg, of the body and fundus of the stomach (proximal extent 1 cm from GEJ.) He completed 4 cycles of neoadjuvant [MASKED] therapy last week. There are no plans for radiation. His oncologist is Dr. [MASKED]. His last CT scan in [MASKED] showed improvement in the gastrohepatic nodes and no sign of metastasis. He has overall done very well except for peripheral neuropathy of his fingers and toes as well as occasional dizziness. He is eating more now (taste of food is improving) without nausea or vomiting. Diarrhea is improving. He weighed 184 lbs before chemo and now weighs 174 lbs. Past Medical History: Hodgkin Lymphoma: Mixed cellularity Hodgkin's Disease with mediastinal mass diagnosed [MASKED]. PET shows disease limited to chest. No B symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy negative for involvement by HD. ABVD x6. Treated by Dr [MASKED], [MASKED]. Gastric Cancer: - [MASKED]: presented with reflux symptoms - [MASKED]: EGD showed an 8-10 cm mass in the body and fundus of the stomach. - [MASKED]: CT Torso showed no distant disease, but there remains a question of the etiology of several omental nodules and non-regional lymph nodes. - [MASKED]: EUS staging showed 4 suspicious lymph nodes, T3N2 disease. Gastric biopsy showed signet ring adenocarcinoma, HER-2 negative (IHC 1+). Biopsy of a gastrohepatic lymph node was positive. - [MASKED] - C1D1 [MASKED] [MASKED] + leucovorin, docetaxel, oxaliplatin) + neulasta PMH/PSH: Peripheral neuropathy BPH possible prostate nodule DVT while on chemotherapy, treated with Lovenox for 3 months ? interstitial lung disease following bleomycin treatment chronic lower back pain s/p b/l IHR as a child [MASKED] years old) s/p R knee arthroscopy Social History: [MASKED] Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer Cancers in the family: no others known Physical Exam: Preop: GEN: NAD HEENT: NCAT, EOMI, anicteric CV: RRR, no murmurs PULM: clear, no respiratory distress BACK: no vertebral tenderness, no CVAT ABD: soft, NT, ND, no mass, no hernia; well-healed laparoscopic scars, old scars from stab wounds also well-healed EXT: warm, no edema, +numbness at tips of fingers and toes, +nail changes, no tenderness, 2+ B/L [MASKED] NEURO: A&Ox3, no focal neurologic deficits Post op: GEN: Well appearing, no acute distress HEENT: NCAT, EOMI, sclera anicteric CV: HDS PULM: No signs of respiratory distress. ABD: soft, non-distended, nontender, J tube sutured in place without erythema or leaking. Drain in place with minimal yellow/ purulent output EXT: Warm, well-perfused NEURO: A&Ox3, no focal neurologic deficits Pertinent Results: [MASKED] 04:16AM BLOOD WBC-5.3 RBC-3.38* Hgb-8.0* Hct-25.2* MCV-75* MCH-23.7* MCHC-31.7* RDW-20.5* RDWSD-54.6* Plt [MASKED] [MASKED] 07:39AM BLOOD Neuts-80.4* Lymphs-13.9* Monos-4.6* Eos-0.4* Baso-0.1 Im [MASKED] AbsNeut-7.30* AbsLymp-1.26 AbsMono-0.42 AbsEos-0.04 AbsBaso-0.01 [MASKED] 04:16AM BLOOD Plt [MASKED] [MASKED] 04:16AM BLOOD Glucose-101* UreaN-7 Creat-0.8 Na-139 K-4.7 Cl-104 HCO3-26 AnGap-9* [MASKED] 04:16AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.2 [MASKED] 04:02AM BLOOD calTIBC-163* VitB12-984* Ferritn-687* TRF-125* Brief Hospital Course: Mr. [MASKED] was admitted to the hospital on [MASKED] after robotic total gastrectomy with esopho-jejunostomy with j tube palcement. This procedure was down without complication and he tolerated it well. He was transferred from the pacu to the floor with an NJ tube in place and a PCA for pain control. He was initially NPO with NJ left in place until post op day 4 when a UGI swallow study was done which confirmed that there was no leak at the anastomosis. He was then slowly progressed to a soft mechanical diet which he tolerated for a short period of time before developing intolerance to solid foods due to epigastric pain. This intolerance coincided with a change in his surgical drain at the anastomosis which became more purulent. This led to a CT scan which showed a fluid collection at the EJ anastomosis, which was being drained by the [MASKED] drain. He was started on IV cipro/ flagyl and his J tube was utilized for tube feeds which he tolerated well. His progression was slowed by his J tube becoming clogged and he was without nutrition for a short time while he awaited replacement. He had an interval scan on [MASKED] which showed a small persistent fluid collection wo his drian was left in place despite minimal output, and he was transitioned to PO cipro flagyl which he will take until [MASKED]. Despite this resolving fluid collection he still had significant pain with solid foods so was kept on liquid. During this admission he also developed a episode of severe right knee pain which was tapped by both rheumatology and orthopedics and found to be pseudogout. This resolved with itra-articular steroid injections successfully. Throughout his prolonged stay he was seen by [MASKED] who recommended disposition to a rehab given his deconditioning. During this hospitalization, the he 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 during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating his home tube feeds at a goal rate of 70cc, as well as diet liquids per oral, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged to acute rehab per pT recs. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. 1 capsule(s) by mouth twice a day RANITIDINE HCL - ranitidine 150 mg capsule. 1 capsule(s) by mouth twice a day TAMSULOSIN [FLOMAX] - Flomax 0.4 mg capsule. 1 capsule(s) by mouth am daily - (Prescribed by Other Provider) Discharge Medications: Active Medications [MASKED] Enoxaparin Sodium 80 mg SC Q 12 hrs LOPERamide 2 mg PO/NG Q12H:PRN loose stool Ciprofloxacin HCl 500 mg PO/NG Q12H Multivitamins W/minerals Chewable 1 TAB PO/NG DAILY MetroNIDAZOLE 500 mg PO/NG TID OxyCODONE (Immediate Release) [MASKED] mg PO/NG Q4H:PRN Pain Simethicone 40-80 mg PO/NG QID:PRN GAS PAIN Tamsulosin 0.8 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: gastric cancer s/p gastrectomy Malnutrition Abdominal abscess Deep Venous Thrombosis Discharge Condition: good Discharge Instructions: Please call your surgeon or return to the Emergency Department if you develop a fever greater than [MASKED] F, shaking chills, chest pain, difficulty breathing, pain with breathing, cough, a rapid heartbeat, dizziness, severe abdominal pain, pain unrelieved by your pain medication, a change in the nature or severity of your pain, severe nausea, vomiting, abdominal bloating, severe diarrhea, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness, swelling from your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment; please refer to your work book for detailed instructions. Do not self- advance your diet and avoid drinking with a straw or chewing gum. To avoid dehydration, remember to sip small amounts of fluid frequently throughout the day to reach a goal of approximately [MASKED] mL per day. Please note the following signs of dehydration: dry mouth, rapid heartbeat, feeling dizzy or faint, dark colored urine, infrequent urination. Medication Instructions: Please refer to the medication list provided with your discharge paperwork for detailed instruction regarding your home and newly prescribed medications. Some of the new medications you will be taking include: 1. Pain medication: You will receive a prescription for liquid oxycodone, an opioid pain medication. This medication will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. You may also take acetaminophen (Tylenol) for pain management; do not exceed 4000 mg per 24 hour period. 2. Constipation: This is a common side effect of opioid pain medication. If you experience constipation, please reduce or eliminate opioid pain medication. You may trial 2 ounces of light prune juice and/or a stool softener (i.e. crushed docusate sodium tablets), twice daily until you resume a normal bowel pattern. Please stop taking this medication if you develop loose stools. Please do not begin taking laxatives including until you have discussed it with your nurse or surgeon. 3. Antacids: You will be taking famotidine tablets, 20 mg twice daily, for one month. This medicine reduces stomach acid production. Please crush. 4. You must not use NSAIDS (non-steroidal anti-inflammatory drugs). Examples include, but are not limited to Aleve, Arthrotec, aspirin, Bufferin, diclofenac, Ecotrin, etodolac, ibuprofen, Indocin, indomethacin, Feldene, ketorolac, meclofenamate, meloxicam, Midol, Motrin, nambumetone, Naprosyn, Naproxen, Nuprin, oxaprozin, Piroxicam, Relafen, Toradol and Voltaren. These agents may cause bleeding and ulcers in your digestive system. If you are unclear whether a medication is considered an NSAID, please ask call your nurse or ask your pharmacist. 5. Vitamins/ minerals: You may resume a chewable multivitamin, however, please discuss when to resume additional vitamin and mineral supplements with your bariatric dietitian. Activity: You should continue walking frequently throughout the day right after surgery; you may climb stairs. You may resume moderate exercise at your discretion, but avoid performing abdominal exercises or lifting items greater than10 to 15 pounds for six weeks. Wound Care: You may remove any remaining gauze from over your incisions. You will have thin paper strips (Steri-Strips) over your incision; please, remove any remaining Steri-Strip seven to 10 days after surgery. You may shower 48 hours following your surgery; avoid scrubbing your incisions and gently pat them dry. Avoid tub baths or swimming until cleared by your surgeon. If there is clear drainage from your incisions, cover with clean, dry gauze. Please call the doctor if you have increased pain, swelling, redness, cloudy, bloody or foul smelling drainage from the incision sites. Avoid direct sun exposure to the incision area for up to 24 months. Do not use any ointments on the incision unless you were told otherwise. Followup Instructions: [MASKED]
[]
[ "N400", "G8929", "Z86718" ]
[ "C162: Malignant neoplasm of body of stomach", "E46: Unspecified protein-calorie malnutrition", "L02211: Cutaneous abscess of abdominal wall", "K9413: Enterostomy malfunction", "I824Z2: Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity", "C161: Malignant neoplasm of fundus of stomach", "G629: Polyneuropathy, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "G8929: Other chronic pain", "M545: Low back pain", "M11261: Other chondrocalcinosis, right knee", "R1013: Epigastric pain", "R1031: Right lower quadrant pain", "Z8571: Personal history of Hodgkin lymphoma", "Z86718: Personal history of other venous thrombosis and embolism" ]
10,036,821
26,439,594
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Percocet / Ativan / latex Attending: ___. Chief Complaint: Abdominal pain following total gastrectomy with roux-en-y esophagojejunostomy (___). Major Surgical or Invasive Procedure: Underwent drain repositioning with Interventional Radiology on ___. History of Present Illness: ___ history of recurrent DVT on lovenox, Hodgkin's lymphoma s/p chemotherapy, pT3N3aM0 gastric cancer s/p neoadjuvant chemotherapy, robotic total gastrectomy with roux-en-y esophagojejunostomy (___) who presents with abdominal pain after recent discharge on ___. His post-operative course was complicated by left gastrocnemius DVT for which he continues on lovenox as well as an abscess adjacent to the esophagojejunostomy anastomosis, for which his surgical drain remains in place with scant purulent output. He completed a course of oral cipro/flagyl at home as planned on ___. During his hospital stay, he was unable to tolerate solids and was discharged to rehab on fulls with J-tube feed supplementation. He recently underwent repeat UGI on ___ after one episode of dysphagia showing a persistent small leakage at the EJ anastomosis site. He presents today complaining of acute onset of lower abdominal pain starting at 7pm tonight that has since worsened to a ___ in intensity. He describes the pain as sharp and coming in waves. He was discharged home on fulls and JTfeeds, which he has tolerated per his baseline with occasional episodes of dry heaving but no retching. He reports have normal bowel function with last BM and flatus tonight and no constipation or diarrhea. No fevers or chills. Reports persistent, scant purulent drainage from the surgical drain. No dysuria. No prior similar episodes of pain. Past Medical History: Hodgkin Lymphoma: Mixed cellularity Hodgkin's Disease with mediastinal mass diagnosed ___. PET shows disease limited to chest. No B symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy negative for involvement by HD. ABVD x6. Treated by Dr ___, ___. Gastric Cancer: - ___: presented with reflux symptoms - ___: EGD showed an 8-10 cm mass in the body and fundus of the stomach. - ___: CT Torso showed no distant disease, but there remains a question of the etiology of several omental nodules and non-regional lymph nodes. - ___: EUS staging showed 4 suspicious lymph nodes, T3N2 disease. Gastric biopsy showed signet ring adenocarcinoma, HER-2 negative (IHC 1+). Biopsy of a gastrohepatic lymph node was positive. - ___ - C1D1 ___ ___ + leucovorin, docetaxel, oxaliplatin) + neulasta PMH/PSH: Peripheral neuropathy BPH possible prostate nodule DVT while on chemotherapy, treated with Lovenox for 3 months ? interstitial lung disease following bleomycin treatment chronic lower back pain s/p b/l IHR as a child ___ years old) s/p R knee arthroscopy Social History: ___ Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer Cancers in the family: no others known Physical Exam: Admission Physical Exam ======================= Vitals-98.4 68 138/72 16 100% RA General- no acute distress, uncomfortable-appearing HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- RRR Chest- no increased WOB on RA Abdomen- soft, TTP in LLQ >RLQ with voluntary guarding, no rebound, mildly distended. Incisions well-healed without erythema or drainage. Drain x1 with scant purulent output. Jtube site c/d/I. Ext- WWP, no notable edema or TTP, compression stockings in place b/l Discharge Physical Exam ======================= ___ 0004 Temp: 99.1 PO BP: 110/67 R Lying HR: 66 RR: 18 O2 sat: 98% O2 delivery: Ra General- no acute distress HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- Regular rate Chest- no increased WOB on RA Abdomen- soft, no tenderness to palpation, no rebound, minimally distended. Incisions well-healed without erythema or drainage. Drain x1 with scant serous output, bulb holding suction. Jtube site without clinical signs of infection. Ext- WWP Pertinent Results: Lab Results =========== ___ 12:00PM BLOOD WBC-7.1 RBC-3.81* Hgb-8.8* Hct-27.9* MCV-73* MCH-23.1* MCHC-31.5* RDW-19.2* RDWSD-50.8* Plt ___ ___ 05:06AM BLOOD WBC-4.0 RBC-3.88* Hgb-8.9* Hct-28.4* MCV-73* MCH-22.9* MCHC-31.3* RDW-19.7* RDWSD-52.0* Plt ___ ___ 01:55AM BLOOD WBC-5.1 RBC-3.75* Hgb-8.6* Hct-27.5* MCV-73* MCH-22.9* MCHC-31.3* RDW-20.0* RDWSD-52.3* Plt ___ ___ 01:55AM BLOOD Neuts-40.6 ___ Monos-7.4 Eos-3.3 Baso-0.4 Im ___ AbsNeut-2.07 AbsLymp-2.46 AbsMono-0.38 AbsEos-0.17 AbsBaso-0.02 ___ 05:15AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-139 K-4.2 Cl-95* HCO3-33* AnGap-11 ___ 05:06AM BLOOD Glucose-66* UreaN-10 Creat-0.7 Na-138 K-4.5 Cl-97 HCO3-28 AnGap-13 ___ 01:55AM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-137 K-4.4 Cl-99 HCO3-29 AnGap-9* ___ 01:55AM BLOOD ALT-42* AST-30 AlkPhos-95 TotBili-0.3 ___ 01:55AM BLOOD Lipase-38 ___ 05:15AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9 ___ 05:06AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.5* ___ 01:55AM BLOOD Albumin-3.4* Imaging ======= DRAIN CATHETER MANIPULATION ___ IMPRESSION: Successful fluoroscopy guided reposition of surgical drain with tip now adjacent to the esophago-jejunal anastomosis. CT abd/pelvis with IV/oral contrast (___): 1. Evaluation of the upper abdomen is slightly limited by extensive streak artifact from dense contrast opacification of the right colon. Within this limitation, no acute intra-abdominal process. Oral contrast extends at least to the level of the transverse colon without evidence of extraluminal contrast. No bowel obstruction. 2. Interval resolution of previously seen left subdiaphragmatic fluid collection adjacent to the esophageal jejunal anastomosis. 3. Decreased size of now trace left pleural effusion. 4. Marked prostatomegaly. UGI IMPRESSION ___: 1. Small leak at the esophagojejunostomy site tracking along abdominal drain. 2. No overt abnormality of the jejunojejunostomy site. Brief Hospital Course: The patient was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain, in the setting of recent total gastrectomy with roux-en-y esophagojejunostomy (___). He was previously found to have an abscess adjacent to the esophagojejunostomy anastomosis, and within this admission underwent drain repositioning with interventional radiology with placement confirmed by fluoroscopy. Throughout his stay, Mr. ___ remained nutritionally supported with his home tube feeding regimen via his J-tube. Nutrition services followed him within admission, and changed the formulation of his tube feeds, which were better tolerated by the patient, causing less diarrhea. At the time of discharge his diet included full liquids, and tubefeeds of Jevity 1.2. 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 his usual lovenox during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating his home tube feeds, as well as diet as above per oral, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged to rehab per ___ recommendations. 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. Enoxaparin Sodium 80 mg SC Q12H 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 3. Tamsulosin 0.8 mg PO QHS 4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 5. LOPERamide 2 mg PO BID:PRN loose stools 6. Simethicone 80 mg PO QID:PRN bloating/gas 7. Pyridoxine 100 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Multivitamins 1 TAB PO DAILY 3. Pregabalin 50 mg PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Docusate Sodium 100 mg PO BID 6. Simethicone 40-80 mg PO QID:PRN bloating/gas 7. Enoxaparin Sodium 80 mg SC Q12H 8. LOPERamide 2 mg PO BID:PRN loose stools 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Pyridoxine 100 mg PO DAILY 11. Tamsulosin 0.8 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ___ history of recurrent DVT on lovenox, Hodgkin's lymphoma s/p chemotherapy, pT3N3aM0 gastric cancer s/p neoadjuvant therapy, robotic total gastrectomy with roux-en-y esophagojejunostomy (___) with resolving lower abdominal pain, now s/p drain repositioning to address fluid collection adjacent to the esophageal jejunal anastomosis. Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you here at ___ ___. You were admitted to our hospital for abdominal pain following your total gastrectomy with roux-en-y esophagojejunostomy (___). You were previously found to have an abscess adjacent to your esophagojejunostomy anastomosis, and underwent drain repositioning with interventional radiology. The drain is functioning appropriately, and you have recovered and are now ready to be discharged back to rehab. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. YOUR BOWELS: - Constipation is a common side effect of medicine such as Percocet or codeine. Diarrhea is a common side effect of tube feeds. You were seen by nutrition at ___, and nutritionists at your rehabilitation facility should be able to address either of these issues for you. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. If diarrhea does not resolve, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
[ "T8143XA", "Y836", "Y929", "K651", "Z903", "Z9049", "R197", "C8192", "C168", "Z934", "G629", "N400", "Z86718", "G8929", "M545", "Z801", "Z8042", "Z7902" ]
Allergies: Percocet / Ativan / latex Chief Complaint: Abdominal pain following total gastrectomy with roux-en-y esophagojejunostomy ([MASKED]). Major Surgical or Invasive Procedure: Underwent drain repositioning with Interventional Radiology on [MASKED]. History of Present Illness: [MASKED] history of recurrent DVT on lovenox, Hodgkin's lymphoma s/p chemotherapy, pT3N3aM0 gastric cancer s/p neoadjuvant chemotherapy, robotic total gastrectomy with roux-en-y esophagojejunostomy ([MASKED]) who presents with abdominal pain after recent discharge on [MASKED]. His post-operative course was complicated by left gastrocnemius DVT for which he continues on lovenox as well as an abscess adjacent to the esophagojejunostomy anastomosis, for which his surgical drain remains in place with scant purulent output. He completed a course of oral cipro/flagyl at home as planned on [MASKED]. During his hospital stay, he was unable to tolerate solids and was discharged to rehab on fulls with J-tube feed supplementation. He recently underwent repeat UGI on [MASKED] after one episode of dysphagia showing a persistent small leakage at the EJ anastomosis site. He presents today complaining of acute onset of lower abdominal pain starting at 7pm tonight that has since worsened to a [MASKED] in intensity. He describes the pain as sharp and coming in waves. He was discharged home on fulls and JTfeeds, which he has tolerated per his baseline with occasional episodes of dry heaving but no retching. He reports have normal bowel function with last BM and flatus tonight and no constipation or diarrhea. No fevers or chills. Reports persistent, scant purulent drainage from the surgical drain. No dysuria. No prior similar episodes of pain. Past Medical History: Hodgkin Lymphoma: Mixed cellularity Hodgkin's Disease with mediastinal mass diagnosed [MASKED]. PET shows disease limited to chest. No B symptoms. Anemic (Hct 32) with MCV 76. Ferritin 403. BM biopsy negative for involvement by HD. ABVD x6. Treated by Dr [MASKED], [MASKED]. Gastric Cancer: - [MASKED]: presented with reflux symptoms - [MASKED]: EGD showed an 8-10 cm mass in the body and fundus of the stomach. - [MASKED]: CT Torso showed no distant disease, but there remains a question of the etiology of several omental nodules and non-regional lymph nodes. - [MASKED]: EUS staging showed 4 suspicious lymph nodes, T3N2 disease. Gastric biopsy showed signet ring adenocarcinoma, HER-2 negative (IHC 1+). Biopsy of a gastrohepatic lymph node was positive. - [MASKED] - C1D1 [MASKED] [MASKED] + leucovorin, docetaxel, oxaliplatin) + neulasta PMH/PSH: Peripheral neuropathy BPH possible prostate nodule DVT while on chemotherapy, treated with Lovenox for 3 months ? interstitial lung disease following bleomycin treatment chronic lower back pain s/p b/l IHR as a child [MASKED] years old) s/p R knee arthroscopy Social History: [MASKED] Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer Cancers in the family: no others known Physical Exam: Admission Physical Exam ======================= Vitals-98.4 68 138/72 16 100% RA General- no acute distress, uncomfortable-appearing HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- RRR Chest- no increased WOB on RA Abdomen- soft, TTP in LLQ >RLQ with voluntary guarding, no rebound, mildly distended. Incisions well-healed without erythema or drainage. Drain x1 with scant purulent output. Jtube site c/d/I. Ext- WWP, no notable edema or TTP, compression stockings in place b/l Discharge Physical Exam ======================= [MASKED] 0004 Temp: 99.1 PO BP: 110/67 R Lying HR: 66 RR: 18 O2 sat: 98% O2 delivery: Ra General- no acute distress HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- Regular rate Chest- no increased WOB on RA Abdomen- soft, no tenderness to palpation, no rebound, minimally distended. Incisions well-healed without erythema or drainage. Drain x1 with scant serous output, bulb holding suction. Jtube site without clinical signs of infection. Ext- WWP Pertinent Results: Lab Results =========== [MASKED] 12:00PM BLOOD WBC-7.1 RBC-3.81* Hgb-8.8* Hct-27.9* MCV-73* MCH-23.1* MCHC-31.5* RDW-19.2* RDWSD-50.8* Plt [MASKED] [MASKED] 05:06AM BLOOD WBC-4.0 RBC-3.88* Hgb-8.9* Hct-28.4* MCV-73* MCH-22.9* MCHC-31.3* RDW-19.7* RDWSD-52.0* Plt [MASKED] [MASKED] 01:55AM BLOOD WBC-5.1 RBC-3.75* Hgb-8.6* Hct-27.5* MCV-73* MCH-22.9* MCHC-31.3* RDW-20.0* RDWSD-52.3* Plt [MASKED] [MASKED] 01:55AM BLOOD Neuts-40.6 [MASKED] Monos-7.4 Eos-3.3 Baso-0.4 Im [MASKED] AbsNeut-2.07 AbsLymp-2.46 AbsMono-0.38 AbsEos-0.17 AbsBaso-0.02 [MASKED] 05:15AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-139 K-4.2 Cl-95* HCO3-33* AnGap-11 [MASKED] 05:06AM BLOOD Glucose-66* UreaN-10 Creat-0.7 Na-138 K-4.5 Cl-97 HCO3-28 AnGap-13 [MASKED] 01:55AM BLOOD Glucose-89 UreaN-11 Creat-0.6 Na-137 K-4.4 Cl-99 HCO3-29 AnGap-9* [MASKED] 01:55AM BLOOD ALT-42* AST-30 AlkPhos-95 TotBili-0.3 [MASKED] 01:55AM BLOOD Lipase-38 [MASKED] 05:15AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9 [MASKED] 05:06AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.5* [MASKED] 01:55AM BLOOD Albumin-3.4* Imaging ======= DRAIN CATHETER MANIPULATION [MASKED] IMPRESSION: Successful fluoroscopy guided reposition of surgical drain with tip now adjacent to the esophago-jejunal anastomosis. CT abd/pelvis with IV/oral contrast ([MASKED]): 1. Evaluation of the upper abdomen is slightly limited by extensive streak artifact from dense contrast opacification of the right colon. Within this limitation, no acute intra-abdominal process. Oral contrast extends at least to the level of the transverse colon without evidence of extraluminal contrast. No bowel obstruction. 2. Interval resolution of previously seen left subdiaphragmatic fluid collection adjacent to the esophageal jejunal anastomosis. 3. Decreased size of now trace left pleural effusion. 4. Marked prostatomegaly. UGI IMPRESSION [MASKED]: 1. Small leak at the esophagojejunostomy site tracking along abdominal drain. 2. No overt abnormality of the jejunojejunostomy site. Brief Hospital Course: The patient was admitted to the General Surgical Service on [MASKED] for evaluation and treatment of abdominal pain, in the setting of recent total gastrectomy with roux-en-y esophagojejunostomy ([MASKED]). He was previously found to have an abscess adjacent to the esophagojejunostomy anastomosis, and within this admission underwent drain repositioning with interventional radiology with placement confirmed by fluoroscopy. Throughout his stay, Mr. [MASKED] remained nutritionally supported with his home tube feeding regimen via his J-tube. Nutrition services followed him within admission, and changed the formulation of his tube feeds, which were better tolerated by the patient, causing less diarrhea. At the time of discharge his diet included full liquids, and tubefeeds of Jevity 1.2. 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 his usual lovenox during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating his home tube feeds, as well as diet as above per oral, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged to rehab per [MASKED] recommendations. 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. Enoxaparin Sodium 80 mg SC Q12H 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 3. Tamsulosin 0.8 mg PO QHS 4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 5. LOPERamide 2 mg PO BID:PRN loose stools 6. Simethicone 80 mg PO QID:PRN bloating/gas 7. Pyridoxine 100 mg PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Multivitamins 1 TAB PO DAILY 3. Pregabalin 50 mg PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Docusate Sodium 100 mg PO BID 6. Simethicone 40-80 mg PO QID:PRN bloating/gas 7. Enoxaparin Sodium 80 mg SC Q12H 8. LOPERamide 2 mg PO BID:PRN loose stools 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Pyridoxine 100 mg PO DAILY 11. Tamsulosin 0.8 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: [MASKED] history of recurrent DVT on lovenox, Hodgkin's lymphoma s/p chemotherapy, pT3N3aM0 gastric cancer s/p neoadjuvant therapy, robotic total gastrectomy with roux-en-y esophagojejunostomy ([MASKED]) with resolving lower abdominal pain, now s/p drain repositioning to address fluid collection adjacent to the esophageal jejunal anastomosis. Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you here at [MASKED] [MASKED]. You were admitted to our hospital for abdominal pain following your total gastrectomy with roux-en-y esophagojejunostomy ([MASKED]). You were previously found to have an abscess adjacent to your esophagojejunostomy anastomosis, and underwent drain repositioning with interventional radiology. The drain is functioning appropriately, and you have recovered and are now ready to be discharged back to rehab. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. YOUR BOWELS: - Constipation is a common side effect of medicine such as Percocet or codeine. Diarrhea is a common side effect of tube feeds. You were seen by nutrition at [MASKED], and nutritionists at your rehabilitation facility should be able to address either of these issues for you. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. If diarrhea does not resolve, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: [MASKED]
[]
[ "Y929", "N400", "Z86718", "G8929", "Z7902" ]
[ "T8143XA: Infection following a procedure, organ and space surgical site, initial encounter", "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", "Y929: Unspecified place or not applicable", "K651: Peritoneal abscess", "Z903: Acquired absence of stomach [part of]", "Z9049: Acquired absence of other specified parts of digestive tract", "R197: Diarrhea, unspecified", "C8192: Hodgkin lymphoma, unspecified, intrathoracic lymph nodes", "C168: Malignant neoplasm of overlapping sites of stomach", "Z934: Other artificial openings of gastrointestinal tract status", "G629: Polyneuropathy, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z86718: Personal history of other venous thrombosis and embolism", "G8929: Other chronic pain", "M545: Low back pain", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "Z8042: Family history of malignant neoplasm of prostate", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,036,821
28,791,904
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Percocet / Ativan / latex Attending: ___ Chief Complaint: Esophageal perforation Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with h/o Hodgkin disease (Dx ___, s/p ABVD x6), Stage III gastric adenocarcinoma (signet ring, cT3N2M0, ypT3N2a, Her-2 neg) s/p 4 cycles neoadjuvant ___ and resection (___) c/b anastomotic leak and esophageal stricture s/p multiple dilations (q2 weeks), LLE DVT (on lovenox), possible ILD following bleomycin treatment presenting after EGD for dilation of esophageal stricture c/b esophageal perforation and pneumomediastinum. He is followed by Dr. ___ seen ___, at which time he had completed 4 cycles of neoadjuvant ___ with path suggestive of poor response. Plan was for transition to surveillance, with EGD q6months for ___ year then annually for up to ___ years based on sx. Subsequently underwent EGD ___ (showing distal esophageal stricture, dilated from 8->10 mm) and again ___ (with stricture dilated again from 8->10mm) with kenalog injection. Mr. ___ presented to GI today for repeat EGD, which showed recurrent distal esophageal stricture that was again dilated from 8->10mm. After dilation, a small 1-2mm defect was noted in the mucosa with air bubbling though it, c/f perforation. ERCP contacted ___ surgery, who will evaluate patient. CT torso ordered and broad-spectrum antibx recommended. CT findings below: CT abd/pelvis: small amount of free air along the gastrohepatic ligament consistent with perforation post ERCP. CT lung: small pneumomediastinum, scattered areas of scarring in lungs bilaterally. ___ FLOOR ==================== On arrival to the floor, Mr. ___ reports mild epigastric pain, but otherwise denies dyspnea, chest pain. His only two oral medications are gabapentin for peripheral neuropathy ___ chemotherapy and Tamsulosin; however, he says he normally needs to take these meds with ice cream. He is amenable to holding these medications for the time being, as he was told by GI to remain strictly NPO for now. He cannot get medications administered through J-tube as this has historically clogged very easily. FYI: Last dose lovenox ___. He is chronically on this for LLE DVT. Past Medical History: - H/o Hodgkin disease (Dx ___, s/p ABVD x6), Stage III Gastric adenocarcinoma (signet ring, cT3N2M0, ypT3N2a, Her-2 neg) s/p 4 cycles neoadjuvant ___ and resection (___) c/b anastomotic leak, TF requirement, esophageal strictures requiring q2week dilations - Peripheral neuropathy - BPH - Possible prostate nodule - LLE DVT ___ while on chemotherapy, on lovenox - ? interstitial lung disease following bleomycin treatment - Chronic lower back pain - CPPD in R knee - s/p b/l IHR as a child ___ years old) - s/p R knee arthroscopy Social History: ___ Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer. Cancers in the family: no others known. Bleeding and clotting disorders in the family: none known Physical Exam: ADMISSION PHYSICAL EXAM: ======================== 97.9, 127/72, HR 60, RR 18, SpO2 98 RA GENERAL: NAD, though reporting mild epigastric pain. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. CARDIAC: RRR, nml s1 s2, no mrg. LUNGS: On RA. CTAB. ABDOMEN: J tube in place, site is c/d/I. Soft, nd, mild epigastric tenderness with palpation. EXTREMITIES: Warm, no ___. SKIN: No rashes. NEUROLOGIC: AOx4. No focal neurologic deficits. ACCESS: Right chest wall port DISCHARGE PHYSICAL EXAM: ======================== ___ 0658 Temp: 98.5 PO BP: 123/69 R Sitting HR: 75 RR: 18 O2 sat: 93% O2 delivery: Ra GENERAL: WDWN adult man in NAD, sitting in bed HEENT: NCAT, sclerae anicteric, normal conjunctivae, oropharynx clear, MMM CARDIAC: RRR, nml s1 s2, no mrg. CHEST: CTAB, no increased work of breathing. No appreciable crepitus ABDOMEN: J tube in place, site is c/d/I. Soft, mild upper abdominal tenderness (improved from prior), non-distended, normoactive BS EXTREMITIES: Warm, DP pulses 2+ bilaterally, no edema NEUROLOGIC: AOx3, CN grossly intact, spontaneously moving all extremities ACCESS: Right chest wall port Pertinent Results: ADMISSION LABS ============== ___ 02:30PM BLOOD WBC-7.4 RBC-5.21 Hgb-12.8* Hct-41.0 MCV-79* MCH-24.6* MCHC-31.2* RDW-19.9* RDWSD-56.1* Plt ___ ___ 02:30PM BLOOD Plt ___ ___ 02:30PM BLOOD UreaN-10 Creat-0.7 Na-144 K-4.5 Cl-102 HCO3-29 AnGap-13 ___ 02:30PM BLOOD Albumin-3.9 ___ 02:35PM BLOOD Lactate-0.9 DISCHARGE LABS ============== ___ 04:36AM BLOOD WBC-3.9* RBC-4.80 Hgb-12.0* Hct-38.3* MCV-80* MCH-25.0* MCHC-31.3* RDW-18.7* RDWSD-54.4* Plt ___ ___ 04:36AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-140 K-4.7 Cl-102 HCO3-29 AnGap-9* ___ 04:36AM BLOOD ALT-43* AST-36 AlkPhos-73 TotBili-0.4 ___ 04:36AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.0 Mg-2.1 IMAGING ======= EGD ___ A benign intrinsic 7-8mm stricture was seen in the distal esophagus at about 38cm. The scope could not traverse the lesion and the exam could not be completed. A wire was advanced beyond the stricture into the jejunal limb. An 8-10 mm balloon was then introduced over the wire for dilation under fluoroscopy and the diameter was dilated from 8 to 10 mm in a stepwise fashion. The stricture was dilated and no waist was noted in the balloon. The balloon was deflated and a small 1-2 mm defect was noted just distal to the stricture with air bubbling suggestive of possible perforation. A pediatric EGD scope was then used which traversed the stricture easily. The defect appeared mostly closed at this time. The jejunal limbs appeared normal. Contrast was injected at this site and it was seen to go into the jejunum without extravasation. Abdomen was soft and no crepitus was noted at the end of the procedure. CT ABDOMEN/PELVIS ___ 1. Small amount of free air along the gastrohepatic ligament consistent with perforation after upper endoscopy. 2. No evidence of metastasis in the abdomen or pelvis 3. Pneumomediastinum is also seen. Please see the report of the CT chest performed on the same day for more details. 4. Prostatomegaly. CT CHEST ___ No extravasation of contrast into the mediastinum or pleura. Small pneumomediastinum following gastric surgery. Scattered areas of scarring in the lungs bilaterally, unchanged. CXR ___ Port-A-Cath catheter tip is at the level of lower SVC. Heart size and mediastinum are stable. There is interval resolution of left pleural effusion. There is no pneumothorax. MICROBIOLOGY ============ ___ 9:30 pm BLOOD CULTURE 1 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:02 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 9:57 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. Brief Hospital Course: ASSESSMENT AND PLAN: ==================== Mr. ___ is a ___ with h/o Hodgkin disease (Dx ___, s/p ABVD x6), Stage III gastric adenocarcinoma (signet ring, cT3N2M0, ypT3N2a, Her-2 neg) s/p 4 cycles neoadjuvant ___ and resection (___) c/b anastomotic leak and esophageal stricture s/p multiple dilations (q2 weeks), LLE DVT (on lovenox), possible ILD following bleomycin treatment presenting after EGD for dilation of esophageal stricture c/b esophageal perforation and pneumomediastinum. TRANSITIONAL ISSUES: New Medications: None Changed Medications: None Stopped/Held Medications: None [] Confirm patient continuing to tolerate regular diet and tube feeds without significant pain [] Confirm resolution of diarrhea ACUTE/ACTIVE ISSUES: ==================== # Esophageal perforation # Pneumomediastinum # Esophageal stricture s/p dilation Presented for routine EGD ___ and underwent dilation of stricture from 8->10mm, with procedure c/b 1-2mm mucosal defect c/f esophageal perforation. Subsequently with pain at base of sternum, upper abdomen. Initially started on zosyn, fluconazole, and vancomycin for prophylactic antibiotics; subsequently transitioned to ciprofloxacin and flagyl, with patient completing 6 days of antibiotics prior to discharge. Initially strict NPO, holding tube feeds, and on IV PPI q12H, holding home anticoagulation. Evaluated by ___ surgery (gastro-esophageal surgery) and thoracic surgery, recommended conservative management. Also followed by ERCP while inpatient. Resumed tube feeds and advanced diet to sips on ___. Pain subsequently improved, with diet advanced to full liquids and patient remaining pain-free prior to discharge. # Diarrhea Several episodes of diarrhea with onset ~1H after starting TF evening of ___. No further episodes overnight. Suspect suspect secondary to resumption of tube feeds at regular rate (high fiber content in Jevity), particularly as patient reports that he frequently has diarrhea with tube feeds when hospitalized. Antibiotics may also be contributory, course completed on ___. # LLE DVT: Diagnosed ___ in L gastroc. On lovenox, last dose ___. Initially held anticoagulation in setting of esophageal perforation. Resumed on ___. CHRONIC/STABLE ISSUES ====================== # Gastric cancer Known signet ring adenocarcinoma, cT3N2M0/ypT3N2a, Stage III (HER-2 testing negative), followed by Dr. ___. S/p 4 cycles neoadjuvant ___ chemotherapy with CT torso ___ without evidence of new disease (although unfortunately on surgical pathology had poor to no response). Per Dr. ___ last note in ___, plan is to transition to surveillance with consideration of immunotherapy if e/o disease progression. # Hodgkin Lymphoma: # Possible bloemycin-induced ILD: Dx ___, s/p treatment with 6 cycles ABVD by Dr. ___ at ___. Residual neuropathy and possible ILD secondary to bleomycin. ___ on PET ___. # Microcytic anemia: p/w Hgb 12.8, Baseline Hgb appears to be ___, last 11.8 on ___. Remained stable during admission, 12.0 on discharge. # Peripheral neuropathy: Secondary to prior chemo. Held home gabapentin while strict NPO, resumed on discharge. # CPPD: Diagnosed in R knee ___, improved with steroid injection but with multiple subsequent flares. More than 35 minutes were spent in planning and coordinating this patient's discharge on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simethicone 40-80 mg PO QID:PRN bloating/gas 2. Tamsulosin 0.8 mg PO QHS 3. Enoxaparin Sodium 80 mg SC Q12H 4. Gabapentin 300 mg PO QHS Discharge Medications: 1. Enoxaparin Sodium 80 mg SC Q12H 2. Gabapentin 300 mg PO QHS 3. Simethicone 40-80 mg PO QID:PRN bloating/gas 4. Tamsulosin 0.8 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Esophageal Perforation Pneumomediastinum SECONDARY DIAGNOSES ==================== Esophageal stricture DVT Diarrhea Gastric cancer Non-hodgkins lymphoma Anemia Peripheral neuropathy CPPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for a perforation of the esophagus sustained during an upper endoscopy. What was done for me while I was in the hospital? - You had imaging that showed a small amount of area in the chest cavity around the esophagus, consistent with a perforation. You were evaluated by the gastric and esophageal surgery team and the thoracic surgery team, who recommended non-surgical management. You received six days of intravenous antibiotics and medication to reduce acid production. - Initially your tube feeds were held and all oral intake was avoided. Subsequently your diet was advanced to liquids and tube feeds resumed without worsening of pain. Your abdominal pain had fully resolved prior to discharge. What should I do when I leave the hospital? - Continue to take all of your medications as prescribed. - Attend all of your follow-up appointments. - Return to the emergency department if you develop significantly worsening abdominal or chest pain, fevers, chills, light-headedness, or other concerning symptoms. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "K9171", "K222", "T8182XA", "K449", "G620", "M25861", "N400", "D509", "R197", "T451X5S", "Y92238", "Z86718", "Z85028", "Z7902", "Z8571" ]
Allergies: Percocet / Ativan / latex Chief Complaint: Esophageal perforation Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with h/o Hodgkin disease (Dx [MASKED], s/p ABVD x6), Stage III gastric adenocarcinoma (signet ring, cT3N2M0, ypT3N2a, Her-2 neg) s/p 4 cycles neoadjuvant [MASKED] and resection ([MASKED]) c/b anastomotic leak and esophageal stricture s/p multiple dilations (q2 weeks), LLE DVT (on lovenox), possible ILD following bleomycin treatment presenting after EGD for dilation of esophageal stricture c/b esophageal perforation and pneumomediastinum. He is followed by Dr. [MASKED] seen [MASKED], at which time he had completed 4 cycles of neoadjuvant [MASKED] with path suggestive of poor response. Plan was for transition to surveillance, with EGD q6months for [MASKED] year then annually for up to [MASKED] years based on sx. Subsequently underwent EGD [MASKED] (showing distal esophageal stricture, dilated from 8->10 mm) and again [MASKED] (with stricture dilated again from 8->10mm) with kenalog injection. Mr. [MASKED] presented to GI today for repeat EGD, which showed recurrent distal esophageal stricture that was again dilated from 8->10mm. After dilation, a small 1-2mm defect was noted in the mucosa with air bubbling though it, c/f perforation. ERCP contacted [MASKED] surgery, who will evaluate patient. CT torso ordered and broad-spectrum antibx recommended. CT findings below: CT abd/pelvis: small amount of free air along the gastrohepatic ligament consistent with perforation post ERCP. CT lung: small pneumomediastinum, scattered areas of scarring in lungs bilaterally. [MASKED] FLOOR ==================== On arrival to the floor, Mr. [MASKED] reports mild epigastric pain, but otherwise denies dyspnea, chest pain. His only two oral medications are gabapentin for peripheral neuropathy [MASKED] chemotherapy and Tamsulosin; however, he says he normally needs to take these meds with ice cream. He is amenable to holding these medications for the time being, as he was told by GI to remain strictly NPO for now. He cannot get medications administered through J-tube as this has historically clogged very easily. FYI: Last dose lovenox [MASKED]. He is chronically on this for LLE DVT. Past Medical History: - H/o Hodgkin disease (Dx [MASKED], s/p ABVD x6), Stage III Gastric adenocarcinoma (signet ring, cT3N2M0, ypT3N2a, Her-2 neg) s/p 4 cycles neoadjuvant [MASKED] and resection ([MASKED]) c/b anastomotic leak, TF requirement, esophageal strictures requiring q2week dilations - Peripheral neuropathy - BPH - Possible prostate nodule - LLE DVT [MASKED] while on chemotherapy, on lovenox - ? interstitial lung disease following bleomycin treatment - Chronic lower back pain - CPPD in R knee - s/p b/l IHR as a child [MASKED] years old) - s/p R knee arthroscopy Social History: [MASKED] Family History: Maternal side: uncle with lung cancer, uncle with prostate cancer. Cancers in the family: no others known. Bleeding and clotting disorders in the family: none known Physical Exam: ADMISSION PHYSICAL EXAM: ======================== 97.9, 127/72, HR 60, RR 18, SpO2 98 RA GENERAL: NAD, though reporting mild epigastric pain. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. CARDIAC: RRR, nml s1 s2, no mrg. LUNGS: On RA. CTAB. ABDOMEN: J tube in place, site is c/d/I. Soft, nd, mild epigastric tenderness with palpation. EXTREMITIES: Warm, no [MASKED]. SKIN: No rashes. NEUROLOGIC: AOx4. No focal neurologic deficits. ACCESS: Right chest wall port DISCHARGE PHYSICAL EXAM: ======================== [MASKED] 0658 Temp: 98.5 PO BP: 123/69 R Sitting HR: 75 RR: 18 O2 sat: 93% O2 delivery: Ra GENERAL: WDWN adult man in NAD, sitting in bed HEENT: NCAT, sclerae anicteric, normal conjunctivae, oropharynx clear, MMM CARDIAC: RRR, nml s1 s2, no mrg. CHEST: CTAB, no increased work of breathing. No appreciable crepitus ABDOMEN: J tube in place, site is c/d/I. Soft, mild upper abdominal tenderness (improved from prior), non-distended, normoactive BS EXTREMITIES: Warm, DP pulses 2+ bilaterally, no edema NEUROLOGIC: AOx3, CN grossly intact, spontaneously moving all extremities ACCESS: Right chest wall port Pertinent Results: ADMISSION LABS ============== [MASKED] 02:30PM BLOOD WBC-7.4 RBC-5.21 Hgb-12.8* Hct-41.0 MCV-79* MCH-24.6* MCHC-31.2* RDW-19.9* RDWSD-56.1* Plt [MASKED] [MASKED] 02:30PM BLOOD Plt [MASKED] [MASKED] 02:30PM BLOOD UreaN-10 Creat-0.7 Na-144 K-4.5 Cl-102 HCO3-29 AnGap-13 [MASKED] 02:30PM BLOOD Albumin-3.9 [MASKED] 02:35PM BLOOD Lactate-0.9 DISCHARGE LABS ============== [MASKED] 04:36AM BLOOD WBC-3.9* RBC-4.80 Hgb-12.0* Hct-38.3* MCV-80* MCH-25.0* MCHC-31.3* RDW-18.7* RDWSD-54.4* Plt [MASKED] [MASKED] 04:36AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-140 K-4.7 Cl-102 HCO3-29 AnGap-9* [MASKED] 04:36AM BLOOD ALT-43* AST-36 AlkPhos-73 TotBili-0.4 [MASKED] 04:36AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.0 Mg-2.1 IMAGING ======= EGD [MASKED] A benign intrinsic 7-8mm stricture was seen in the distal esophagus at about 38cm. The scope could not traverse the lesion and the exam could not be completed. A wire was advanced beyond the stricture into the jejunal limb. An 8-10 mm balloon was then introduced over the wire for dilation under fluoroscopy and the diameter was dilated from 8 to 10 mm in a stepwise fashion. The stricture was dilated and no waist was noted in the balloon. The balloon was deflated and a small 1-2 mm defect was noted just distal to the stricture with air bubbling suggestive of possible perforation. A pediatric EGD scope was then used which traversed the stricture easily. The defect appeared mostly closed at this time. The jejunal limbs appeared normal. Contrast was injected at this site and it was seen to go into the jejunum without extravasation. Abdomen was soft and no crepitus was noted at the end of the procedure. CT ABDOMEN/PELVIS [MASKED] 1. Small amount of free air along the gastrohepatic ligament consistent with perforation after upper endoscopy. 2. No evidence of metastasis in the abdomen or pelvis 3. Pneumomediastinum is also seen. Please see the report of the CT chest performed on the same day for more details. 4. Prostatomegaly. CT CHEST [MASKED] No extravasation of contrast into the mediastinum or pleura. Small pneumomediastinum following gastric surgery. Scattered areas of scarring in the lungs bilaterally, unchanged. CXR [MASKED] Port-A-Cath catheter tip is at the level of lower SVC. Heart size and mediastinum are stable. There is interval resolution of left pleural effusion. There is no pneumothorax. MICROBIOLOGY ============ [MASKED] 9:30 pm BLOOD CULTURE 1 OF 2. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 5:02 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 9:57 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. Brief Hospital Course: ASSESSMENT AND PLAN: ==================== Mr. [MASKED] is a [MASKED] with h/o Hodgkin disease (Dx [MASKED], s/p ABVD x6), Stage III gastric adenocarcinoma (signet ring, cT3N2M0, ypT3N2a, Her-2 neg) s/p 4 cycles neoadjuvant [MASKED] and resection ([MASKED]) c/b anastomotic leak and esophageal stricture s/p multiple dilations (q2 weeks), LLE DVT (on lovenox), possible ILD following bleomycin treatment presenting after EGD for dilation of esophageal stricture c/b esophageal perforation and pneumomediastinum. TRANSITIONAL ISSUES: New Medications: None Changed Medications: None Stopped/Held Medications: None [] Confirm patient continuing to tolerate regular diet and tube feeds without significant pain [] Confirm resolution of diarrhea ACUTE/ACTIVE ISSUES: ==================== # Esophageal perforation # Pneumomediastinum # Esophageal stricture s/p dilation Presented for routine EGD [MASKED] and underwent dilation of stricture from 8->10mm, with procedure c/b 1-2mm mucosal defect c/f esophageal perforation. Subsequently with pain at base of sternum, upper abdomen. Initially started on zosyn, fluconazole, and vancomycin for prophylactic antibiotics; subsequently transitioned to ciprofloxacin and flagyl, with patient completing 6 days of antibiotics prior to discharge. Initially strict NPO, holding tube feeds, and on IV PPI q12H, holding home anticoagulation. Evaluated by [MASKED] surgery (gastro-esophageal surgery) and thoracic surgery, recommended conservative management. Also followed by ERCP while inpatient. Resumed tube feeds and advanced diet to sips on [MASKED]. Pain subsequently improved, with diet advanced to full liquids and patient remaining pain-free prior to discharge. # Diarrhea Several episodes of diarrhea with onset ~1H after starting TF evening of [MASKED]. No further episodes overnight. Suspect suspect secondary to resumption of tube feeds at regular rate (high fiber content in Jevity), particularly as patient reports that he frequently has diarrhea with tube feeds when hospitalized. Antibiotics may also be contributory, course completed on [MASKED]. # LLE DVT: Diagnosed [MASKED] in L gastroc. On lovenox, last dose [MASKED]. Initially held anticoagulation in setting of esophageal perforation. Resumed on [MASKED]. CHRONIC/STABLE ISSUES ====================== # Gastric cancer Known signet ring adenocarcinoma, cT3N2M0/ypT3N2a, Stage III (HER-2 testing negative), followed by Dr. [MASKED]. S/p 4 cycles neoadjuvant [MASKED] chemotherapy with CT torso [MASKED] without evidence of new disease (although unfortunately on surgical pathology had poor to no response). Per Dr. [MASKED] last note in [MASKED], plan is to transition to surveillance with consideration of immunotherapy if e/o disease progression. # Hodgkin Lymphoma: # Possible bloemycin-induced ILD: Dx [MASKED], s/p treatment with 6 cycles ABVD by Dr. [MASKED] at [MASKED]. Residual neuropathy and possible ILD secondary to bleomycin. [MASKED] on PET [MASKED]. # Microcytic anemia: p/w Hgb 12.8, Baseline Hgb appears to be [MASKED], last 11.8 on [MASKED]. Remained stable during admission, 12.0 on discharge. # Peripheral neuropathy: Secondary to prior chemo. Held home gabapentin while strict NPO, resumed on discharge. # CPPD: Diagnosed in R knee [MASKED], improved with steroid injection but with multiple subsequent flares. More than 35 minutes were spent in planning and coordinating this patient's discharge on [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simethicone 40-80 mg PO QID:PRN bloating/gas 2. Tamsulosin 0.8 mg PO QHS 3. Enoxaparin Sodium 80 mg SC Q12H 4. Gabapentin 300 mg PO QHS Discharge Medications: 1. Enoxaparin Sodium 80 mg SC Q12H 2. Gabapentin 300 mg PO QHS 3. Simethicone 40-80 mg PO QID:PRN bloating/gas 4. Tamsulosin 0.8 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Esophageal Perforation Pneumomediastinum SECONDARY DIAGNOSES ==================== Esophageal stricture DVT Diarrhea Gastric cancer Non-hodgkins lymphoma Anemia Peripheral neuropathy CPPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking part in your care here at [MASKED]! Why was I admitted to the hospital? - You were admitted for a perforation of the esophagus sustained during an upper endoscopy. What was done for me while I was in the hospital? - You had imaging that showed a small amount of area in the chest cavity around the esophagus, consistent with a perforation. You were evaluated by the gastric and esophageal surgery team and the thoracic surgery team, who recommended non-surgical management. You received six days of intravenous antibiotics and medication to reduce acid production. - Initially your tube feeds were held and all oral intake was avoided. Subsequently your diet was advanced to liquids and tube feeds resumed without worsening of pain. Your abdominal pain had fully resolved prior to discharge. What should I do when I leave the hospital? - Continue to take all of your medications as prescribed. - Attend all of your follow-up appointments. - Return to the emergency department if you develop significantly worsening abdominal or chest pain, fevers, chills, light-headedness, or other concerning symptoms. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N400", "D509", "Z86718", "Z7902" ]
[ "K9171: Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure", "K222: Esophageal obstruction", "T8182XA: Emphysema (subcutaneous) resulting from a procedure, initial encounter", "K449: Diaphragmatic hernia without obstruction or gangrene", "G620: Drug-induced polyneuropathy", "M25861: Other specified joint disorders, right knee", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "D509: Iron deficiency anemia, unspecified", "R197: Diarrhea, unspecified", "T451X5S: Adverse effect of antineoplastic and immunosuppressive drugs, sequela", "Y92238: Other place in hospital as the place of occurrence of the external cause", "Z86718: Personal history of other venous thrombosis and embolism", "Z85028: Personal history of other malignant neoplasm of stomach", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z8571: Personal history of Hodgkin lymphoma" ]
10,036,942
23,803,237
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: TEE on ___ Midline placement ___ attach Pertinent Results: ADMISSION LABS: ================ ___ 04:10PM BLOOD WBC-10.1* RBC-4.22* Hgb-12.7* Hct-38.3* MCV-91 MCH-30.1 MCHC-33.2 RDW-12.7 RDWSD-41.7 Plt ___ ___ 04:10PM BLOOD Neuts-76.8* Lymphs-15.1* Monos-6.6 Eos-0.8* Baso-0.3 Im ___ AbsNeut-7.75* AbsLymp-1.52 AbsMono-0.67 AbsEos-0.08 AbsBaso-0.03 ___ 04:10PM BLOOD Glucose-99 UreaN-9 Creat-0.6 Na-135 K-4.0 Cl-97 HCO3-28 AnGap-10 ___ 04:40AM BLOOD ALT-15 AST-14 AlkPhos-66 TotBili-0.7 ___ 04:40AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.0 Mg-1.7 ___ 04:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS* ___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 04:40AM BLOOD HCV Ab-NEG ___ 4:10 pm BLOOD CULTURE **FINAL REPORT ___ STAPH AUREUS COAG + | STAPH AUREUS COAG + | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 0.25 S <=0.12 S OXACILLIN------------- 0.5 S 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S ___ 5:18 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. ___ 6:25 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. ___ 7:34 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. CXR ___ Borderline cardiac silhouette size, likely accentuated by AP technique. Otherwise, no definite acute intrathoracic process. CT HEAD W/O CONTRAST ___ IMPRESSION: No acute intracranial process or fracture. TTE 1) Possibly very small vegetation on the pulmonary valve. Image quality is excellent. We seldomly see the pulmonary valve this well depicted and therefore the nodularity could be part of a normal variant including Lambl's exrescene. 2) Mitral valve appears without vegetation. There is a very small mobile structure on the atrial side , the differential is likely torn mitral valve, beam hardening artifact, howver in this clinical scenario vegetation (less likely) cannot be excluded. CHEST CT W/ CONTRAST 1. Possible minimal bronchial inflammation. The lungs are otherwise clear. 2. No evidence of rib fracture or other osseous or soft tissue abnormality. DISCHARGE LABS: ================ ___ 07:50AM BLOOD WBC-9.0 RBC-4.38* Hgb-13.3* Hct-40.5 MCV-93 MCH-30.4 MCHC-32.8 RDW-12.1 RDWSD-41.3 Plt ___ ___ 06:20AM BLOOD Neuts-52.6 ___ Monos-9.2 Eos-0.9* Baso-0.6 Im ___ AbsNeut-3.42 AbsLymp-2.35 AbsMono-0.60 AbsEos-0.06 AbsBaso-0.04 ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-142 K-4.5 Cl-101 HCO3-24 AnGap-17 ___ 07:50AM BLOOD ALT-20 AST-24 LD(LDH)-176 AlkPhos-71 TotBili-0.2 ___ 07:50AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9 ___ 02:37PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-POS* ___ 04:00PM URINE bnzodzp-NEG barbitr-NEG opiates-POS* cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG ___ 11:25AM URINE AMPHETAMINES, LC/MS-PND Brief Hospital Course: BRIEF HOSPITAL COURSE: ======================= This is a ___ male patient with a history of IVDU w/ last use of heroin ___ who presents with 5 days of persistent exertional chest pressure w/o radiation and dyspnea who was found to be running a low grade fever, found to have MSSA bacteremia with TEE without signs of endocarditis TRANSITIONAL ISSUES: ===================== [] Continue treatment with IV cefazolin for a total of 14 days from first negative blood culture (until ___ [] Will need to ensure has established with a ___ clinic on discharge [] Needs to establish care with a PCP at discharge [] Confirmatory testing for amphetamines on Utox was pending at time of discharge ACUTE ISSUES: ============= #MSSA bacteremia Bacteremia iso IVDU with last positive blood culture on ___. TTE with question of vegetation on pulmonary valve but no evidence of endocarditis on TEE. ID following with inpatient - patient meets all criteria of uncomplicated MSSA bacteremia (TEE negative, clearance of blood culture by 72h, defervescence within 72 hrs of therapy, no evidence/sxs of metastatic infection), will plan for 2 total weeks of therapy from first negative blood culture (___). On cefazolin 2g q8hr until ___ with midline in place. #Left costochondral pain Focal pain on exam on the left concerning for septic costochondritis vs abscess vs osteo given GPC bacteremia. However, chest CT negative on ___ for soft tissue abnormality/infectious process. In the hospital patient was treated with IV ketorolac for 3 days then transitioned to PO ibuprofen, which was alternated with Tylenol. #Opioid use disorder Uses heroin every day ___ times based on how he's feeling). Last treated for substance use in ___ with naltrexone injections. Was previously on suboxone. Patient began to exhibit sxs of withdrawal while inpatient, scoring >10 on ___ scale. Patient seen by addiction psychiatry - stated that he is interested in methadone maintenance therapy and feels that daily ___ clinic visits would be good for him to provide some daily structure - wishes to receive methadone daily at ___ clinic on ___. Started patient on 40mg methadone qd while inpatient. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. CeFAZolin 2 g IV Q8H 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 4. Lidocaine 5% Patch 1 PTCH TD QPM upper back pain 5. Methadone 40 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 7. Ramelteon 8 mg PO QHS:PRN Insomia Should be given 30 minutes before bedtime 8. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Staph aureus bacteremia Opioid use disorder Left costochondral pain 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 were admitted to the hospital with 5 days of chest pain and concern for an infection. WHAT HAPPENED TO ME IN THE HOSPITAL? - Your blood cultures grew a bacteria called staph aureus. We started you on IV antibiotics for this - We got a picture (called an echocardiogram) of your heart which did not show any infection of your heart valves. - You will continue on antibiotics for a total of 14 day, end date ___. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "R7881", "F1123", "B9561", "R0789", "F329", "F4310", "F909", "F17200", "Z23", "Z915", "Z813", "M62830" ]
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: TEE on [MASKED] Midline placement [MASKED] attach Pertinent Results: ADMISSION LABS: ================ [MASKED] 04:10PM BLOOD WBC-10.1* RBC-4.22* Hgb-12.7* Hct-38.3* MCV-91 MCH-30.1 MCHC-33.2 RDW-12.7 RDWSD-41.7 Plt [MASKED] [MASKED] 04:10PM BLOOD Neuts-76.8* Lymphs-15.1* Monos-6.6 Eos-0.8* Baso-0.3 Im [MASKED] AbsNeut-7.75* AbsLymp-1.52 AbsMono-0.67 AbsEos-0.08 AbsBaso-0.03 [MASKED] 04:10PM BLOOD Glucose-99 UreaN-9 Creat-0.6 Na-135 K-4.0 Cl-97 HCO3-28 AnGap-10 [MASKED] 04:40AM BLOOD ALT-15 AST-14 AlkPhos-66 TotBili-0.7 [MASKED] 04:40AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.0 Mg-1.7 [MASKED] 04:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-POS* [MASKED] 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 04:40AM BLOOD HCV Ab-NEG [MASKED] 4:10 pm BLOOD CULTURE **FINAL REPORT [MASKED] STAPH AUREUS COAG + | STAPH AUREUS COAG + | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 0.25 S <=0.12 S OXACILLIN------------- 0.5 S 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S [MASKED] 5:18 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STAPH AUREUS COAG +. [MASKED] 6:25 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STAPH AUREUS COAG +. [MASKED] 7:34 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. CXR [MASKED] Borderline cardiac silhouette size, likely accentuated by AP technique. Otherwise, no definite acute intrathoracic process. CT HEAD W/O CONTRAST [MASKED] IMPRESSION: No acute intracranial process or fracture. TTE 1) Possibly very small vegetation on the pulmonary valve. Image quality is excellent. We seldomly see the pulmonary valve this well depicted and therefore the nodularity could be part of a normal variant including Lambl's exrescene. 2) Mitral valve appears without vegetation. There is a very small mobile structure on the atrial side , the differential is likely torn mitral valve, beam hardening artifact, howver in this clinical scenario vegetation (less likely) cannot be excluded. CHEST CT W/ CONTRAST 1. Possible minimal bronchial inflammation. The lungs are otherwise clear. 2. No evidence of rib fracture or other osseous or soft tissue abnormality. DISCHARGE LABS: ================ [MASKED] 07:50AM BLOOD WBC-9.0 RBC-4.38* Hgb-13.3* Hct-40.5 MCV-93 MCH-30.4 MCHC-32.8 RDW-12.1 RDWSD-41.3 Plt [MASKED] [MASKED] 06:20AM BLOOD Neuts-52.6 [MASKED] Monos-9.2 Eos-0.9* Baso-0.6 Im [MASKED] AbsNeut-3.42 AbsLymp-2.35 AbsMono-0.60 AbsEos-0.06 AbsBaso-0.04 [MASKED] 07:50AM BLOOD Plt [MASKED] [MASKED] 07:50AM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-142 K-4.5 Cl-101 HCO3-24 AnGap-17 [MASKED] 07:50AM BLOOD ALT-20 AST-24 LD(LDH)-176 AlkPhos-71 TotBili-0.2 [MASKED] 07:50AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9 [MASKED] 02:37PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-POS* [MASKED] 04:00PM URINE bnzodzp-NEG barbitr-NEG opiates-POS* cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG [MASKED] 11:25AM URINE AMPHETAMINES, LC/MS-PND Brief Hospital Course: BRIEF HOSPITAL COURSE: ======================= This is a [MASKED] male patient with a history of IVDU w/ last use of heroin [MASKED] who presents with 5 days of persistent exertional chest pressure w/o radiation and dyspnea who was found to be running a low grade fever, found to have MSSA bacteremia with TEE without signs of endocarditis TRANSITIONAL ISSUES: ===================== [] Continue treatment with IV cefazolin for a total of 14 days from first negative blood culture (until [MASKED] [] Will need to ensure has established with a [MASKED] clinic on discharge [] Needs to establish care with a PCP at discharge [] Confirmatory testing for amphetamines on Utox was pending at time of discharge ACUTE ISSUES: ============= #MSSA bacteremia Bacteremia iso IVDU with last positive blood culture on [MASKED]. TTE with question of vegetation on pulmonary valve but no evidence of endocarditis on TEE. ID following with inpatient - patient meets all criteria of uncomplicated MSSA bacteremia (TEE negative, clearance of blood culture by 72h, defervescence within 72 hrs of therapy, no evidence/sxs of metastatic infection), will plan for 2 total weeks of therapy from first negative blood culture ([MASKED]). On cefazolin 2g q8hr until [MASKED] with midline in place. #Left costochondral pain Focal pain on exam on the left concerning for septic costochondritis vs abscess vs osteo given GPC bacteremia. However, chest CT negative on [MASKED] for soft tissue abnormality/infectious process. In the hospital patient was treated with IV ketorolac for 3 days then transitioned to PO ibuprofen, which was alternated with Tylenol. #Opioid use disorder Uses heroin every day [MASKED] times based on how he's feeling). Last treated for substance use in [MASKED] with naltrexone injections. Was previously on suboxone. Patient began to exhibit sxs of withdrawal while inpatient, scoring >10 on [MASKED] scale. Patient seen by addiction psychiatry - stated that he is interested in methadone maintenance therapy and feels that daily [MASKED] clinic visits would be good for him to provide some daily structure - wishes to receive methadone daily at [MASKED] clinic on [MASKED]. Started patient on 40mg methadone qd while inpatient. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. CeFAZolin 2 g IV Q8H 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 4. Lidocaine 5% Patch 1 PTCH TD QPM upper back pain 5. Methadone 40 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 7. Ramelteon 8 mg PO QHS:PRN Insomia Should be given 30 minutes before bedtime 8. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Staph aureus bacteremia Opioid use disorder Left costochondral pain 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 were admitted to the hospital with 5 days of chest pain and concern for an infection. WHAT HAPPENED TO ME IN THE HOSPITAL? - Your blood cultures grew a bacteria called staph aureus. We started you on IV antibiotics for this - We got a picture (called an echocardiogram) of your heart which did not show any infection of your heart valves. - You will continue on antibiotics for a total of 14 day, end date [MASKED]. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "F329" ]
[ "R7881: Bacteremia", "F1123: Opioid dependence with withdrawal", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "R0789: Other chest pain", "F329: Major depressive disorder, single episode, unspecified", "F4310: Post-traumatic stress disorder, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F17200: Nicotine dependence, unspecified, uncomplicated", "Z23: Encounter for immunization", "Z915: Personal history of self-harm", "Z813: Family history of other psychoactive substance abuse and dependence", "M62830: Muscle spasm of back" ]
10,037,313
22,489,707
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: fibroid uterus Major Surgical or Invasive Procedure: Abdominal multiple myomectomy Physical Exam: Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP Pertinent Results: ___ 10:00AM WBC-3.0* RBC-3.59* HGB-10.6* HCT-34.5 MCV-96# MCH-29.5# MCHC-30.7* RDW-16.1* RDWSD-48.3* ___ 10:00AM WBC-3.0* RBC-3.59* HGB-10.6* HCT-34.5 MCV-96# MCH-29.5# MCHC-30.7* RDW-16.1* RDWSD-48.3* Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after undergoing and abdominal multiple myomectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid/toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to oxycodone/acetaminophen/ibuprofen(pain meds). By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Norethindrone 5mg QD Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*1 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Fibroid uterus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___ , You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. 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: ___
[ "D251", "D252" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: fibroid uterus Major Surgical or Invasive Procedure: Abdominal multiple myomectomy Physical Exam: Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP Pertinent Results: [MASKED] 10:00AM WBC-3.0* RBC-3.59* HGB-10.6* HCT-34.5 MCV-96# MCH-29.5# MCHC-30.7* RDW-16.1* RDWSD-48.3* [MASKED] 10:00AM WBC-3.0* RBC-3.59* HGB-10.6* HCT-34.5 MCV-96# MCH-29.5# MCHC-30.7* RDW-16.1* RDWSD-48.3* Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after undergoing and abdominal multiple myomectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid/toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to oxycodone/acetaminophen/ibuprofen(pain meds). By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Norethindrone 5mg QD Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*1 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Fibroid uterus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED] , You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. [MASKED] office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. 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]
[]
[]
[ "D251: Intramural leiomyoma of uterus", "D252: Subserosal leiomyoma of uterus" ]
10,037,602
26,699,121
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: quaternium 15 / potassium dichronate / balsam of ___ / nickel / paraben / fragrances / glycerol monothiogylconate / tea tree oil / benzoyl peroxide Attending: ___ ___ Complaint: Right knee osteoarthritis Major Surgical or Invasive Procedure: ___: R TKR History of Present Illness: ___ year old female with right knee osteoarthritis now s/p R TKR. Past Medical History: PMH: HLD, HTN, OA, Thyroid nodule, GERD, Depression Shx: ___ Family History: non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 06:30AM BLOOD WBC-12.3* RBC-3.33* Hgb-8.9* Hct-28.4* MCV-85 MCH-26.7 MCHC-31.3* RDW-14.3 RDWSD-44.9 Plt ___ ___ 05:40AM BLOOD WBC-12.3* RBC-3.53* Hgb-9.6* Hct-30.0* MCV-85 MCH-27.2 MCHC-32.0 RDW-14.0 RDWSD-43.0 Plt ___ ___ 06:06AM BLOOD WBC-11.0* RBC-3.73* Hgb-10.0*# Hct-31.9*# MCV-86 MCH-26.8 MCHC-31.3* RDW-13.9 RDWSD-43.6 Plt ___ ___ 06:30AM BLOOD Plt ___ ___ 05:40AM BLOOD Plt ___ ___ 06:06AM BLOOD Plt ___ ___ 06:06AM BLOOD Glucose-124* UreaN-17 Creat-0.7 Na-138 K-4.2 Cl-100 HCO3-26 AnGap-12 ___ 06:06AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 ___ 11:00AM BLOOD HBsAg-NEG HBsAb-POS ___ 11:00AM BLOOD HIV Ab-NEG ___ 11:00AM BLOOD HCV Ab-NEG ___ 06:06AM BLOOD ___ 11:00AM BLOOD Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was unremarkable. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 325 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. ___ is discharged to home with services in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 320 mg PO DAILY 2. betamethasone, augmented 0.05 % topical BID 3. Atorvastatin 20 mg PO QPM 4. Omeprazole 40 mg PO DAILY 5. Loratadine 10 mg PO DAILY 6. Sertraline 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 300 mg PO TID 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 6. Senna 8.6 mg PO BID 7. Atorvastatin 20 mg PO QPM 8. betamethasone, augmented 0.05 % topical BID 9. Loratadine 10 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Valsartan 320 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 325 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 3 weeks after surgery. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize with assistive devices (___) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Weight bearing as tolerated on the operative extremity. Mobilize with assistive devices (___) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Treatments Frequency: Remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: ___
[ "M1711", "I10", "E785", "E041", "K219", "F329", "E669", "Z6839" ]
Allergies: quaternium 15 / potassium dichronate / balsam of [MASKED] / nickel / paraben / fragrances / glycerol monothiogylconate / tea tree oil / benzoyl peroxide [MASKED] Complaint: Right knee osteoarthritis Major Surgical or Invasive Procedure: [MASKED]: R TKR History of Present Illness: [MASKED] year old female with right knee osteoarthritis now s/p R TKR. Past Medical History: PMH: HLD, HTN, OA, Thyroid nodule, GERD, Depression Shx: [MASKED] Family History: non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:30AM BLOOD WBC-12.3* RBC-3.33* Hgb-8.9* Hct-28.4* MCV-85 MCH-26.7 MCHC-31.3* RDW-14.3 RDWSD-44.9 Plt [MASKED] [MASKED] 05:40AM BLOOD WBC-12.3* RBC-3.53* Hgb-9.6* Hct-30.0* MCV-85 MCH-27.2 MCHC-32.0 RDW-14.0 RDWSD-43.0 Plt [MASKED] [MASKED] 06:06AM BLOOD WBC-11.0* RBC-3.73* Hgb-10.0*# Hct-31.9*# MCV-86 MCH-26.8 MCHC-31.3* RDW-13.9 RDWSD-43.6 Plt [MASKED] [MASKED] 06:30AM BLOOD Plt [MASKED] [MASKED] 05:40AM BLOOD Plt [MASKED] [MASKED] 06:06AM BLOOD Plt [MASKED] [MASKED] 06:06AM BLOOD Glucose-124* UreaN-17 Creat-0.7 Na-138 K-4.2 Cl-100 HCO3-26 AnGap-12 [MASKED] 06:06AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 [MASKED] 11:00AM BLOOD HBsAg-NEG HBsAb-POS [MASKED] 11:00AM BLOOD HIV Ab-NEG [MASKED] 11:00AM BLOOD HCV Ab-NEG [MASKED] 06:06AM BLOOD [MASKED] 11:00AM BLOOD Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was unremarkable. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 325 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. [MASKED] is discharged to home with services in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 320 mg PO DAILY 2. betamethasone, augmented 0.05 % topical BID 3. Atorvastatin 20 mg PO QPM 4. Omeprazole 40 mg PO DAILY 5. Loratadine 10 mg PO DAILY 6. Sertraline 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 300 mg PO TID 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate 6. Senna 8.6 mg PO BID 7. Atorvastatin 20 mg PO QPM 8. betamethasone, augmented 0.05 % topical BID 9. Loratadine 10 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Valsartan 320 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Right knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 325 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 3 weeks after surgery. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize with assistive devices ([MASKED]) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Weight bearing as tolerated on the operative extremity. Mobilize with assistive devices ([MASKED]) if needed. Range of motion at the knee as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Treatments Frequency: Remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: [MASKED]
[]
[ "I10", "E785", "K219", "F329", "E669" ]
[ "M1711: Unilateral primary osteoarthritis, right knee", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E041: Nontoxic single thyroid nodule", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "Z6839: Body mass index [BMI] 39.0-39.9, adult" ]
10,037,861
24,540,843
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: metformin Attending: ___. Chief Complaint: Right Subdural Hematoma. Major Surgical or Invasive Procedure: ___ - Right craniotomy for evacuation of subdural hematoma. History of Present Illness: Mr. ___ is a ___ M with significant cardiac history including ICD placement, EF 25%, afib on Coumadin. He complained of headache to his wife and took two Aspirin of unknown dose this morning. Later she heard a loud noise and found the patient collapsed and unable to stand. He was transferred to an outside hospital with a GCS 3 and intubated on arrival. SBP was 160-220 and decreased to 120's with positive pressure ventilation and propofol. A NCHCT was concerning for extensive hemorrhage including R SDH, IVH and SAH with 15mm right to left shift. INR 3.2 at outside hospital, reversed with K-centra and vitamin K. He was transferred to ___ ED via medflight and given Mannitol 50G, Keppra 1G on transport. Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes (hgba1c 8) 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: PCI to mid LAD ___ - ___: None 3. OTHER PAST MEDICAL HISTORY: CKD stage III baseline Ct 1.2-1.5 ischemic CM s/p ICD, EF 25% Afib formerly on warfarin Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAMINATON ON ADMISSION: O: T: 97.8 BP: 104/48 HR: 59 R: 17 O2Sats: 100% intubated Gen: WD/WN, comfortable, NAD. HEENT: Pupils: pupils equal and round, non-reactive. 2mm bilaterally. EOMs: unable to assess. Neck: Supple. Extrem: Cool and dusky bilateral upper extremities. Cool and pale bilateral lower extremities. GCS on neurosurgical evaluation: 3T Neuro: Intubated. + cough. No corneals. Pupils equally round and non-reactive to light. 3mm bilaterally. Tongue appears midline and appears to be fasciculating around ET tube. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Minimally triple flexing to noxious. Toes downgoing bilaterally. PHYSICAL EXAMINATION ON DISCHARGE: XXX Pertinent Results: ___ - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Large subdural hematoma overlying the right hemisphere measuring up to 1.2 cm in maximum thickness with mixed density, but predominantly acute. This subdural hemorrhage also extends along the right falx and tentorium. 2. Hemorrhagic contusion in the right temporal lobe measuring 1.3 x 1.8cm. 3. Leftward subfalcine herniation. 4. Tiny amount of blood in the atrium of the left lateral ventricle. ___ - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Status post right craniotomy and evacuation of subdural blood products with expected post procedural changes including pneumocephalus and extracranial soft tissue swelling, fluid, and subcutaneous air. 2. Significantly decreased leftward shift of normally midline structures, now measuring 8 mm. 3. Persistent subdural blood along the right falx and tentorium and smaller amounts of blood along the left-sided aspect of the falx and layering in the atrium of the left-lateral ventricle, unchanged. 4. Slightly increased size of an intraparenchymal hematoma in the right temporal lobe may be related to patient position/planes of scanning, now measuring 2.2 x 4.6 cm (previously 2.5 x 4.0 cm). Close attention on follow-up is recommend. ___ - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Expected postoperative changes with similar appearance of known intraparenchymal hematoma in the right temporal lobe with surrounding vasogenic edema and unchanged leftward shift of midline structures. There is no evidence of infarction or new hemorrhage. ___ - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Status post right craniotomy with expected postoperative changes. Stable right subdural, right temporal intraparenchymal, and bilateral subarachnoid hemorrhages. No evidence of new hemorrhage. 2. Stable edema surrounding the right temporal intraparenchymal hemorrhage. 3. Stable 9 mm of right-to-left midline shift. ___ - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Enlarging right subdural hematoma, now with a maximum thickness of 14 mm (previously 12 mm). 2. Increased mass-effect with increased leftward shift of normally midline structures, now measuring 10 mm (previously 8 mm). 3. Likely unchanged right temporal lobe intraparenchymal component. 4. Unchanged foci of subarachnoid blood within sulci of the left frontal lobe and intraventricular blood. ___ - Bilateral Upper Extremity Vascular Study IMPRESSION: 1. No evidence of deep vein thrombosis in the bilateral upper extremity veins. 2. Occlusive thrombus seen in the left cephalic vein only at the level of the antecubital fossa. Normal flow is seen within this vein in the left upper arm. 3. Slow flow is incidentally noted in the right basilic vein. ___ - CT HEAD WITHOUT CONTRAST IMPRESSION: -Right subdural hematoma measuring up to 1.4 mm in greatest thickness, is overall similar in size from prior examination status post right pterional craniotomy for decompression, with expected decreased it pneumocephalus. -Interval expected evolution of parafalcine subdural hematoma. The remainder of the multi compartment hemorrhages are similar to prior examination. -No new hemorrhage. No acute large territory infarct. ___ CXR Compared to chest radiographs ___ through ___. Residual atelectasis or consolidation at the left lung base and mild edema at the right base on the only focal pulmonary abnormalities. Moderate cardiomegaly has improved since ___. Pleural effusions are likely but not appreciable. No pneumothorax. Cardiopulmonary support devices in standard placements. Probably mild edema in the right lower lobe Brief Hospital Course: Mr. ___ was admitted the neuro ICU on ___ s/p fall several days prior to presentation to the hospital. He underwent a right craniotomy for evacuation of subdural hematoma on ___. On ___, the patient was made DNR due to family wished after reviewing his poor neurological exam. At that time, he remained on pressors which had been started on after the OR. Due to continued need for pressors, a CTA of the torso was done to rule out an abscess. The scan was negative for abscess, but there was an incidental findings of 2.9 cm infrarenal aortic aneurysm. 1.4 cm right common iliac artery aneurysm. On ___, the patient was noted to have seizures in the setting of an unchanged NCHCT. His AEDs were optimized while monitored on continuous EEG. The patient eventually required a midazolam drip to adequately control the seizures. On ___, the patient was started on a course of antibiotics for a presumed pneumonia; he required a cooling blanket for continuous temperature increases. He was also on an insulin drip for poorly controlled sugars. After discussion with the patient's family, per their wished, he was transitioned to Care Measures Only on ___ and was extubated at 1600 in the afternoon. The patient expired at 2308. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 3. Spironolactone 25 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Digoxin 0.125 mg PO EVERY OTHER DAY 7. Warfarin 2.5 mg PO 6X/WEEK (___) 8. Warfarin 1.25 mg PO 1X/WEEK (___) 9. Atorvastatin 80 mg PO QPM 10. glimepiride 4 mg oral DAILY 11. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.rhamn A - ___ - L . a c - ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) Dose is Unknown oral DAILY 12. Vitamin D ___ UNIT PO DAILY Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Right Subdural Hematoma Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: ___
[ "S065X7A", "G935", "J9600", "R6521", "A419", "I5023", "I130", "N390", "Z9911", "N179", "J95851", "E870", "I82612", "W19XXXA", "Y92009", "Z66", "Z515", "Z95810", "I4891", "Z7901", "E785", "E1122", "N183", "I2510", "Z955", "I252", "I255", "Z9282", "Z87891", "G40901", "B965", "I9581", "R4020", "B9689", "Y848", "Y92230", "S06357A", "N200", "I714" ]
Allergies: metformin Chief Complaint: Right Subdural Hematoma. Major Surgical or Invasive Procedure: [MASKED] - Right craniotomy for evacuation of subdural hematoma. History of Present Illness: Mr. [MASKED] is a [MASKED] M with significant cardiac history including ICD placement, EF 25%, afib on Coumadin. He complained of headache to his wife and took two Aspirin of unknown dose this morning. Later she heard a loud noise and found the patient collapsed and unable to stand. He was transferred to an outside hospital with a GCS 3 and intubated on arrival. SBP was 160-220 and decreased to 120's with positive pressure ventilation and propofol. A NCHCT was concerning for extensive hemorrhage including R SDH, IVH and SAH with 15mm right to left shift. INR 3.2 at outside hospital, reversed with K-centra and vitamin K. He was transferred to [MASKED] ED via medflight and given Mannitol 50G, Keppra 1G on transport. Past Medical History: 1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes (hgba1c 8) 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: PCI to mid LAD [MASKED] - [MASKED]: None 3. OTHER PAST MEDICAL HISTORY: CKD stage III baseline Ct 1.2-1.5 ischemic CM s/p ICD, EF 25% Afib formerly on warfarin Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAMINATON ON ADMISSION: O: T: 97.8 BP: 104/48 HR: 59 R: 17 O2Sats: 100% intubated Gen: WD/WN, comfortable, NAD. HEENT: Pupils: pupils equal and round, non-reactive. 2mm bilaterally. EOMs: unable to assess. Neck: Supple. Extrem: Cool and dusky bilateral upper extremities. Cool and pale bilateral lower extremities. GCS on neurosurgical evaluation: 3T Neuro: Intubated. + cough. No corneals. Pupils equally round and non-reactive to light. 3mm bilaterally. Tongue appears midline and appears to be fasciculating around ET tube. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Minimally triple flexing to noxious. Toes downgoing bilaterally. PHYSICAL EXAMINATION ON DISCHARGE: XXX Pertinent Results: [MASKED] - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Large subdural hematoma overlying the right hemisphere measuring up to 1.2 cm in maximum thickness with mixed density, but predominantly acute. This subdural hemorrhage also extends along the right falx and tentorium. 2. Hemorrhagic contusion in the right temporal lobe measuring 1.3 x 1.8cm. 3. Leftward subfalcine herniation. 4. Tiny amount of blood in the atrium of the left lateral ventricle. [MASKED] - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Status post right craniotomy and evacuation of subdural blood products with expected post procedural changes including pneumocephalus and extracranial soft tissue swelling, fluid, and subcutaneous air. 2. Significantly decreased leftward shift of normally midline structures, now measuring 8 mm. 3. Persistent subdural blood along the right falx and tentorium and smaller amounts of blood along the left-sided aspect of the falx and layering in the atrium of the left-lateral ventricle, unchanged. 4. Slightly increased size of an intraparenchymal hematoma in the right temporal lobe may be related to patient position/planes of scanning, now measuring 2.2 x 4.6 cm (previously 2.5 x 4.0 cm). Close attention on follow-up is recommend. [MASKED] - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Expected postoperative changes with similar appearance of known intraparenchymal hematoma in the right temporal lobe with surrounding vasogenic edema and unchanged leftward shift of midline structures. There is no evidence of infarction or new hemorrhage. [MASKED] - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Status post right craniotomy with expected postoperative changes. Stable right subdural, right temporal intraparenchymal, and bilateral subarachnoid hemorrhages. No evidence of new hemorrhage. 2. Stable edema surrounding the right temporal intraparenchymal hemorrhage. 3. Stable 9 mm of right-to-left midline shift. [MASKED] - CT HEAD WITHOUT CONTRAST IMPRESSION: 1. Enlarging right subdural hematoma, now with a maximum thickness of 14 mm (previously 12 mm). 2. Increased mass-effect with increased leftward shift of normally midline structures, now measuring 10 mm (previously 8 mm). 3. Likely unchanged right temporal lobe intraparenchymal component. 4. Unchanged foci of subarachnoid blood within sulci of the left frontal lobe and intraventricular blood. [MASKED] - Bilateral Upper Extremity Vascular Study IMPRESSION: 1. No evidence of deep vein thrombosis in the bilateral upper extremity veins. 2. Occlusive thrombus seen in the left cephalic vein only at the level of the antecubital fossa. Normal flow is seen within this vein in the left upper arm. 3. Slow flow is incidentally noted in the right basilic vein. [MASKED] - CT HEAD WITHOUT CONTRAST IMPRESSION: -Right subdural hematoma measuring up to 1.4 mm in greatest thickness, is overall similar in size from prior examination status post right pterional craniotomy for decompression, with expected decreased it pneumocephalus. -Interval expected evolution of parafalcine subdural hematoma. The remainder of the multi compartment hemorrhages are similar to prior examination. -No new hemorrhage. No acute large territory infarct. [MASKED] CXR Compared to chest radiographs [MASKED] through [MASKED]. Residual atelectasis or consolidation at the left lung base and mild edema at the right base on the only focal pulmonary abnormalities. Moderate cardiomegaly has improved since [MASKED]. Pleural effusions are likely but not appreciable. No pneumothorax. Cardiopulmonary support devices in standard placements. Probably mild edema in the right lower lobe Brief Hospital Course: Mr. [MASKED] was admitted the neuro ICU on [MASKED] s/p fall several days prior to presentation to the hospital. He underwent a right craniotomy for evacuation of subdural hematoma on [MASKED]. On [MASKED], the patient was made DNR due to family wished after reviewing his poor neurological exam. At that time, he remained on pressors which had been started on after the OR. Due to continued need for pressors, a CTA of the torso was done to rule out an abscess. The scan was negative for abscess, but there was an incidental findings of 2.9 cm infrarenal aortic aneurysm. 1.4 cm right common iliac artery aneurysm. On [MASKED], the patient was noted to have seizures in the setting of an unchanged NCHCT. His AEDs were optimized while monitored on continuous EEG. The patient eventually required a midazolam drip to adequately control the seizures. On [MASKED], the patient was started on a course of antibiotics for a presumed pneumonia; he required a cooling blanket for continuous temperature increases. He was also on an insulin drip for poorly controlled sugars. After discussion with the patient's family, per their wished, he was transitioned to Care Measures Only on [MASKED] and was extubated at 1600 in the afternoon. The patient expired at 2308. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 3. Spironolactone 25 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Digoxin 0.125 mg PO EVERY OTHER DAY 7. Warfarin 2.5 mg PO 6X/WEEK ([MASKED]) 8. Warfarin 1.25 mg PO 1X/WEEK ([MASKED]) 9. Atorvastatin 80 mg PO QPM 10. glimepiride 4 mg oral DAILY 11. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.rhamn A - [MASKED] - L . a c - [MASKED] acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) Dose is Unknown oral DAILY 12. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Right Subdural Hematoma Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: [MASKED]
[]
[ "I130", "N390", "N179", "Z66", "Z515", "I4891", "Z7901", "E785", "E1122", "I2510", "Z955", "I252", "Z87891", "Y92230" ]
[ "S065X7A: Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain injury before regaining consciousness, initial encounter", "G935: Compression of brain", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "R6521: Severe sepsis with septic shock", "A419: Sepsis, unspecified organism", "I5023: Acute on chronic systolic (congestive) heart failure", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N390: Urinary tract infection, site not specified", "Z9911: Dependence on respirator [ventilator] status", "N179: Acute kidney failure, unspecified", "J95851: Ventilator associated pneumonia", "E870: Hyperosmolality and hypernatremia", "I82612: Acute embolism and thrombosis of superficial veins of left upper extremity", "W19XXXA: Unspecified fall, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "E785: Hyperlipidemia, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction", "I255: Ischemic cardiomyopathy", "Z9282: Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility", "Z87891: Personal history of nicotine dependence", "G40901: Epilepsy, unspecified, not intractable, with status epilepticus", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "I9581: Postprocedural hypotension", "R4020: Unspecified coma", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "S06357A: Traumatic hemorrhage of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter", "N200: Calculus of kidney", "I714: Abdominal aortic aneurysm, without rupture" ]
10,037,928
24,885,579
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Aspirin / Sulfasalazine / Lisinopril / Codeine / nitrofurantoin / Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ w/ hx of HTN and IDDM who is presenting here to the ED for a 1 day hx of RLQ abd pain. She says she has never had these sx before. ROS is diffusely +ve, including n/v, loose stools, ?melena, lightheadedness and/or dizziness; ROS is o/w -ve except as noted above. Her labs show WBC 7.7, and a CT A/P was obtained which showed a dilated appendix to 1.3 cm diameter w/ surrounding fat stranding and ?phlegmon c/f appendicitis, for which we were consulted. Past Medical History: DM2 HTN Hyperlipidemia Depression Anxiety Iron deficiency anemia GERD Chronic back pain Insomnia Tongue cancer, sees specialist at ___ H/o stomach ulcers Social History: ___ Family History: She had brother with lung CA, daughter with endometrial cancer Physical Exam: PHYSICAL EXAMINATION: upon admission: ___: Temp: 98.2 HR: 105 BP: 177/69 Resp: 24 O(2)Sat: 96 Normal Constitutional: Patient is well-appearing and in no acute distress HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Neck is supple Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nondistended, tender to palpation in the left lower quadrant and suprapubic region with voluntary guarding Rectal: Heme Positive Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent, moving all extremities Psych: Normal mood, Normal mentation Physical examination upon discharge: ___: vital signs: t=98.5, hr=77, bp=131/61,rr=18, 95% room air GENERAL: NAD CV: ns1, s2, no murmurs LUNGS: coarse BS bil ABDOMEN: soft, non-tender EXT: no pedal edema bil, no calf tenderness bil NEURO: alert and oriented x 3 Pertinent Results: ___ 05:18AM BLOOD WBC-10.3* RBC-4.04 Hgb-12.4 Hct-38.0 MCV-94 MCH-30.7 MCHC-32.6 RDW-12.6 RDWSD-43.9 Plt ___ ___ 04:20AM BLOOD WBC-11.9* RBC-3.97 Hgb-12.3 Hct-37.6 MCV-95 MCH-31.0 MCHC-32.7 RDW-12.5 RDWSD-43.9 Plt ___ ___ 06:50PM BLOOD WBC-7.7 RBC-4.58 Hgb-14.1 Hct-42.4 MCV-93 MCH-30.8 MCHC-33.3 RDW-12.6 RDWSD-42.8 Plt ___ ___ 06:50PM BLOOD Neuts-82.6* Lymphs-10.6* Monos-6.0 Eos-0.4* Baso-0.3 Im ___ AbsNeut-6.38* AbsLymp-0.82* AbsMono-0.46 AbsEos-0.03* AbsBaso-0.02 ___ 05:18AM BLOOD Plt ___ ___ 05:18AM BLOOD Glucose-181* UreaN-11 Creat-1.1 Na-142 K-4.1 Cl-107 HCO3-19* AnGap-16 ___ 04:20AM BLOOD Glucose-180* UreaN-10 Creat-1.1 Na-140 K-3.7 Cl-104 HCO3-24 AnGap-12 ___ 06:50PM BLOOD Glucose-328* UreaN-22* Creat-1.3* Na-137 K-5.1 Cl-95* HCO3-24 AnGap-18 ___ 06:50PM BLOOD ALT-28 AST-32 AlkPhos-104 TotBili-0.9 ___ 05:18AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.8 ___ 06:26AM BLOOD %HbA1c-11.2* eAG-275* ___: cat scan abd/pelvis: Dilated appendix measuring 1.3 cm with significant surrounding fat stranding, compatible with acute appendicitis. Of note, the appearance is slightly atypical given isolated involvement of the appendiceal base with the inflammation centered at the base of the cecum and appendix. The mid to distal appendix and including the tip are all normal in appearance. No evidence of perforation or abscess. Brief Hospital Course: ___ year old female admitted to the hospital with abdominal pain. Upon admission, the patient was made NPO, given intravenous fluids, and underwent a cat scan which showed a dilated appendix. The patient underwent serial abdominal examinations and placed on bowel rest. She was placed on a course of ciprofloxacin and flagyl. During the patient's hospitalization, she was noted to have elevated blood sugars. The ___ Diabetes ___ was consulted for recommendations in blood sugar management. On HD #3, the patient's abdominal pain decreased and she was started on clear liquids and advanced to a regular diet. Her white blood cell count normalized. The patient was discharged home with her family on HD#5. Her vital signs were stable and she was afebrile. She had return of bowel function and was voiding without difficulty. The patient was instructed to complete a course of ciprofloxacin and flagyl. Discharge instructions were reviewed and questions answered. A follow-up appointment was made in the acute care clinic. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Propranolol 20 mg PO BID 2. Atorvastatin 40 mg PO QPM 3. amLODIPine 10 mg PO DAILY 4. Mirtazapine 15 mg PO QHS 5. Omeprazole 40 mg PO DAILY 6. PARoxetine 40 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 10 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*12 Tablet Refills:*0 2. Glargine 25 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*18 Tablet Refills:*0 4. amLODIPine 10 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Mirtazapine 15 mg PO QHS 7. Omeprazole 40 mg PO DAILY 8. PARoxetine 40 mg PO DAILY 9. Propranolol 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with lower abdominal pain and tarry stools. You underwent cat scan imaging which showed acute appendicitis. You were started on antibiotics and your white blood cell count was monitored. During your hospital stay, you were noted to have elevation in your blood sugars and the ___ Diabetes was consulted and made adjustments in your diabetes medication. Your vital signs have been stable and you are preparing for discharge with the following recommedations: 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, or abdominal pain *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: ___
[ "K3580", "E1165", "C029", "I10", "Z794", "E785", "F329", "F419", "D509", "K219", "G8929", "M545", "G4700", "Z8711", "Z801", "Z8049" ]
Allergies: Aspirin / Sulfasalazine / Lisinopril / Codeine / nitrofurantoin / Sulfa (Sulfonamide Antibiotics) Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] w/ hx of HTN and IDDM who is presenting here to the ED for a 1 day hx of RLQ abd pain. She says she has never had these sx before. ROS is diffusely +ve, including n/v, loose stools, ?melena, lightheadedness and/or dizziness; ROS is o/w -ve except as noted above. Her labs show WBC 7.7, and a CT A/P was obtained which showed a dilated appendix to 1.3 cm diameter w/ surrounding fat stranding and ?phlegmon c/f appendicitis, for which we were consulted. Past Medical History: DM2 HTN Hyperlipidemia Depression Anxiety Iron deficiency anemia GERD Chronic back pain Insomnia Tongue cancer, sees specialist at [MASKED] H/o stomach ulcers Social History: [MASKED] Family History: She had brother with lung CA, daughter with endometrial cancer Physical Exam: PHYSICAL EXAMINATION: upon admission: [MASKED]: Temp: 98.2 HR: 105 BP: 177/69 Resp: 24 O(2)Sat: 96 Normal Constitutional: Patient is well-appearing and in no acute distress HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Neck is supple Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nondistended, tender to palpation in the left lower quadrant and suprapubic region with voluntary guarding Rectal: Heme Positive Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent, moving all extremities Psych: Normal mood, Normal mentation Physical examination upon discharge: [MASKED]: vital signs: t=98.5, hr=77, bp=131/61,rr=18, 95% room air GENERAL: NAD CV: ns1, s2, no murmurs LUNGS: coarse BS bil ABDOMEN: soft, non-tender EXT: no pedal edema bil, no calf tenderness bil NEURO: alert and oriented x 3 Pertinent Results: [MASKED] 05:18AM BLOOD WBC-10.3* RBC-4.04 Hgb-12.4 Hct-38.0 MCV-94 MCH-30.7 MCHC-32.6 RDW-12.6 RDWSD-43.9 Plt [MASKED] [MASKED] 04:20AM BLOOD WBC-11.9* RBC-3.97 Hgb-12.3 Hct-37.6 MCV-95 MCH-31.0 MCHC-32.7 RDW-12.5 RDWSD-43.9 Plt [MASKED] [MASKED] 06:50PM BLOOD WBC-7.7 RBC-4.58 Hgb-14.1 Hct-42.4 MCV-93 MCH-30.8 MCHC-33.3 RDW-12.6 RDWSD-42.8 Plt [MASKED] [MASKED] 06:50PM BLOOD Neuts-82.6* Lymphs-10.6* Monos-6.0 Eos-0.4* Baso-0.3 Im [MASKED] AbsNeut-6.38* AbsLymp-0.82* AbsMono-0.46 AbsEos-0.03* AbsBaso-0.02 [MASKED] 05:18AM BLOOD Plt [MASKED] [MASKED] 05:18AM BLOOD Glucose-181* UreaN-11 Creat-1.1 Na-142 K-4.1 Cl-107 HCO3-19* AnGap-16 [MASKED] 04:20AM BLOOD Glucose-180* UreaN-10 Creat-1.1 Na-140 K-3.7 Cl-104 HCO3-24 AnGap-12 [MASKED] 06:50PM BLOOD Glucose-328* UreaN-22* Creat-1.3* Na-137 K-5.1 Cl-95* HCO3-24 AnGap-18 [MASKED] 06:50PM BLOOD ALT-28 AST-32 AlkPhos-104 TotBili-0.9 [MASKED] 05:18AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.8 [MASKED] 06:26AM BLOOD %HbA1c-11.2* eAG-275* [MASKED]: cat scan abd/pelvis: Dilated appendix measuring 1.3 cm with significant surrounding fat stranding, compatible with acute appendicitis. Of note, the appearance is slightly atypical given isolated involvement of the appendiceal base with the inflammation centered at the base of the cecum and appendix. The mid to distal appendix and including the tip are all normal in appearance. No evidence of perforation or abscess. Brief Hospital Course: [MASKED] year old female admitted to the hospital with abdominal pain. Upon admission, the patient was made NPO, given intravenous fluids, and underwent a cat scan which showed a dilated appendix. The patient underwent serial abdominal examinations and placed on bowel rest. She was placed on a course of ciprofloxacin and flagyl. During the patient's hospitalization, she was noted to have elevated blood sugars. The [MASKED] Diabetes [MASKED] was consulted for recommendations in blood sugar management. On HD #3, the patient's abdominal pain decreased and she was started on clear liquids and advanced to a regular diet. Her white blood cell count normalized. The patient was discharged home with her family on HD#5. Her vital signs were stable and she was afebrile. She had return of bowel function and was voiding without difficulty. The patient was instructed to complete a course of ciprofloxacin and flagyl. Discharge instructions were reviewed and questions answered. A follow-up appointment was made in the acute care clinic. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Propranolol 20 mg PO BID 2. Atorvastatin 40 mg PO QPM 3. amLODIPine 10 mg PO DAILY 4. Mirtazapine 15 mg PO QHS 5. Omeprazole 40 mg PO DAILY 6. PARoxetine 40 mg PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 10 Days RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*12 Tablet Refills:*0 2. Glargine 25 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*18 Tablet Refills:*0 4. amLODIPine 10 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Mirtazapine 15 mg PO QHS 7. Omeprazole 40 mg PO DAILY 8. PARoxetine 40 mg PO DAILY 9. Propranolol 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with lower abdominal pain and tarry stools. You underwent cat scan imaging which showed acute appendicitis. You were started on antibiotics and your white blood cell count was monitored. During your hospital stay, you were noted to have elevation in your blood sugars and the [MASKED] Diabetes was consulted and made adjustments in your diabetes medication. Your vital signs have been stable and you are preparing for discharge with the following recommedations: 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, or abdominal pain *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: [MASKED]
[]
[ "E1165", "I10", "Z794", "E785", "F329", "F419", "D509", "K219", "G8929", "G4700" ]
[ "K3580: Unspecified acute appendicitis", "E1165: Type 2 diabetes mellitus with hyperglycemia", "C029: Malignant neoplasm of tongue, unspecified", "I10: Essential (primary) hypertension", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "D509: Iron deficiency anemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G8929: Other chronic pain", "M545: Low back pain", "G4700: Insomnia, unspecified", "Z8711: Personal history of peptic ulcer disease", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "Z8049: Family history of malignant neoplasm of other genital organs" ]
10,038,141
21,658,233
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: alendronate sodium Attending: ___. Chief Complaint: Disinhibited conduct, progressively worsening gait, and large volume urinary incontinence. Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ yo woman with medical history of HTN, GERD, and recent personality changes presenting to the ED sent from her assisted living facility with ___ weeks of disinhibited conduct, progressively worsening gait, and large volume urinary incontinence. Per discussion with her son she has been in ___ ___ with subtle cognitive decline. She had been doing well there until the end of ___, however he reports in the last ___ weeks she has shown significant personality changes including disinhibition, aggression (yelling/hitting staff), and becoming very confrontational which is out of her character. He also complains she has developed gait instability, initially requiring a walker and much worse in the last week to the point that she is unable to stand on her own and has been requiring a wheelchair to get around. She also has large volume urinary incontinence during the same period which is new for her. Per her PCP ___ (___) she was initially evaluated in ___. At the time she was having mild psychiatric issues which she describes as hallucinations and flight of ideas. She was started on Seroquel bid with significant improvement. At the time she was described as "verbose but appropriate". She was seen again by Dr. ___ ___ weeks ago for evaluation of falls up to three times per day. She was also acting inappropriately disrobing herself in her living facility. At the time the case was discussed with a neurologist at ___ which thought she may have "frontal lobe syndrome". MRI/MRA was performed which per report showed lacunar infarcts, moderate atrophy, and small vessel ischemic disease. At some point during the last ___ weeks he was admitted to a psych facility and started on Zoloft, Remeron, and Seroquel. Her son reports she takes Ativan 1mg TID for many decades for anxiety. On arrival to the ED she was agitated requiring lorazepam 2mg PO total, Seroquel 25mg PO x1, and home Depakote 125 mg. Psychiatry evaluated and confirmed ___. Recommended Thiamine supplementation due to concerns for Wernike's. On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Reports bladder incontinence. Firmly denies difficulty with gait. On general review of systems, the patient denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Past Medical History: HTN GERD LT radial fracture with hardware in place Recently seen by neurologist at ___ w/"frontal lobe syndrome" Per psych note: "No psych history prior ___ who is sent via ___ from her assisted living facility for significantly worsening aggression, impulsivity, and gait disturbance over the last two months". Social History: ___ Family History: Mother: died of possible MI at ___ yo Dad: died at age ___ of unknown causes Son: Healthy Physical ___: ============== ADMISSION EXAM ============== Vitals: 98.1 74 137/81 16 99% RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: MS: Awake, alert, oriented x 3. Able to relate history with difficulty as rationalizes her gait issues by saying her socks are sticky, her shoes were tight, or her toenails were too long. Inattentive, unable to name ___ backwards as she writes them down FWD and then reads them in BW order. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Content of speech bizarre as describes formed hallucinations ("when I close my eyes I see a bunny"). Mood is labile. Able to follow both midline and appendicular commands. Cranial Nerves: PERRL 4-3mm brisk. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. Motor - Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 4+ 5 5 5 5 5 R 5 ___ ___ 4+ 5 5 5 5 5 - Sensory - No deficits to light touch, but patient would not allow us to touch her feet any further to assess for proprioception -DTRs: Bi Tri ___ Pat Ach L 3 3 3 3 1 R 3 3 3 3 1 Plantar response upgoing bilaterally. Unable to test for jaw jerk due to poor cooperation. Coordination: No dysmetria with finger to nose testing bilaterally. Gait testing attempted but patient with broad base stance and significant retropulsion, unable to stand unassisted. ============== DISCHARGE EXAM ============== Essentially unchanged. -VS: T:98.___.5 BP: 145-153/79-84 HR: ___ RR: 18 O2: 97% RA -GEN: Awake in bed, NAD -HEENT: NC/AT -NECK: Supple -CV: warm, well perfused -PULM: normal inspiratory effort -ABD: Soft, NT/ND. -EXT: No clubbing, cyanosis, or edema. -MS: Alert, oriented x3. Verbally combative throughout exam. Unable to perform luria sequence. States MOYF and MOYB. ___ recall ___ with categories. Spontaneously repeated the 3 words correctly ~10 minutes later. Naming intact. Repetition and comprehension intact. Able to read and write. Follows commands, but perseverates on prior task. -CN: PERRL ___. Limited upgaze, otherwise EOMI. Face symmetric. Tongue midline. Intact sensation in V1-V3. -Motor: Mildly increased tone. Postural tremor L>R. ___ bilateral delt/bic/tri, 4+ IP b/l, giveway weakness bilateral quad/ham, ___ bilateral TA/Gas -DTR: R toe down. L toe mute. (+)palmar-mental reflex R>L, (-) glabellar reflex. (+) jaw jerk Bi Tri ___ Pat Ach L 3 3 3 3 1 R 3 3 3 3 1 -Sensory: Intact to light touch throughout. -Coordination: Intact finger to nose, mild postural tremor bilaterally. Finger tapping more clumsy on L. -Gait: Requires assistance to sit at the edge of bed, retropulses when attempts to stand. Requires two-person assist to stand upright. Pertinent Results: ==== LABS ==== ___ 06:24PM BLOOD WBC-10.8* RBC-4.64 Hgb-12.9 Hct-41.1 MCV-89 MCH-27.8 MCHC-31.4* RDW-14.3 RDWSD-46.1 Plt ___ ___ 06:24PM BLOOD Neuts-74.9* Lymphs-14.7* Monos-6.5 Eos-3.0 Baso-0.4 Im ___ AbsNeut-8.13* AbsLymp-1.59 AbsMono-0.71 AbsEos-0.32 AbsBaso-0.04 ___ 05:00AM BLOOD WBC-8.2 RBC-4.39 Hgb-12.3 Hct-39.7 MCV-90 MCH-28.0 MCHC-31.0* RDW-14.3 RDWSD-47.6* Plt ___ ___ 05:00AM BLOOD ___ PTT-31.7 ___ ___ 06:24PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-140 K-3.7 Cl-101 HCO3-25 AnGap-18 ___ 05:00AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-143 K-3.8 Cl-104 HCO3-28 AnGap-15 ___ 06:24PM BLOOD ALT-8 AST-13 AlkPhos-114* TotBili-0.3 ___ 05:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1 ___ 05:00AM BLOOD VitB12-580 Folate-10 ___ 05:00AM BLOOD TSH-1.0 ___ 06:24PM BLOOD Valproa-23* ___ 06:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:22AM URINE Color-Straw Appear-Hazy Sp ___ ___ 12:22AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG - CSF ___ 04:07PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-94* Polys-5 ___ Monos-24 Eos-1 TotProt-55* Glucose-54 FLUID CULTURE-PRELIMINARY; ACID FAST CULTURE-PRELIMINARY NEG - Micro SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-PENDING Blood (LYME) Lyme IgG-PENDING; Lyme IgM-PENDING URINE CULTURE-NEGATIVE ======= IMAGING ======= - ___ CT Head 1. No evidence of acute intracranial abnormalities. Specifically, no evidence for normal pressure hydrocephalus. 2. Age related global atrophy and chronic microangiopathy. 3. Mild left sphenoid sinus disease. Brief Hospital Course: Ms. ___ is a ___ yo woman with medical history of HTN, GERD, and progressive personality changes presenting to the ED sent from her assisted living facility with ___ weeks of worsening disinhibited conduct, worsening gait, and large volume urinary incontinence, diagnosed with Fronto-Temporal Dementia. Neurologic exam is limited by labile mood but notable for numerous frontal signs including inattention, disinhibition, inability to perform Luria sequence, brisk but symmetric reflexes, and significant retropulsion with attempted gait assessment. NCHCT with evidence of atrophy (especially frontally) and small vessel ischemic disease. History, exam, and imaging most consistent with fronto-temporal dementia, likely exacerbated by chronic vascular dementia. CSF studies were normal and showed no evidence of infection or inflammatory process. Opening pressure was slightly elevated at 21cm, however this done in ___ with the patient supine rather in flexed lateral position and likely represents false elevation. Suspicion was low for NPH. She is medically cleared for discharge. Studies for Lyme and syphilis are pending, but these are sufficiently unlikely given the overall clinical presentation that their pending status should not be a barrier to discharge to an appropriate care facility. She was evaluated by psychiatry who assessed the determined her to meet ___ for inability to care for self in the community, absence of insight into her care needs or presentation, and that she would benefit from an admission to a ___ facility (see note from Dr. ___, ___. # Dementia: Likely frontotemporal dementia. - Continue divalproex ___ TID. Consider increasing if LFTs stable. - Stop memantine. - Continue quetiapine 25mg QHS PRN. - Continue lorazepam taper to discontinuation. Currently 0.5mg BID (home 1mg TID). Contributing to disinhibition. CV: # Hypertension: - Continue atenolol 25mg BID. Consider resumption of home 50mg dose, or switch to agent with more CNS effects, such as propranolol. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Sertraline 50 mg PO DAILY 3. QUEtiapine Fumarate 25 mg PO BID 4. Atenolol 50 mg PO BID 5. Divalproex (DELayed Release) 125 mg PO TID 6. Mirtazapine 7.5 mg PO QHS 7. LORazepam 1 mg PO TID 8. Vitamin D 1000 UNIT PO DAILY 9. Cyanocobalamin 100 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Divalproex Sod. Sprinkles 125 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Heparin 5000 UNIT SC BID 5. Senna 17.2 mg PO HS 6. Thiamine 100 mg PO DAILY 7. Atenolol 25 mg PO BID 8. LORazepam 0.5 mg PO BID 9. QUEtiapine Fumarate 25 mg PO QHS:PRN agitation 10. Cyanocobalamin 100 mcg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Sertraline 50 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Frontotemporal Dementia 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: Ms. ___, You were admitted for symptoms of disinhibited conduct, including physical aggression, and worsening gait. Upon evaluation, you did not have evidence for any infectious, inflammatory, or other treatable cause for these symptoms. You showed neuropsychiatric signs consistent with a form of dementia that initially affects executive function (inhibition and planning). You will be referred to a care facility that specializes in this and similar conditions, and they will be best able to care for you. We made the following changes to your medications: - Weaning your Ativan (lorazepam). This worsens cognitive function and disinhibition. - STOP Remeron (mirtazapine). As it did not be appear to be having any effect and in order to simplify your medication regimen. - REDUCE Seroquel (quetiapine) from 25mg TWICE PER DAY to 25mg AT NIGHT IF NEEDED. This medicine is for agitation - which was not prominent during your stay - and can be used for now only when needed, in order to avoid excessive sedation. Thank you, Your ___ Neurology Team Followup Instructions: ___
[ "G3109", "F0281", "E512", "F070", "Z781", "I10", "K219", "F603", "F6089", "Z853", "R3981" ]
Allergies: alendronate sodium Chief Complaint: Disinhibited conduct, progressively worsening gait, and large volume urinary incontinence. Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [MASKED] yo woman with medical history of HTN, GERD, and recent personality changes presenting to the ED sent from her assisted living facility with [MASKED] weeks of disinhibited conduct, progressively worsening gait, and large volume urinary incontinence. Per discussion with her son she has been in [MASKED] [MASKED] with subtle cognitive decline. She had been doing well there until the end of [MASKED], however he reports in the last [MASKED] weeks she has shown significant personality changes including disinhibition, aggression (yelling/hitting staff), and becoming very confrontational which is out of her character. He also complains she has developed gait instability, initially requiring a walker and much worse in the last week to the point that she is unable to stand on her own and has been requiring a wheelchair to get around. She also has large volume urinary incontinence during the same period which is new for her. Per her PCP [MASKED] ([MASKED]) she was initially evaluated in [MASKED]. At the time she was having mild psychiatric issues which she describes as hallucinations and flight of ideas. She was started on Seroquel bid with significant improvement. At the time she was described as "verbose but appropriate". She was seen again by Dr. [MASKED] [MASKED] weeks ago for evaluation of falls up to three times per day. She was also acting inappropriately disrobing herself in her living facility. At the time the case was discussed with a neurologist at [MASKED] which thought she may have "frontal lobe syndrome". MRI/MRA was performed which per report showed lacunar infarcts, moderate atrophy, and small vessel ischemic disease. At some point during the last [MASKED] weeks he was admitted to a psych facility and started on Zoloft, Remeron, and Seroquel. Her son reports she takes Ativan 1mg TID for many decades for anxiety. On arrival to the ED she was agitated requiring lorazepam 2mg PO total, Seroquel 25mg PO x1, and home Depakote 125 mg. Psychiatry evaluated and confirmed [MASKED]. Recommended Thiamine supplementation due to concerns for Wernike's. On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Reports bladder incontinence. Firmly denies difficulty with gait. On general review of systems, the patient denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Past Medical History: HTN GERD LT radial fracture with hardware in place Recently seen by neurologist at [MASKED] w/"frontal lobe syndrome" Per psych note: "No psych history prior [MASKED] who is sent via [MASKED] from her assisted living facility for significantly worsening aggression, impulsivity, and gait disturbance over the last two months". Social History: [MASKED] Family History: Mother: died of possible MI at [MASKED] yo Dad: died at age [MASKED] of unknown causes Son: Healthy Physical [MASKED]: ============== ADMISSION EXAM ============== Vitals: 98.1 74 137/81 16 99% RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple [MASKED]: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: MS: Awake, alert, oriented x 3. Able to relate history with difficulty as rationalizes her gait issues by saying her socks are sticky, her shoes were tight, or her toenails were too long. Inattentive, unable to name [MASKED] backwards as she writes them down FWD and then reads them in BW order. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Content of speech bizarre as describes formed hallucinations ("when I close my eyes I see a bunny"). Mood is labile. Able to follow both midline and appendicular commands. Cranial Nerves: PERRL 4-3mm brisk. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength [MASKED] bilaterally. Tongue midline. Motor - Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 4+ 5 5 5 5 5 R 5 [MASKED] [MASKED] 4+ 5 5 5 5 5 - Sensory - No deficits to light touch, but patient would not allow us to touch her feet any further to assess for proprioception -DTRs: Bi Tri [MASKED] Pat Ach L 3 3 3 3 1 R 3 3 3 3 1 Plantar response upgoing bilaterally. Unable to test for jaw jerk due to poor cooperation. Coordination: No dysmetria with finger to nose testing bilaterally. Gait testing attempted but patient with broad base stance and significant retropulsion, unable to stand unassisted. ============== DISCHARGE EXAM ============== Essentially unchanged. -VS: T:98.[MASKED].5 BP: 145-153/79-84 HR: [MASKED] RR: 18 O2: 97% RA -GEN: Awake in bed, NAD -HEENT: NC/AT -NECK: Supple -CV: warm, well perfused -PULM: normal inspiratory effort -ABD: Soft, NT/ND. -EXT: No clubbing, cyanosis, or edema. -MS: Alert, oriented x3. Verbally combative throughout exam. Unable to perform luria sequence. States MOYF and MOYB. [MASKED] recall [MASKED] with categories. Spontaneously repeated the 3 words correctly ~10 minutes later. Naming intact. Repetition and comprehension intact. Able to read and write. Follows commands, but perseverates on prior task. -CN: PERRL [MASKED]. Limited upgaze, otherwise EOMI. Face symmetric. Tongue midline. Intact sensation in V1-V3. -Motor: Mildly increased tone. Postural tremor L>R. [MASKED] bilateral delt/bic/tri, 4+ IP b/l, giveway weakness bilateral quad/ham, [MASKED] bilateral TA/Gas -DTR: R toe down. L toe mute. (+)palmar-mental reflex R>L, (-) glabellar reflex. (+) jaw jerk Bi Tri [MASKED] Pat Ach L 3 3 3 3 1 R 3 3 3 3 1 -Sensory: Intact to light touch throughout. -Coordination: Intact finger to nose, mild postural tremor bilaterally. Finger tapping more clumsy on L. -Gait: Requires assistance to sit at the edge of bed, retropulses when attempts to stand. Requires two-person assist to stand upright. Pertinent Results: ==== LABS ==== [MASKED] 06:24PM BLOOD WBC-10.8* RBC-4.64 Hgb-12.9 Hct-41.1 MCV-89 MCH-27.8 MCHC-31.4* RDW-14.3 RDWSD-46.1 Plt [MASKED] [MASKED] 06:24PM BLOOD Neuts-74.9* Lymphs-14.7* Monos-6.5 Eos-3.0 Baso-0.4 Im [MASKED] AbsNeut-8.13* AbsLymp-1.59 AbsMono-0.71 AbsEos-0.32 AbsBaso-0.04 [MASKED] 05:00AM BLOOD WBC-8.2 RBC-4.39 Hgb-12.3 Hct-39.7 MCV-90 MCH-28.0 MCHC-31.0* RDW-14.3 RDWSD-47.6* Plt [MASKED] [MASKED] 05:00AM BLOOD [MASKED] PTT-31.7 [MASKED] [MASKED] 06:24PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-140 K-3.7 Cl-101 HCO3-25 AnGap-18 [MASKED] 05:00AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-143 K-3.8 Cl-104 HCO3-28 AnGap-15 [MASKED] 06:24PM BLOOD ALT-8 AST-13 AlkPhos-114* TotBili-0.3 [MASKED] 05:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1 [MASKED] 05:00AM BLOOD VitB12-580 Folate-10 [MASKED] 05:00AM BLOOD TSH-1.0 [MASKED] 06:24PM BLOOD Valproa-23* [MASKED] 06:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 12:22AM URINE Color-Straw Appear-Hazy Sp [MASKED] [MASKED] 12:22AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG - CSF [MASKED] 04:07PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-94* Polys-5 [MASKED] Monos-24 Eos-1 TotProt-55* Glucose-54 FLUID CULTURE-PRELIMINARY; ACID FAST CULTURE-PRELIMINARY NEG - Micro SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-PENDING Blood (LYME) Lyme IgG-PENDING; Lyme IgM-PENDING URINE CULTURE-NEGATIVE ======= IMAGING ======= - [MASKED] CT Head 1. No evidence of acute intracranial abnormalities. Specifically, no evidence for normal pressure hydrocephalus. 2. Age related global atrophy and chronic microangiopathy. 3. Mild left sphenoid sinus disease. Brief Hospital Course: Ms. [MASKED] is a [MASKED] yo woman with medical history of HTN, GERD, and progressive personality changes presenting to the ED sent from her assisted living facility with [MASKED] weeks of worsening disinhibited conduct, worsening gait, and large volume urinary incontinence, diagnosed with Fronto-Temporal Dementia. Neurologic exam is limited by labile mood but notable for numerous frontal signs including inattention, disinhibition, inability to perform Luria sequence, brisk but symmetric reflexes, and significant retropulsion with attempted gait assessment. NCHCT with evidence of atrophy (especially frontally) and small vessel ischemic disease. History, exam, and imaging most consistent with fronto-temporal dementia, likely exacerbated by chronic vascular dementia. CSF studies were normal and showed no evidence of infection or inflammatory process. Opening pressure was slightly elevated at 21cm, however this done in [MASKED] with the patient supine rather in flexed lateral position and likely represents false elevation. Suspicion was low for NPH. She is medically cleared for discharge. Studies for Lyme and syphilis are pending, but these are sufficiently unlikely given the overall clinical presentation that their pending status should not be a barrier to discharge to an appropriate care facility. She was evaluated by psychiatry who assessed the determined her to meet [MASKED] for inability to care for self in the community, absence of insight into her care needs or presentation, and that she would benefit from an admission to a [MASKED] facility (see note from Dr. [MASKED], [MASKED]. # Dementia: Likely frontotemporal dementia. - Continue divalproex [MASKED] TID. Consider increasing if LFTs stable. - Stop memantine. - Continue quetiapine 25mg QHS PRN. - Continue lorazepam taper to discontinuation. Currently 0.5mg BID (home 1mg TID). Contributing to disinhibition. CV: # Hypertension: - Continue atenolol 25mg BID. Consider resumption of home 50mg dose, or switch to agent with more CNS effects, such as propranolol. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Sertraline 50 mg PO DAILY 3. QUEtiapine Fumarate 25 mg PO BID 4. Atenolol 50 mg PO BID 5. Divalproex (DELayed Release) 125 mg PO TID 6. Mirtazapine 7.5 mg PO QHS 7. LORazepam 1 mg PO TID 8. Vitamin D 1000 UNIT PO DAILY 9. Cyanocobalamin 100 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Divalproex Sod. Sprinkles 125 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Heparin 5000 UNIT SC BID 5. Senna 17.2 mg PO HS 6. Thiamine 100 mg PO DAILY 7. Atenolol 25 mg PO BID 8. LORazepam 0.5 mg PO BID 9. QUEtiapine Fumarate 25 mg PO QHS:PRN agitation 10. Cyanocobalamin 100 mcg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Sertraline 50 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Frontotemporal Dementia 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: Ms. [MASKED], You were admitted for symptoms of disinhibited conduct, including physical aggression, and worsening gait. Upon evaluation, you did not have evidence for any infectious, inflammatory, or other treatable cause for these symptoms. You showed neuropsychiatric signs consistent with a form of dementia that initially affects executive function (inhibition and planning). You will be referred to a care facility that specializes in this and similar conditions, and they will be best able to care for you. We made the following changes to your medications: - Weaning your Ativan (lorazepam). This worsens cognitive function and disinhibition. - STOP Remeron (mirtazapine). As it did not be appear to be having any effect and in order to simplify your medication regimen. - REDUCE Seroquel (quetiapine) from 25mg TWICE PER DAY to 25mg AT NIGHT IF NEEDED. This medicine is for agitation - which was not prominent during your stay - and can be used for now only when needed, in order to avoid excessive sedation. Thank you, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
[]
[ "I10", "K219" ]
[ "G3109: Other frontotemporal dementia", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "E512: Wernicke's encephalopathy", "F070: Personality change due to known physiological condition", "Z781: Physical restraint status", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "F603: Borderline personality disorder", "F6089: Other specific personality disorders", "Z853: Personal history of malignant neoplasm of breast", "R3981: Functional urinary incontinence" ]
10,038,332
21,419,608
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / lima beans Attending: ___. Chief Complaint: buttock pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old with PMH of paraplegia below T10 since age ___ due to a gunshot wound, recurrent UTIs (self-caths due to neurogenic bladder), hx of prostatic abscess, unspecified psychotic disorder (bipolar vs schizophrenia), hx of opioid use disorder on suboxone who presents with 3 abdominal pain and cough and found to have perirectal phlegmon and being admitted for IV antibiotics. Patient states he was in his usual state of health until about 3 days ago when he began having abdominal pain, distention, productive cough, and fever to Tmax just over 100. He did not have a bowel movement for 5 days, then had a small bowel movement yesterday that was non-bloody. He denies N/V, sore throat, nasal congestion, dysuria. In the ED, initial vitals were: T 99.5 HR 105 BP 148/91 RR 18 - Exam notable for: Soft tissue swelling around gluteal cleft - Labs notable for: Hgb 12.7, UA with small leuk, neg nitrites, 2 WBC, no bacteria. Normal LFTs and BMP. - Imaging was notable for: CT A/P 1. Extensive soft tissue inflammatory changes surround the gluteal cleft and anal verge with 4 mm radiodense focus which could represent a foreign body (2:76). No drainable fluid collection. 2. No definite perianal fistula identified although close proximity to the external sphincter at 6 o'clock with linear high-density tract raises this possibility (2:80). Pelvic MRI could further evaluate. 3. Phlegmon reaches superiorly near the coccyx although there are no osseous changes to raise suspicion for osteomyelitis. 4. No bowel obstruction. Moderate to large stool burden throughout the colon. 5. Cholelithiasis. CXR: FINDINGS: Slight increased opacification overlying the upper lungs is likely due to technical factors and overlying soft tissue as the lateral radiograph demonstrates clear lungs. Cardiomediastinal silhouette and hila are normal. No pneumothorax or pleural effusion. Radiopaque foreign body overlying the posterior lower thoracic spine is unchanged from multiple prior radiographs. IMPRESSION: No evidence of pneumonia. Patient was seen by Colorectal surgery who could not identify abscess on exam. Reviewed imaging with radiology and felt findings were consistent with phlegmon with no identifiable fluid collection. - Patient was given: - PO Acetaminophen 1000 mg - IV CefTRIAXone 1 gm - IV MetroNIDAZOLE 500 mg Upon arrival to the floor, patient states he is having 'stinging' abdominal pain all over. He states this has been going on for about 3 days and has been getting progressively worse. He has had worsening abdominal distention and has not had a regular BM in over 5 days. He also reports some coughing with yellow sputum production but no sore throat, nasal congestion, or SOB. He has also had pain in his perirectal area but has not been as bad as abdominal pain. Denies any changes in urine color or cloudy urine, chills, N/V, blood in stool, or any other discharge in perianal area. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward ___ 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abscesses in neck, back, perianal 5. Recurrent sacral decubitus ulcers status post debridement in the OR on ___ and ___ & ___ (growing MRSA) 6. Pseudomonal prostatic abscess in ___ Prostatis in ___ 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___ 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation Social History: ___ Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITAL SIGNS: ___ 0826 Temp: 98.5 PO BP: 119/78 HR: 70 RR: 20 O2 sat: 98% GENERAL: Pleasant, well appearing, in no acute distress. HEENT: Oropharynx clear, no erythema or tonsillar swelling NECK: No LAD CARDIAC: Regular rhythm, normal rate. Normal S1, S2, no murmurs. LUNGS: Clear to auscultation bialterally ABDOMEN: Mildly distended but soft. Some mild discomfort with deep palpation in lower quadrants. No rebound or guarding BACK: Mild left sided paraspinal muscle tenderness to palpation. RECTAL: Has large bilateral sacral scars from prior infected sacral ulcers that are well healed. Mild tenderness to palpation just superior to anus in gluteal cleft. No erythema, induration, or fluctuance noted. No expressible discharge. EXTREMITIES: Warm with 2+ DP/radial pulses NEUROLOGIC: Paraplegia with ___ strength in lower extremities bilaterally. Normalt ___ strength in upper extremities. Normal sensation throughout. DISCHARGE PHYSICAL EXAM: ====================== VITAL SIGNS:24 HR Data (last updated ___ @ 2353) Temp: 98.7 (Tm 98.7), BP: 136/80 (129-136/78-84), HR: 72 (72-79), RR: 18, O2 sat: 98% (97-98), O2 delivery: Ra GENERAL: Pleasant, well appearing, in no acute distress. CARDIAC: Regular rhythm, normal rate. Normal S1, S2, no murmurs. LUNGS: Clear to auscultation bilaterally ABDOMEN: +Normal bowel sounds, soft, distended, mildly tender to deep palpation LLQ. No rebound or guarding EXTREMITIES: Warm with 2+ DP/radial pulses NEUROLOGIC: Paraplegia with ___ strength in lower extremities bilaterally. Normal ___ strength in upper extremities. Pertinent Results: ADMISSION LABS: ============== ___ 05:16AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 11:45PM GLUCOSE-118* UREA N-7 CREAT-0.7 SODIUM-141 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-12 ___ 11:45PM ALT(SGPT)-9 AST(SGOT)-15 ALK PHOS-58 TOT BILI-0.4 ___ 11:45PM LIPASE-43 ___ 11:45PM ALBUMIN-4.2 CALCIUM-9.7 PHOSPHATE-3.3 MAGNESIUM-1.9 IRON-66 ___ 11:45PM calTIBC-267 FERRITIN-134 TRF-205 ___ 11:45PM WBC-4.9 RBC-4.31* HGB-12.7* HCT-39.0* MCV-91 MCH-29.5 MCHC-32.6 RDW-12.1 RDWSD-40.3 ___ 11:45PM NEUTS-37.9 ___ MONOS-13.4* EOS-3.9 BASOS-0.6 IM ___ AbsNeut-1.86 AbsLymp-2.16 AbsMono-0.66 AbsEos-0.19 AbsBaso-0.03 ___ 11:45PM PLT COUNT-280 ___ 11:45PM RET AUT-2.4* ABS RET-0.10 ___ 07:45PM URINE HOURS-RANDOM ___ 07:45PM URINE UHOLD-HOLD ___ 07:45PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM* ___ 07:45PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 DISCHARGE LABS: =============== ___ 06:45AM BLOOD WBC-4.0 RBC-4.42* Hgb-13.0* Hct-40.9 MCV-93 MCH-29.4 MCHC-31.8* RDW-12.4 RDWSD-42.3 Plt ___ ___ 06:30AM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-142 K-4.7 Cl-102 HCO3-30 AnGap-10 ___ 06:30AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9 IMAGING: ======== ___ PELVIS W&W/O CONTRAS IMPRESSION: 1. No drainable fluid collection, perianal fistula, or significant phlegmonous change. 2. Chronic changes in the pelvis include areas of scarring and fibrosis, postsurgical changes related to sacral decubitus ulcer debridement and flap reconstruction, and chronic atrophy of the levator plate. 3. Mild edema and enhancement of the intersphincteric space consistent with granulation tissue, suggesting chronic inflammation. ___ ABD & PELVIS WITH CO IMPRESSION: 1. Extensive soft tissue inflammatory changes surround the gluteal cleft and anal verge with 4 mm radiodense focus which could represent a foreign body or dystrophic calcification (2:76). No drainable fluid collection. 2. No definite perianal fistula identified although close proximity to the external sphincter at 6 o'clock with linear high-density tract raises this possibility (2:80). Pelvic MRI could further evaluate. 3. Phlegmon reaches superiorly near the coccyx although there are no osseous changes to raise suspicion for osteomyelitis. This also could be better assessed on MRI. 4. No bowel obstruction. Moderate to large stool burden throughout the colon. 5. Cholelithiasis. ___ (PA & LAT) IMPRESSION: No evidence of pneumonia. MICROBIOLOGY: ============= ___ 7:45 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: VIRIDANS STREPTOCOCCI. 10,000-100,000 CFU/mL. Brief Hospital Course: This is a ___ year old with past medical history of T10 paraplegia complicated by neurogenic bladder and recurrent UTIs and prior prostatic abscess, unspecified psychotic disorder, opioid use disorder on suboxone, admitted ___ with several days of abdominal pain, initial cross-sectional imaging raising concern for perirectal phlegmon but subsquent MRI only showing chronic changes without signs of acute infection, course only otherwise notable for constipation, able to be discharged home on augmented bowel regimen # Abnormal CT Rectum Patient presented with abdominal pain, with CT imaging raising concern for perirectal fistula. Given history of MRSA, he was covered empirically with IV vanc, CTX, and PO flagyl. Exam only showed chronic changes. Subsequent MRI pelvis did not show evidence of abscess, fistula, or phlegmon (abnormalities seen on CT were thought to be chronic changes due to a healed pressure ulcer with flap), as such patient was discharged home without antibiotics. Formal read still pending at discharge, but second attending radiologist looked at the image and confirmed unofficial read of no acute infection. # Constipation # Abdominal Pain Patient presented complaint in the ED was abdominal pain and constipation. CT scan with signs of constipation without obstructin. Constipation thought to be secondary to suboxone. Pt provided with an aggressive bowel regimen, eventually requiring bowel preparation to resolve constipation. Patient subsequently transitioned to bowel regimen with senna and miralax. Abdominal pain markedly improved and patient was able to be discharged home # T10 Paraplegia c/b Neurogenic Bladder # Hx of Recurrent UTIs w/ prior ESBL Infection # Hx of prostatic abscess Patient has a history of recuurent UTIs likely related to self-catheterization due to neurogenic bladder. No urinary symptoms during this admission. Allowed patient to continue straight cath this admission. Continued suppression regimen of fosfomycin # History of Opioid Use Disorder, in remission On Suboxone and followed in ___ clinic. Reports 13 months of sobriety. Continued Suboxone-naloxone 8mg-2mg qd. Notified ___ with addiction team ___ when patient was discharged. # CODE: full (presumed) # CONTACT: HCP: ___ Relationship: MOTHER Phone: ___ TRANSITIONAL ISSUES: ================== - Discharged home - Patient reported noncompliance with tamsulosin 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. > 30 minutes spent on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 3. Gabapentin 800 mg PO TID 4. Multivitamins 1 TAB PO DAILY 5. Oxybutynin XL (*NF*) 20 mg Other DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. Venlafaxine XR 75 mg PO DAILY 8. alprostadil 20 mcg injection DAILY:PRN 9. Naloxone Nasal Spray 4 mg IH ASDIR 10. Vyvanse (lisdexamfetamine) 50 mg oral DAILY 11. Fosfomycin Tromethamine 3 g PO 1X/WEEK (TH) Discharge Medications: 1. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. alprostadil 20 mcg injection DAILY:PRN 4. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 5. Fosfomycin Tromethamine 3 g PO 1X/WEEK (TH) 6. Gabapentin 800 mg PO TID 7. Multivitamins 1 TAB PO DAILY 8. Naloxone Nasal Spray 4 mg IH ASDIR RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasally As needed Disp #*1 Bottle Refills:*0 9. Oxybutynin XL (*NF*) 20 mg Other DAILY 10. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a day Disp #*30 Packet Refills:*0 11. Venlafaxine XR 75 mg PO DAILY 12. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: # Generalized abdominal pain secondary to # Constipation # Abnormal CT Rectum # T10 Paraplegia c/b Neurogenic Bladder # Hx of Recurrent UTIs w/ prior ESBL Infection # History of Opioid Use Disorder, in remission Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent with wheelchair Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. Please see below for more information on your hospitalization. WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were having pain in your buttock WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - We did imaging which was reassuring - We started antibiotics for an infection on your buttock - You completed your antibiotics while you were in the hospital. - You were constipated. We gave you medications to help you have bowel movements. 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 - Continue your medications for constipation. It is important that you have a bowel movement every day. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, rectal pain, fever/chills, or blood in your stool. It was a pleasure taking part in your care here at ___! We wish you all the best! - Your ___ Care Team Followup Instructions: ___
[ "K5903", "G8220", "F1120", "R933", "T507X5A", "Y92019", "S24103S", "W3400XS", "F29", "F909", "Z8614", "G8929", "Z902", "D550", "N319", "N39498", "Z87440" ]
Allergies: aspirin / lima beans Chief Complaint: buttock pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year old with PMH of paraplegia below T10 since age [MASKED] due to a gunshot wound, recurrent UTIs (self-caths due to neurogenic bladder), hx of prostatic abscess, unspecified psychotic disorder (bipolar vs schizophrenia), hx of opioid use disorder on suboxone who presents with 3 abdominal pain and cough and found to have perirectal phlegmon and being admitted for IV antibiotics. Patient states he was in his usual state of health until about 3 days ago when he began having abdominal pain, distention, productive cough, and fever to Tmax just over 100. He did not have a bowel movement for 5 days, then had a small bowel movement yesterday that was non-bloody. He denies N/V, sore throat, nasal congestion, dysuria. In the ED, initial vitals were: T 99.5 HR 105 BP 148/91 RR 18 - Exam notable for: Soft tissue swelling around gluteal cleft - Labs notable for: Hgb 12.7, UA with small leuk, neg nitrites, 2 WBC, no bacteria. Normal LFTs and BMP. - Imaging was notable for: CT A/P 1. Extensive soft tissue inflammatory changes surround the gluteal cleft and anal verge with 4 mm radiodense focus which could represent a foreign body (2:76). No drainable fluid collection. 2. No definite perianal fistula identified although close proximity to the external sphincter at 6 o'clock with linear high-density tract raises this possibility (2:80). Pelvic MRI could further evaluate. 3. Phlegmon reaches superiorly near the coccyx although there are no osseous changes to raise suspicion for osteomyelitis. 4. No bowel obstruction. Moderate to large stool burden throughout the colon. 5. Cholelithiasis. CXR: FINDINGS: Slight increased opacification overlying the upper lungs is likely due to technical factors and overlying soft tissue as the lateral radiograph demonstrates clear lungs. Cardiomediastinal silhouette and hila are normal. No pneumothorax or pleural effusion. Radiopaque foreign body overlying the posterior lower thoracic spine is unchanged from multiple prior radiographs. IMPRESSION: No evidence of pneumonia. Patient was seen by Colorectal surgery who could not identify abscess on exam. Reviewed imaging with radiology and felt findings were consistent with phlegmon with no identifiable fluid collection. - Patient was given: - PO Acetaminophen 1000 mg - IV CefTRIAXone 1 gm - IV MetroNIDAZOLE 500 mg Upon arrival to the floor, patient states he is having 'stinging' abdominal pain all over. He states this has been going on for about 3 days and has been getting progressively worse. He has had worsening abdominal distention and has not had a regular BM in over 5 days. He also reports some coughing with yellow sputum production but no sore throat, nasal congestion, or SOB. He has also had pain in his perirectal area but has not been as bad as abdominal pain. Denies any changes in urine color or cloudy urine, chills, N/V, blood in stool, or any other discharge in perianal area. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward [MASKED] 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abscesses in neck, back, perianal 5. Recurrent sacral decubitus ulcers status post debridement in the OR on [MASKED] and [MASKED] & [MASKED] (growing MRSA) 6. Pseudomonal prostatic abscess in [MASKED] Prostatis in [MASKED] 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy [MASKED] 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation Social History: [MASKED] Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITAL SIGNS: [MASKED] 0826 Temp: 98.5 PO BP: 119/78 HR: 70 RR: 20 O2 sat: 98% GENERAL: Pleasant, well appearing, in no acute distress. HEENT: Oropharynx clear, no erythema or tonsillar swelling NECK: No LAD CARDIAC: Regular rhythm, normal rate. Normal S1, S2, no murmurs. LUNGS: Clear to auscultation bialterally ABDOMEN: Mildly distended but soft. Some mild discomfort with deep palpation in lower quadrants. No rebound or guarding BACK: Mild left sided paraspinal muscle tenderness to palpation. RECTAL: Has large bilateral sacral scars from prior infected sacral ulcers that are well healed. Mild tenderness to palpation just superior to anus in gluteal cleft. No erythema, induration, or fluctuance noted. No expressible discharge. EXTREMITIES: Warm with 2+ DP/radial pulses NEUROLOGIC: Paraplegia with [MASKED] strength in lower extremities bilaterally. Normalt [MASKED] strength in upper extremities. Normal sensation throughout. DISCHARGE PHYSICAL EXAM: ====================== VITAL SIGNS:24 HR Data (last updated [MASKED] @ 2353) Temp: 98.7 (Tm 98.7), BP: 136/80 (129-136/78-84), HR: 72 (72-79), RR: 18, O2 sat: 98% (97-98), O2 delivery: Ra GENERAL: Pleasant, well appearing, in no acute distress. CARDIAC: Regular rhythm, normal rate. Normal S1, S2, no murmurs. LUNGS: Clear to auscultation bilaterally ABDOMEN: +Normal bowel sounds, soft, distended, mildly tender to deep palpation LLQ. No rebound or guarding EXTREMITIES: Warm with 2+ DP/radial pulses NEUROLOGIC: Paraplegia with [MASKED] strength in lower extremities bilaterally. Normal [MASKED] strength in upper extremities. Pertinent Results: ADMISSION LABS: ============== [MASKED] 05:16AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 11:45PM GLUCOSE-118* UREA N-7 CREAT-0.7 SODIUM-141 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-12 [MASKED] 11:45PM ALT(SGPT)-9 AST(SGOT)-15 ALK PHOS-58 TOT BILI-0.4 [MASKED] 11:45PM LIPASE-43 [MASKED] 11:45PM ALBUMIN-4.2 CALCIUM-9.7 PHOSPHATE-3.3 MAGNESIUM-1.9 IRON-66 [MASKED] 11:45PM calTIBC-267 FERRITIN-134 TRF-205 [MASKED] 11:45PM WBC-4.9 RBC-4.31* HGB-12.7* HCT-39.0* MCV-91 MCH-29.5 MCHC-32.6 RDW-12.1 RDWSD-40.3 [MASKED] 11:45PM NEUTS-37.9 [MASKED] MONOS-13.4* EOS-3.9 BASOS-0.6 IM [MASKED] AbsNeut-1.86 AbsLymp-2.16 AbsMono-0.66 AbsEos-0.19 AbsBaso-0.03 [MASKED] 11:45PM PLT COUNT-280 [MASKED] 11:45PM RET AUT-2.4* ABS RET-0.10 [MASKED] 07:45PM URINE HOURS-RANDOM [MASKED] 07:45PM URINE UHOLD-HOLD [MASKED] 07:45PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM* [MASKED] 07:45PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 DISCHARGE LABS: =============== [MASKED] 06:45AM BLOOD WBC-4.0 RBC-4.42* Hgb-13.0* Hct-40.9 MCV-93 MCH-29.4 MCHC-31.8* RDW-12.4 RDWSD-42.3 Plt [MASKED] [MASKED] 06:30AM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-142 K-4.7 Cl-102 HCO3-30 AnGap-10 [MASKED] 06:30AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9 IMAGING: ======== [MASKED] PELVIS W&W/O CONTRAS IMPRESSION: 1. No drainable fluid collection, perianal fistula, or significant phlegmonous change. 2. Chronic changes in the pelvis include areas of scarring and fibrosis, postsurgical changes related to sacral decubitus ulcer debridement and flap reconstruction, and chronic atrophy of the levator plate. 3. Mild edema and enhancement of the intersphincteric space consistent with granulation tissue, suggesting chronic inflammation. [MASKED] ABD & PELVIS WITH CO IMPRESSION: 1. Extensive soft tissue inflammatory changes surround the gluteal cleft and anal verge with 4 mm radiodense focus which could represent a foreign body or dystrophic calcification (2:76). No drainable fluid collection. 2. No definite perianal fistula identified although close proximity to the external sphincter at 6 o'clock with linear high-density tract raises this possibility (2:80). Pelvic MRI could further evaluate. 3. Phlegmon reaches superiorly near the coccyx although there are no osseous changes to raise suspicion for osteomyelitis. This also could be better assessed on MRI. 4. No bowel obstruction. Moderate to large stool burden throughout the colon. 5. Cholelithiasis. [MASKED] (PA & LAT) IMPRESSION: No evidence of pneumonia. MICROBIOLOGY: ============= [MASKED] 7:45 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: VIRIDANS STREPTOCOCCI. 10,000-100,000 CFU/mL. Brief Hospital Course: This is a [MASKED] year old with past medical history of T10 paraplegia complicated by neurogenic bladder and recurrent UTIs and prior prostatic abscess, unspecified psychotic disorder, opioid use disorder on suboxone, admitted [MASKED] with several days of abdominal pain, initial cross-sectional imaging raising concern for perirectal phlegmon but subsquent MRI only showing chronic changes without signs of acute infection, course only otherwise notable for constipation, able to be discharged home on augmented bowel regimen # Abnormal CT Rectum Patient presented with abdominal pain, with CT imaging raising concern for perirectal fistula. Given history of MRSA, he was covered empirically with IV vanc, CTX, and PO flagyl. Exam only showed chronic changes. Subsequent MRI pelvis did not show evidence of abscess, fistula, or phlegmon (abnormalities seen on CT were thought to be chronic changes due to a healed pressure ulcer with flap), as such patient was discharged home without antibiotics. Formal read still pending at discharge, but second attending radiologist looked at the image and confirmed unofficial read of no acute infection. # Constipation # Abdominal Pain Patient presented complaint in the ED was abdominal pain and constipation. CT scan with signs of constipation without obstructin. Constipation thought to be secondary to suboxone. Pt provided with an aggressive bowel regimen, eventually requiring bowel preparation to resolve constipation. Patient subsequently transitioned to bowel regimen with senna and miralax. Abdominal pain markedly improved and patient was able to be discharged home # T10 Paraplegia c/b Neurogenic Bladder # Hx of Recurrent UTIs w/ prior ESBL Infection # Hx of prostatic abscess Patient has a history of recuurent UTIs likely related to self-catheterization due to neurogenic bladder. No urinary symptoms during this admission. Allowed patient to continue straight cath this admission. Continued suppression regimen of fosfomycin # History of Opioid Use Disorder, in remission On Suboxone and followed in [MASKED] clinic. Reports 13 months of sobriety. Continued Suboxone-naloxone 8mg-2mg qd. Notified [MASKED] with addiction team [MASKED] when patient was discharged. # CODE: full (presumed) # CONTACT: HCP: [MASKED] Relationship: MOTHER Phone: [MASKED] TRANSITIONAL ISSUES: ================== - Discharged home - Patient reported noncompliance with tamsulosin 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. > 30 minutes spent on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 3. Gabapentin 800 mg PO TID 4. Multivitamins 1 TAB PO DAILY 5. Oxybutynin XL (*NF*) 20 mg Other DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. Venlafaxine XR 75 mg PO DAILY 8. alprostadil 20 mcg injection DAILY:PRN 9. Naloxone Nasal Spray 4 mg IH ASDIR 10. Vyvanse (lisdexamfetamine) 50 mg oral DAILY 11. Fosfomycin Tromethamine 3 g PO 1X/WEEK (TH) Discharge Medications: 1. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. alprostadil 20 mcg injection DAILY:PRN 4. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 5. Fosfomycin Tromethamine 3 g PO 1X/WEEK (TH) 6. Gabapentin 800 mg PO TID 7. Multivitamins 1 TAB PO DAILY 8. Naloxone Nasal Spray 4 mg IH ASDIR RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasally As needed Disp #*1 Bottle Refills:*0 9. Oxybutynin XL (*NF*) 20 mg Other DAILY 10. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a day Disp #*30 Packet Refills:*0 11. Venlafaxine XR 75 mg PO DAILY 12. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: # Generalized abdominal pain secondary to # Constipation # Abnormal CT Rectum # T10 Paraplegia c/b Neurogenic Bladder # Hx of Recurrent UTIs w/ prior ESBL Infection # History of Opioid Use Disorder, in remission Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent with wheelchair Discharge Instructions: Dear Mr. [MASKED], It was a privilege caring for you at [MASKED]. Please see below for more information on your hospitalization. WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were having pain in your buttock WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - We did imaging which was reassuring - We started antibiotics for an infection on your buttock - You completed your antibiotics while you were in the hospital. - You were constipated. We gave you medications to help you have bowel movements. 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 - Continue your medications for constipation. It is important that you have a bowel movement every day. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, rectal pain, fever/chills, or blood in your stool. 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]
[]
[ "G8929" ]
[ "K5903: Drug induced constipation", "G8220: Paraplegia, unspecified", "F1120: Opioid dependence, uncomplicated", "R933: Abnormal findings on diagnostic imaging of other parts of digestive tract", "T507X5A: Adverse effect of analeptics and opioid receptor antagonists, initial encounter", "Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause", "S24103S: Unspecified injury at T7-T10 level of thoracic spinal cord, sequela", "W3400XS: Accidental discharge from unspecified firearms or gun, sequela", "F29: Unspecified psychosis not due to a substance or known physiological condition", "F909: Attention-deficit hyperactivity disorder, unspecified type", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection", "G8929: Other chronic pain", "Z902: Acquired absence of lung [part of]", "D550: Anemia due to glucose-6-phosphate dehydrogenase [G6PD] deficiency", "N319: Neuromuscular dysfunction of bladder, unspecified", "N39498: Other specified urinary incontinence", "Z87440: Personal history of urinary (tract) infections" ]
10,038,332
22,514,900
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: CC: ___, Wound Eval Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo man with h/o T10 paraplegia and recurrent UTIs, who presents via own wheelchair to the ___ ED with multiple concerns including "bed sores", new UTI and fever, as well as wanting detox from heroin. On review of the record, the patient was last seen in clinic by Dr. ___ on ___, at which time he was sober and being followed by ___ (___) ___. He was subsequently seen in the BID ED on ___ for recurrent UTI, discharged with cipro (despite cultures showing resistance to this). He appears to have most recently contacted his PCP ___ ___ with recurrent UTI Sx, was prescribed 9d of fosfomycin. Of note, discharged ___ on 6 wks of fosfomycin for E. coli prostatitis with resistance to ampicillin/Augmentin, ciprofloxacin, TMP-SMX, but susceptible to cephalosporins, had single follow-up visit with ID in early ___. His most recent positive urine culture was from ___, once again showed E. coli, with similar resistance pattern and additional resistance to gentamicin. In terms of his opioid use disorder, patient reports he has been to multiple detox facilities as well has had outpatient services. He was previously on suboxone, last 2 months ago at which time he relapsed. He has intermittently relapsed and has been discharged from multiple facilities due to inability to keep appointments. He feels depressed with ___ when he relapses, which is what prompted him to come to the ED during this time. He is motivated to stay sober this time around. In the ED, initial VS were: 6 98.4 111 147/90 18 98% RA Exam notable for: paraplegia, abdomen soft, stage 1 sacral ulcers, bilateral EKG: Not visible on Dash Labs showed: CBC 8.0 > 13.7 / 40.9 < 296, MCV: 89, N:60.2% BMP: K+ 4.2, BUN/Cr ___, Gluc 153 UA: ___, SG 1.030, Leuk Lg, Prot 30, Glu 150, Ket Tr, WBC > 182, Bact Few, Epi 2 Tox Serum Negative - ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Urine Positive - Cocaine Urine Negative - Benzos, Barbs, Opiates, Amphet, Mthdne, Oxycodone Imaging showed: CXR ___ FINDINGS: The lungs are hyperexpanded expanded but clear. There is no pleural abnormality the heart size is within normal limits. The mediastinal and hilar contours unremarkable. Calcific density projecting over the lower thoracic vertebra are unchanged in configuration. Consults: Psychiatry: "No s12, will contact BEST to look for EATS (dual-diagnosis unlocked unit), if patient attempting to leave prior to placement, please call psych for re-eval. For opioid withdrawal, would recommend: - Clonidine 0.1mg BID (hold for SBP <100, HR <55, or orthostatic changes) - Robaxin 750mg Q6H PRN muscle pain/cramps - Bentyl 20mg PO Q4H PRN GI cramps - Vistaril 50mg IM/PO Q4H PRN anxiety - Kaopectate 30 mL PO PRN after each loose stool - Acetaminophen 650mg Q6H PRN pain Page ___ with questions." Patient received: - Ceftriaxone 1gm IV x2 - NS 1L x1 Transfer VS were: 98.4 77 138/78 18 100% RA On arrival to the floor, patient reports feeling well. Endorses story above. He reports he was supposed to have an appointment with his PCP today but went to the ED due to symptoms of dysuria and urinary frequency for the past 2 days despite taking fosfomycin as well as wanting to be placed in a facility to detox. He was also concerned that he possibly may have pyelonephritis as he has had this previously and persistent pain in his L buttock where he has a pressure ulcer. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward ___ 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in ___ 5. Recurrent sacral decubitus ulcers status post debridement in the OR on ___ and ___ & ___ (growing MRSA) 6. Pseudomonal prostatic abscess in ___ Prostatis in ___ 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___ 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in ___ raised, in ___, completed high school in ___ and some post grad ___ training. Has one son, now ___ yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on ___ who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use ___ ___. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use ___ ___ but was found with cocaine in his urine on this admission in ___. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS: 98.3 PO 132 / 82 R Sitting 70 20 94 RA GENERAL: NAD HEENT: EOMI, PERRL, anicteric sclera, MMM, poor dentition NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: NT, mildly firm, +BS, no hepatosplenomegaly EXTREMITIES: ___ muscle wasting NEURO: A&Ox3, ___ strength in UE bilaterally, intact rectal tone GU: No prostate tenderness on DRE SKIN: warm and well perfused, stage 1 pressure ulcer on the L buttock DISCHARGE PHYSICAL EXAM: VS: ___ 0710 Temp: 98.5 PO BP: 119/52 L HR: 90 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: NAD HEENT: EOMI, PERRL, anicteric sclera, MMM, poor dentition NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: NT, mildly firm, +BS, no hepatosplenomegaly EXTREMITIES: ___ muscle wasting NEURO: A&Ox3, ___ strength in UE bilaterally, intact rectal tone SKIN: warm and well perfused Pertinent Results: ADMISSION LABS ___ 01:59AM WBC-8.0 RBC-4.59* HGB-13.7 HCT-40.9 MCV-89 MCH-29.8 MCHC-33.5 RDW-11.8 RDWSD-38.1 ___ 01:59AM NEUTS-60.2 ___ MONOS-12.3 EOS-2.0 BASOS-0.5 IM ___ AbsNeut-4.79 AbsLymp-1.97 AbsMono-0.98* AbsEos-0.16 AbsBaso-0.04 ___ 01:59AM PLT COUNT-296 ___ 01:35AM URINE HOURS-RANDOM ___ 01:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 01:35AM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 01:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-150* KETONE-TR* BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG* ___ 01:35AM URINE RBC-0 WBC->182* BACTERIA-FEW* YEAST-NONE EPI-2 ___ 01:35AM URINE MUCOUS-FEW* ___ 12:40AM GLUCOSE-153* UREA N-14 CREAT-1.0 SODIUM-140 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-30 ANION GAP-12 ___ 12:40AM estGFR-Using this ___ 12:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG IMAGING: CXR ___ IMPRESSION: No focal consolidation. No evidence of pneumonia. CT A/P ___ IMPRESSION: 1. 2.2 x 1 cm oval-shaped hypodensity in the right posterolateral prostatic apex is similar in appearance to prior MRI from ___ and may represent a chronic abscess or phlegmon. Consider pelvic MRI for further evaluation. 2. No CT evidence of pyelonephritis or renal abscess. 3. Diffuse fecal loading throughout the large bowel. MRI ___ IMPRESSION: 1. No prostatic abscess or phlegmon. Specifically, abnormality noted on CT from ___ within right peripheral zone corresponds to normal prostatic parenchyma. 2. Evidence of prior prostatitis within left peripheral zone. 3. Chronic bilateral sacral decubitus ulcers. Of note, study is not dedicated for evaluation of osteomyelitis and the findings are markedly improved compared to prior MR. ___: **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. STAPHYLOCOCCUS SAPROPHYTICUS, PRESUMPTIVE IDENTIFICATION. 10,000-100,000 CFU/mL. Routine susceptibility testing of urine isolates of S. saprophyticus is not advised because infections respond to concentrations achieved in urine of antimicrobial agents commonly used to treat acute uncomplicated urinary infections (e.g., nitrofurantoin, trimethoprim, trimethoprim sulfamethoxazole or a fluoroquinolone).. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE LABS: ___ 06:20AM BLOOD WBC-8.3 RBC-4.01* Hgb-12.0* Hct-38.0* MCV-95 MCH-29.9 MCHC-31.6* RDW-12.6 RDWSD-43.5 Plt ___ ___ 06:20AM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-143 K-4.5 Cl-102 HCO3-27 AnGap-14 ___ 06:20AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ year old man with paraplegia as a result of a GSW, neurogenic bladder with chronic intermittent straight caths, with recurrent UTIs with various organisms, now on chronic suppressive methenamine presenting with urinary tract infection, passive ___, and opioid withdrawal symptoms. ACUTE ISSUES: ============= # Opioid withdrawal, detox # History of polysubstance abuse # Passive ___ Serum and urine tox screens on admission only positive for cocaine. As per prior records, enrolled in multiple detox programs previously but discharged due to inconsistent medication use and lost to follow-up. Evaluated by psych given passive ___ on presentation but not sectionable on their evaluation. Recommended BEST screening for placement vs. CCS, dual diagnosis unit. Unable to successfully place this patient in above during the hospitalization. HIV/HCV checked for risk stratification and returned negative. Initiated on suboxone while inpatient as patient was having mild withdrawal symptoms not controlled with other medications with improvement. Plan to follow-up with Dr. ___ from psychiatry for suboxone. # UTI w/ history of drug-resistant E. Coli # History of prostatitis Symtpoms and UA consistent with UTI, started on IV ceftriaxone. On prophylactic methenamine hippurate on admission though from prior ID notes likely not providing much benefit as urine pH on testing has been too high to activate the drug. Urine culture growing cephalosporin/fluoroquinoline sensitive enterobacter. CT A/P obtained to r/o chronic abscess vs. phlegmon, though no signs of this on pelvic MRI. Transitioned from IV ceftriaxone to PO ciprofloxacin on discharge. Plan for 2 week course for early seeding of the prostate (end date ___. On discharge, for UTI ppx, ID recommended 3g fosfomycin PO q10 days rather than methanamine. CHRONIC ISSUES: =============== # Neurogenic bladder: Continued xxybutynin 10 mg PO BID (takes ER 20 mg daily at home), Tamsulosin 0.4 mg PO QHS with intermittent straight caths. # Chronic constipation: Continue bowel regimen PRN # history of ?bipolar vs schizophrenia - not currently taking any medications. # chronic low back pain: Continued Gabapentin 800 mg PO TID, Acetaminophen 650 mg PO Q8H:PRN Pain - Mild TRANSTIONAL ISSUES =================== - Last date of ciprofloxacin ___. - Start fosfomycin 3g PO q10 days on ___ - ID, PCP, and psychiatry for suboxone follow-up as above. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Gabapentin 800 mg PO TID 2. Tamsulosin 0.4 mg PO QHS 3. Ascorbic Acid ___ mg PO BID 4. methenamine hippurate 1 gram oral BID 5. oxybutynin chloride 20 mg oral DAILY Discharge Medications: 1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 3. Docusate Sodium 200 mg PO BID:PRN constipation RX *docusate sodium 100 mg 2 tablet(s) by mouth BID:PRN Disp #*60 Tablet Refills:*0 4. Fosfomycin Tromethamine 3 g PO Q10DAYS UTI prophylaxis Dissolve in ___ oz (90-120 mL) water and take immediately RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by mouth Q10days Disp #*3 Packet Refills:*0 5. Polyethylene Glycol 17 g PO TID:PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth TID:PRN Disp #*24 Packet Refills:*0 6. Senna 17.2 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 2 tablets by mouth BID:PRN Disp #*60 Tablet Refills:*0 7. Gabapentin 800 mg PO TID RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 8. oxybutynin chloride 20 mg oral DAILY RX *oxybutynin chloride 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 9. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Complicated urinary tract infection Opioid dependence with withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted to ___ for a urinary tract infection. We started you on intravenous antibiotics. We did imaging to make sure that you did not have an abscess of your prostate. We transitioned you to an oral antibiotic that you will take until ___. You also started experiencing withdrawal symptoms while here. We started you on suboxone and arranged for you to follow up with Dr. ___ for this. It was a pleasure caring for you. Wishing you the best, Your ___ Team Followup Instructions: ___
[ "N390", "E7401", "L89321", "L89312", "F1420", "G8220", "N318", "F209", "R45851", "F1123", "B9689", "N39498", "M545", "G8929", "F319", "K5909", "N411", "Z9114", "Z9119", "Z87440", "Z8614", "Z993", "Z590", "S24103S", "X959XXS", "R419" ]
Allergies: aspirin Chief Complaint: CC: [MASKED], Wound Eval Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] yo man with h/o T10 paraplegia and recurrent UTIs, who presents via own wheelchair to the [MASKED] ED with multiple concerns including "bed sores", new UTI and fever, as well as wanting detox from heroin. On review of the record, the patient was last seen in clinic by Dr. [MASKED] on [MASKED], at which time he was sober and being followed by [MASKED] ([MASKED]) [MASKED]. He was subsequently seen in the BID ED on [MASKED] for recurrent UTI, discharged with cipro (despite cultures showing resistance to this). He appears to have most recently contacted his PCP [MASKED] [MASKED] with recurrent UTI Sx, was prescribed 9d of fosfomycin. Of note, discharged [MASKED] on 6 wks of fosfomycin for E. coli prostatitis with resistance to ampicillin/Augmentin, ciprofloxacin, TMP-SMX, but susceptible to cephalosporins, had single follow-up visit with ID in early [MASKED]. His most recent positive urine culture was from [MASKED], once again showed E. coli, with similar resistance pattern and additional resistance to gentamicin. In terms of his opioid use disorder, patient reports he has been to multiple detox facilities as well has had outpatient services. He was previously on suboxone, last 2 months ago at which time he relapsed. He has intermittently relapsed and has been discharged from multiple facilities due to inability to keep appointments. He feels depressed with [MASKED] when he relapses, which is what prompted him to come to the ED during this time. He is motivated to stay sober this time around. In the ED, initial VS were: 6 98.4 111 147/90 18 98% RA Exam notable for: paraplegia, abdomen soft, stage 1 sacral ulcers, bilateral EKG: Not visible on Dash Labs showed: CBC 8.0 > 13.7 / 40.9 < 296, MCV: 89, N:60.2% BMP: K+ 4.2, BUN/Cr [MASKED], Gluc 153 UA: [MASKED], SG 1.030, Leuk Lg, Prot 30, Glu 150, Ket Tr, WBC > 182, Bact Few, Epi 2 Tox Serum Negative - ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Urine Positive - Cocaine Urine Negative - Benzos, Barbs, Opiates, Amphet, Mthdne, Oxycodone Imaging showed: CXR [MASKED] FINDINGS: The lungs are hyperexpanded expanded but clear. There is no pleural abnormality the heart size is within normal limits. The mediastinal and hilar contours unremarkable. Calcific density projecting over the lower thoracic vertebra are unchanged in configuration. Consults: Psychiatry: "No s12, will contact BEST to look for EATS (dual-diagnosis unlocked unit), if patient attempting to leave prior to placement, please call psych for re-eval. For opioid withdrawal, would recommend: - Clonidine 0.1mg BID (hold for SBP <100, HR <55, or orthostatic changes) - Robaxin 750mg Q6H PRN muscle pain/cramps - Bentyl 20mg PO Q4H PRN GI cramps - Vistaril 50mg IM/PO Q4H PRN anxiety - Kaopectate 30 mL PO PRN after each loose stool - Acetaminophen 650mg Q6H PRN pain Page [MASKED] with questions." Patient received: - Ceftriaxone 1gm IV x2 - NS 1L x1 Transfer VS were: 98.4 77 138/78 18 100% RA On arrival to the floor, patient reports feeling well. Endorses story above. He reports he was supposed to have an appointment with his PCP today but went to the ED due to symptoms of dysuria and urinary frequency for the past 2 days despite taking fosfomycin as well as wanting to be placed in a facility to detox. He was also concerned that he possibly may have pyelonephritis as he has had this previously and persistent pain in his L buttock where he has a pressure ulcer. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward [MASKED] 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in [MASKED] 5. Recurrent sacral decubitus ulcers status post debridement in the OR on [MASKED] and [MASKED] & [MASKED] (growing MRSA) 6. Pseudomonal prostatic abscess in [MASKED] Prostatis in [MASKED] 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy [MASKED] 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in [MASKED] raised, in [MASKED], completed high school in [MASKED] and some post grad [MASKED] training. Has one son, now [MASKED] yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on [MASKED] who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use [MASKED] [MASKED]. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use [MASKED] [MASKED] but was found with cocaine in his urine on this admission in [MASKED]. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION PHYSICAL EXAM: ADMISSION PHYSICAL EXAM: VS: 98.3 PO 132 / 82 R Sitting 70 20 94 RA GENERAL: NAD HEENT: EOMI, PERRL, anicteric sclera, MMM, poor dentition NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: NT, mildly firm, +BS, no hepatosplenomegaly EXTREMITIES: [MASKED] muscle wasting NEURO: A&Ox3, [MASKED] strength in UE bilaterally, intact rectal tone GU: No prostate tenderness on DRE SKIN: warm and well perfused, stage 1 pressure ulcer on the L buttock DISCHARGE PHYSICAL EXAM: VS: [MASKED] 0710 Temp: 98.5 PO BP: 119/52 L HR: 90 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: NAD HEENT: EOMI, PERRL, anicteric sclera, MMM, poor dentition NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: NT, mildly firm, +BS, no hepatosplenomegaly EXTREMITIES: [MASKED] muscle wasting NEURO: A&Ox3, [MASKED] strength in UE bilaterally, intact rectal tone SKIN: warm and well perfused Pertinent Results: ADMISSION LABS [MASKED] 01:59AM WBC-8.0 RBC-4.59* HGB-13.7 HCT-40.9 MCV-89 MCH-29.8 MCHC-33.5 RDW-11.8 RDWSD-38.1 [MASKED] 01:59AM NEUTS-60.2 [MASKED] MONOS-12.3 EOS-2.0 BASOS-0.5 IM [MASKED] AbsNeut-4.79 AbsLymp-1.97 AbsMono-0.98* AbsEos-0.16 AbsBaso-0.04 [MASKED] 01:59AM PLT COUNT-296 [MASKED] 01:35AM URINE HOURS-RANDOM [MASKED] 01:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 01:35AM URINE COLOR-Yellow APPEAR-Hazy* SP [MASKED] [MASKED] 01:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-150* KETONE-TR* BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG* [MASKED] 01:35AM URINE RBC-0 WBC->182* BACTERIA-FEW* YEAST-NONE EPI-2 [MASKED] 01:35AM URINE MUCOUS-FEW* [MASKED] 12:40AM GLUCOSE-153* UREA N-14 CREAT-1.0 SODIUM-140 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-30 ANION GAP-12 [MASKED] 12:40AM estGFR-Using this [MASKED] 12:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG IMAGING: CXR [MASKED] IMPRESSION: No focal consolidation. No evidence of pneumonia. CT A/P [MASKED] IMPRESSION: 1. 2.2 x 1 cm oval-shaped hypodensity in the right posterolateral prostatic apex is similar in appearance to prior MRI from [MASKED] and may represent a chronic abscess or phlegmon. Consider pelvic MRI for further evaluation. 2. No CT evidence of pyelonephritis or renal abscess. 3. Diffuse fecal loading throughout the large bowel. MRI [MASKED] IMPRESSION: 1. No prostatic abscess or phlegmon. Specifically, abnormality noted on CT from [MASKED] within right peripheral zone corresponds to normal prostatic parenchyma. 2. Evidence of prior prostatitis within left peripheral zone. 3. Chronic bilateral sacral decubitus ulcers. Of note, study is not dedicated for evaluation of osteomyelitis and the findings are markedly improved compared to prior MR. [MASKED]: **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. STAPHYLOCOCCUS SAPROPHYTICUS, PRESUMPTIVE IDENTIFICATION. 10,000-100,000 CFU/mL. Routine susceptibility testing of urine isolates of S. saprophyticus is not advised because infections respond to concentrations achieved in urine of antimicrobial agents commonly used to treat acute uncomplicated urinary infections (e.g., nitrofurantoin, trimethoprim, trimethoprim sulfamethoxazole or a fluoroquinolone).. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROBACTER CLOACAE COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE LABS: [MASKED] 06:20AM BLOOD WBC-8.3 RBC-4.01* Hgb-12.0* Hct-38.0* MCV-95 MCH-29.9 MCHC-31.6* RDW-12.6 RDWSD-43.5 Plt [MASKED] [MASKED] 06:20AM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-143 K-4.5 Cl-102 HCO3-27 AnGap-14 [MASKED] 06:20AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.0 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with paraplegia as a result of a GSW, neurogenic bladder with chronic intermittent straight caths, with recurrent UTIs with various organisms, now on chronic suppressive methenamine presenting with urinary tract infection, passive [MASKED], and opioid withdrawal symptoms. ACUTE ISSUES: ============= # Opioid withdrawal, detox # History of polysubstance abuse # Passive [MASKED] Serum and urine tox screens on admission only positive for cocaine. As per prior records, enrolled in multiple detox programs previously but discharged due to inconsistent medication use and lost to follow-up. Evaluated by psych given passive [MASKED] on presentation but not sectionable on their evaluation. Recommended BEST screening for placement vs. CCS, dual diagnosis unit. Unable to successfully place this patient in above during the hospitalization. HIV/HCV checked for risk stratification and returned negative. Initiated on suboxone while inpatient as patient was having mild withdrawal symptoms not controlled with other medications with improvement. Plan to follow-up with Dr. [MASKED] from psychiatry for suboxone. # UTI w/ history of drug-resistant E. Coli # History of prostatitis Symtpoms and UA consistent with UTI, started on IV ceftriaxone. On prophylactic methenamine hippurate on admission though from prior ID notes likely not providing much benefit as urine pH on testing has been too high to activate the drug. Urine culture growing cephalosporin/fluoroquinoline sensitive enterobacter. CT A/P obtained to r/o chronic abscess vs. phlegmon, though no signs of this on pelvic MRI. Transitioned from IV ceftriaxone to PO ciprofloxacin on discharge. Plan for 2 week course for early seeding of the prostate (end date [MASKED]. On discharge, for UTI ppx, ID recommended 3g fosfomycin PO q10 days rather than methanamine. CHRONIC ISSUES: =============== # Neurogenic bladder: Continued xxybutynin 10 mg PO BID (takes ER 20 mg daily at home), Tamsulosin 0.4 mg PO QHS with intermittent straight caths. # Chronic constipation: Continue bowel regimen PRN # history of ?bipolar vs schizophrenia - not currently taking any medications. # chronic low back pain: Continued Gabapentin 800 mg PO TID, Acetaminophen 650 mg PO Q8H:PRN Pain - Mild TRANSTIONAL ISSUES =================== - Last date of ciprofloxacin [MASKED]. - Start fosfomycin 3g PO q10 days on [MASKED] - ID, PCP, and psychiatry for suboxone follow-up as above. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Gabapentin 800 mg PO TID 2. Tamsulosin 0.4 mg PO QHS 3. Ascorbic Acid [MASKED] mg PO BID 4. methenamine hippurate 1 gram oral BID 5. oxybutynin chloride 20 mg oral DAILY Discharge Medications: 1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 3. Docusate Sodium 200 mg PO BID:PRN constipation RX *docusate sodium 100 mg 2 tablet(s) by mouth BID:PRN Disp #*60 Tablet Refills:*0 4. Fosfomycin Tromethamine 3 g PO Q10DAYS UTI prophylaxis Dissolve in [MASKED] oz (90-120 mL) water and take immediately RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by mouth Q10days Disp #*3 Packet Refills:*0 5. Polyethylene Glycol 17 g PO TID:PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth TID:PRN Disp #*24 Packet Refills:*0 6. Senna 17.2 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 2 tablets by mouth BID:PRN Disp #*60 Tablet Refills:*0 7. Gabapentin 800 mg PO TID RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 8. oxybutynin chloride 20 mg oral DAILY RX *oxybutynin chloride 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 9. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Complicated urinary tract infection Opioid dependence with withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] for a urinary tract infection. We started you on intravenous antibiotics. We did imaging to make sure that you did not have an abscess of your prostate. We transitioned you to an oral antibiotic that you will take until [MASKED]. You also started experiencing withdrawal symptoms while here. We started you on suboxone and arranged for you to follow up with Dr. [MASKED] for this. It was a pleasure caring for you. Wishing you the best, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N390", "G8929" ]
[ "N390: Urinary tract infection, site not specified", "E7401: von Gierke disease", "L89321: Pressure ulcer of left buttock, stage 1", "L89312: Pressure ulcer of right buttock, stage 2", "F1420: Cocaine dependence, uncomplicated", "G8220: Paraplegia, unspecified", "N318: Other neuromuscular dysfunction of bladder", "F209: Schizophrenia, unspecified", "R45851: Suicidal ideations", "F1123: Opioid dependence with withdrawal", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "N39498: Other specified urinary incontinence", "M545: Low back pain", "G8929: Other chronic pain", "F319: Bipolar disorder, unspecified", "K5909: Other constipation", "N411: Chronic prostatitis", "Z9114: Patient's other noncompliance with medication regimen", "Z9119: Patient's noncompliance with other medical treatment and regimen", "Z87440: Personal history of urinary (tract) infections", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection", "Z993: Dependence on wheelchair", "Z590: Homelessness", "S24103S: Unspecified injury at T7-T10 level of thoracic spinal cord, sequela", "X959XXS: Assault by unspecified firearm discharge, sequela", "R419: Unspecified symptoms and signs involving cognitive functions and awareness" ]
10,038,332
22,517,908
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / lima beans Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission Labs ============== ___ 02:25AM BLOOD WBC-8.4 RBC-3.92* Hgb-11.1* Hct-36.5* MCV-93 MCH-28.3 MCHC-30.4* RDW-13.3 RDWSD-45.4 Plt ___ ___ 02:25AM BLOOD Neuts-54.8 ___ Monos-18.7* Eos-4.1 Baso-0.6 Im ___ AbsNeut-4.60 AbsLymp-1.67 AbsMono-1.57* AbsEos-0.34 AbsBaso-0.05 ___ 02:25AM BLOOD Plt ___ ___ 02:25AM BLOOD Glucose-83 UreaN-14 Creat-0.7 Na-137 K-4.2 Cl-95* HCO3-26 AnGap-16 ___ 02:25AM BLOOD ALT-28 AST-45* AlkPhos-67 TotBili-0.5 ___ 09:30AM BLOOD CK(CPK)-347* ___ 02:25AM BLOOD Albumin-4.1 Calcium-9.5 Phos-4.0 Mg-2.1 Relevant Imaging ================ ___ NCHCT IMPRESSION: No acute intracranial process. Discharge Labs ============== ___ 05:47AM BLOOD WBC-7.8 RBC-4.06* Hgb-11.9* Hct-38.5* MCV-95 MCH-29.3 MCHC-30.9* RDW-13.2 RDWSD-45.8 Plt ___ ___ 05:47AM BLOOD Plt ___ ___ 05:47AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-141 K-5.0 Cl-99 HCO3-28 AnGap-14 ___ 05:47AM BLOOD Calcium-9.8 Phos-3.4 Mg-2.1 Brief Hospital Course: TRANSITIONAL ISSUES =================== [ ] Continue to monitor tolerance of suboxone (discharged on 8mg-2mg BID), close follow up with ___ clinic [ ] Social Work: Resources for wheelchair and homeless shelter [ ] Patient should have outpatient ID follow up for recurrent UTIs. [ ] Needs Hep B immunization [ ] Consider colonoscopy as outpatient for anemia ASSESSMENT AND PLAN: ==================== ___ man with a history of T10 paraplegia, neurogenic bladder with recurrent MDR UTIs, polysubstance use disorder (recent cocaine, heroin relapse) presenting with myalgias and change in urine odor. He had eloped one day prior to admission while awaiting rehab placement. He was treated for withdrawal symptoms, and initiated on suboxone. ACUTE ISSUES ============= #Encephalopathy #Substance use disorder #Undomiciled #Withdrawal During most recent hospitalization, he presented with acute cocaine, opioid intoxication. After stabilization, he eloped from the hospital, and used heroin and cocaine immediately following discharge. He was found to be more somnolent prior to this admission. He complained of myalgias and chills, consistent with withdrawal. Flu PCR negative, HIV negative, CK 347, and renal function intact. ___ was negative for intracranial process. Symptoms were thought to be secondary to substance use, and improved. Per addiction psych, the team discontinued methadone, and initiated suboxone on ___. He was also treated with clonidine and hydroxyzine for vasomotor symptoms. #Pyuria #Neurogenic bladder #Hx of MDR UTI Patient has had no change in urinary symptoms, and denies dysuria. He has only noticed "a bad smell" to his urine. He usually straight caths. He has been afebrile without elevated WBC. Urine grew E. Coli on ___, sensitive only to gentamicin, meropenem, and ertapenem. Prior urine culture in ___ grew Enterobacter cloacae, resistant to Bactrim otherwise pan-sensitive. ___ UCx grew Ecoli only sensitive to meropenem/gentamicin. ID recommended repeat UA to look for persistent pyuria, which showed a decrease in the number of white blood cells. They recommended outpatient follow up in clinic for recurrent UTIs. He was also continued on his home oxybutynin. CHRONIC ISSUES =============== #Bipolar disorder #ADHD Patient continued home dextroamphetamine and venlafaxine. # Neuropathy Patient continued home gabapentin. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO TID 2. CloNIDine 0.1 mg PO BID 3. Venlafaxine 75 mg PO BID 4. Methadone 55 mg PO DAILY 5. Nicotine Patch 14 mg/day TD DAILY 6. Famotidine 20 mg PO Q12H 7. Dextroamphetamine 15 mg PO DAILY 8. oxybutynin chloride 10 mg oral DAILY 9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Medications: 1. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID Consider prescribing naloxone at discharge 2. CloNIDine 0.1 mg PO BID 3. Dextroamphetamine 15 mg PO DAILY 4. Famotidine 20 mg PO Q12H 5. Gabapentin 800 mg PO TID 6. Nicotine Patch 14 mg/day TD DAILY 7. oxybutynin chloride 10 mg oral DAILY 8. Venlafaxine 75 mg PO BID 9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY ======= Substance Use Disorder SECONDARY ========= Bipolar Disorder Neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You returned to the hospital after leaving against medical advice due to bodyaches and chills. You returned after using both cocaine and heroin. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were treated for opioid withdrawal, and started on Suboxone daily. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed - Please follow up with all the appointments scheduled with your doctor ___ you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
[ "F1123", "G92", "G8220", "F1423", "R8281", "F319", "G629", "F909", "L89321", "Z902", "S24153S", "S21209S", "W3400XS", "Z87440", "Z8614", "D75A", "N319", "N39498", "Z590", "Z818", "B9620" ]
Allergies: aspirin / lima beans Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission Labs ============== [MASKED] 02:25AM BLOOD WBC-8.4 RBC-3.92* Hgb-11.1* Hct-36.5* MCV-93 MCH-28.3 MCHC-30.4* RDW-13.3 RDWSD-45.4 Plt [MASKED] [MASKED] 02:25AM BLOOD Neuts-54.8 [MASKED] Monos-18.7* Eos-4.1 Baso-0.6 Im [MASKED] AbsNeut-4.60 AbsLymp-1.67 AbsMono-1.57* AbsEos-0.34 AbsBaso-0.05 [MASKED] 02:25AM BLOOD Plt [MASKED] [MASKED] 02:25AM BLOOD Glucose-83 UreaN-14 Creat-0.7 Na-137 K-4.2 Cl-95* HCO3-26 AnGap-16 [MASKED] 02:25AM BLOOD ALT-28 AST-45* AlkPhos-67 TotBili-0.5 [MASKED] 09:30AM BLOOD CK(CPK)-347* [MASKED] 02:25AM BLOOD Albumin-4.1 Calcium-9.5 Phos-4.0 Mg-2.1 Relevant Imaging ================ [MASKED] NCHCT IMPRESSION: No acute intracranial process. Discharge Labs ============== [MASKED] 05:47AM BLOOD WBC-7.8 RBC-4.06* Hgb-11.9* Hct-38.5* MCV-95 MCH-29.3 MCHC-30.9* RDW-13.2 RDWSD-45.8 Plt [MASKED] [MASKED] 05:47AM BLOOD Plt [MASKED] [MASKED] 05:47AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-141 K-5.0 Cl-99 HCO3-28 AnGap-14 [MASKED] 05:47AM BLOOD Calcium-9.8 Phos-3.4 Mg-2.1 Brief Hospital Course: TRANSITIONAL ISSUES =================== [ ] Continue to monitor tolerance of suboxone (discharged on 8mg-2mg BID), close follow up with [MASKED] clinic [ ] Social Work: Resources for wheelchair and homeless shelter [ ] Patient should have outpatient ID follow up for recurrent UTIs. [ ] Needs Hep B immunization [ ] Consider colonoscopy as outpatient for anemia ASSESSMENT AND PLAN: ==================== [MASKED] man with a history of T10 paraplegia, neurogenic bladder with recurrent MDR UTIs, polysubstance use disorder (recent cocaine, heroin relapse) presenting with myalgias and change in urine odor. He had eloped one day prior to admission while awaiting rehab placement. He was treated for withdrawal symptoms, and initiated on suboxone. ACUTE ISSUES ============= #Encephalopathy #Substance use disorder #Undomiciled #Withdrawal During most recent hospitalization, he presented with acute cocaine, opioid intoxication. After stabilization, he eloped from the hospital, and used heroin and cocaine immediately following discharge. He was found to be more somnolent prior to this admission. He complained of myalgias and chills, consistent with withdrawal. Flu PCR negative, HIV negative, CK 347, and renal function intact. [MASKED] was negative for intracranial process. Symptoms were thought to be secondary to substance use, and improved. Per addiction psych, the team discontinued methadone, and initiated suboxone on [MASKED]. He was also treated with clonidine and hydroxyzine for vasomotor symptoms. #Pyuria #Neurogenic bladder #Hx of MDR UTI Patient has had no change in urinary symptoms, and denies dysuria. He has only noticed "a bad smell" to his urine. He usually straight caths. He has been afebrile without elevated WBC. Urine grew E. Coli on [MASKED], sensitive only to gentamicin, meropenem, and ertapenem. Prior urine culture in [MASKED] grew Enterobacter cloacae, resistant to Bactrim otherwise pan-sensitive. [MASKED] UCx grew Ecoli only sensitive to meropenem/gentamicin. ID recommended repeat UA to look for persistent pyuria, which showed a decrease in the number of white blood cells. They recommended outpatient follow up in clinic for recurrent UTIs. He was also continued on his home oxybutynin. CHRONIC ISSUES =============== #Bipolar disorder #ADHD Patient continued home dextroamphetamine and venlafaxine. # Neuropathy Patient continued home gabapentin. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO TID 2. CloNIDine 0.1 mg PO BID 3. Venlafaxine 75 mg PO BID 4. Methadone 55 mg PO DAILY 5. Nicotine Patch 14 mg/day TD DAILY 6. Famotidine 20 mg PO Q12H 7. Dextroamphetamine 15 mg PO DAILY 8. oxybutynin chloride 10 mg oral DAILY 9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Medications: 1. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID Consider prescribing naloxone at discharge 2. CloNIDine 0.1 mg PO BID 3. Dextroamphetamine 15 mg PO DAILY 4. Famotidine 20 mg PO Q12H 5. Gabapentin 800 mg PO TID 6. Nicotine Patch 14 mg/day TD DAILY 7. oxybutynin chloride 10 mg oral DAILY 8. Venlafaxine 75 mg PO BID 9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY ======= Substance Use Disorder SECONDARY ========= Bipolar Disorder Neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You returned to the hospital after leaving against medical advice due to bodyaches and chills. You returned after using both cocaine and heroin. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were treated for opioid withdrawal, and started on Suboxone daily. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed - Please follow up with all the appointments scheduled with your doctor [MASKED] you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
[]
[]
[ "F1123: Opioid dependence with withdrawal", "G92: Toxic encephalopathy", "G8220: Paraplegia, unspecified", "F1423: Cocaine dependence with withdrawal", "R8281: Pyuria", "F319: Bipolar disorder, unspecified", "G629: Polyneuropathy, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "L89321: Pressure ulcer of left buttock, stage 1", "Z902: Acquired absence of lung [part of]", "S24153S: Other incomplete lesion at T7-T10 level of thoracic spinal cord, sequela", "S21209S: Unspecified open wound of unspecified back wall of thorax without penetration into thoracic cavity, sequela", "W3400XS: Accidental discharge from unspecified firearms or gun, sequela", "Z87440: Personal history of urinary (tract) infections", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection", "D75A: Glucose-6-phosphate dehydrogenase (G6PD) deficiency without anemia", "N319: Neuromuscular dysfunction of bladder, unspecified", "N39498: Other specified urinary incontinence", "Z590: Homelessness", "Z818: Family history of other mental and behavioral disorders", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere" ]
10,038,332
22,921,487
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Decubitus pressure ulcer Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a PMH of T10 paraplegia ___ GSW with chronic decubitus ulcers and history MRSA abscesses, recently seen for perirectal abscess with I+D and L ischial decubitus ulcer presenting for worsening of his decubitus ulcer. He states the ulcer has worsened over the past several weeks and the air mattress cushion device he had been using for the ulcer broke several weeks ago. He was seen in ___ earlier today for this complaint and was referred to the ED for evaluation of possible infection related to his ulcer. He also describes some hot/cold sensations, although he has not checked his temperature to note a frank fever. He notes this may be similar to prior symptoms that he has with UTIs. He performs CIC and denies any recent changes in his urine or difficulty with catheterization. He denies any cough or shortness of breath. He has been eating and drinking well without significant abdominal pain. He endorses increased constipation. He endorses increased pain, at first stating 'everywhere' and then saying specifically over his decub ulcer. In the ED, initial vitals were: 97.6 90 133/81 18 100% RA - Labs were significant for WBC 20, Plt 576, lactate 3.1 - CT revealed inflammation surrounding decubitus ulcer without evidence of deep tissue infection or osteomyelitis - Surgery was consulted who did not feel that the patient required surgical management of his decub and who recommended admission to medicine for workup of leukocytosis. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward ___ 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in ___ 5. Recurrent sacral decubitus ulcers status post debridement in the OR on ___ and ___ & ___ (growing MRSA) 6. Pseudomonal prostatic abscess in ___ Prostatis in ___ 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___ 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in ___ raised, in ___, completed high school in ___ and some post grad ___ training. Has one son, now ___ yo, who he still sees. Currently living in assisted living facility. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use ___ ___. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use ___ ___ -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD - sister, cousin, maternal GM. Physical Exam: ***Admission Physical Exam*** VITALS: Tc: 98.5 BP: 99/57 HR: 96 RR: 18 O2 Sat: 97 RA GENERAL: lying in bed on anterior side, slightly somnolent with some mumbled responses to questions, NAD HEENT: Sclera anicteric, MMM, EOMI, PERRL NECK: Supple, JVP normal HEART: RRR, S1, S2, no r/g/m LUNGS: CTAB ABDOMEN: Soft, non-tender, non-distended, bowel sounds in all four quadrants GU: No foley EXTREMITY: WWWP, no c/c/e. Left ischial sacral decub with significant protuberance without surrounding erythema or undermining. No rectal abscess NEURO: Ox3, motor exam c/w T10 paralysis SKIN: Tattoo of gun over left chest, tribal tattoo on left forearm, scar on right shoulder s/p GSW, scars in lower spine s/p GSW ***Discharge Physical Exam*** VITALS: Tm 98.6 Tc 98.3, 123/68 (106-124/59-74), HR 93 (76-93), RR (18 (___), 100% on RA (99-100) GENERAL: lying in bed on R side, awake and alert, pleasant, NAD HEENT: Sclera anicteric, MMM, EOMI, PERRL NECK: Supple, JVP normal HEART: RRR, S1, S2, no r/g/m LUNGS: CTAB ABDOMEN: Soft, non-tender, non-distended, bowel sounds in all four quadrants GU: No foley EXTREMITY: WWWP, no c/c/e. Left ischial sacral decub with no longer significant protuberance, no surrounding erythema or undermining. No rectal abscess. NEURO: AOx3, motor exam c/w T10 paralysis SKIN: R buttock decubitus ulcer (approx. 6cm in diameter), with granulated base, clean margins, no purulence. Tattoo of gun over left chest, tribal tattoo on left forearm, scar on right shoulder s/p GSW, scars in lower spine s/p GSW Pertinent Results: ***Admission Labs*** ___ 08:12PM ___ PTT-31.4 ___ ___ 08:07PM URINE HOURS-RANDOM ___ 08:07PM URINE UHOLD-HOLD ___ 08:07PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 08:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-8.0 LEUK-LG ___ 08:07PM URINE RBC-2 WBC->182* BACTERIA-FEW YEAST-NONE EPI-3 ___ 08:07PM URINE AMORPH-RARE ___ 08:07PM URINE MUCOUS-RARE ___ 08:00PM LACTATE-3.1* K+-4.1 ___ 08:00PM LACTATE-3.1* K+-4.1 ___ 06:35PM VoidSpec-QNS ___ 06:25PM GLUCOSE-93 UREA N-14 CREAT-0.8 SODIUM-136 POTASSIUM-5.9* CHLORIDE-97 TOTAL CO2-23 ANION GAP-22* ___ 06:25PM estGFR-Using this ___ 06:25PM CRP-26.6* ___ 06:25PM WBC-20.6*# RBC-4.36* HGB-12.7* HCT-39.7* MCV-91 MCH-29.1 MCHC-32.0 RDW-12.9 RDWSD-42.5 ___ 06:25PM NEUTS-83.3* LYMPHS-6.5* MONOS-8.7 EOS-0.4* BASOS-0.4 IM ___ AbsNeut-17.16* AbsLymp-1.34 AbsMono-1.79* AbsEos-0.09 AbsBaso-0.09* ___ 06:25PM PLT COUNT-576*# Imaging: ___ CT PELVIS Left decubitus ulcer without associated drainable fluid collection or subcutaneous emphysema. Underlying bone is unremarkable. ***Discharge Labs*** ___ 04:40AM BLOOD WBC-4.3 RBC-3.71* Hgb-10.7* Hct-34.2* MCV-92 MCH-28.8 MCHC-31.3* RDW-13.2 RDWSD-44.4 Plt ___ ___ 04:40AM BLOOD Plt ___ ___ 04:40AM BLOOD Glucose-75 UreaN-8 Creat-0.7 Na-138 K-4.3 Cl-99 HCO3-30 AnGap-13 ___ 04:40AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.___SSESSMENT & PLAN: ___ with a PMH of T10 paraplegia presenting with worsened decub ulcer found to have UTI with enterococcus sensitive to ampicillin. # UTI: WBC 20.8 on admission, elevated lactate, and UA with significant WBCs consistent with UTI. Patient had no pulmonary signs (CTAB, satting weel on room air), and decubitus ulcer (discussed in section below) on exam and CT imaging showed no signs of infection. Given the patient's need for self straight catheterization, he is at risk for recurrent UTIs. He was started on CTX 1g Q24 while urine cultures pending. During this time he had one episode of nausea/vomiting, and had diaphoresis overnight. Urine cultures grew ENTEROCOCCUS SP. sensitive to ampicllin. Patient was started on Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H for 7 day course. (Note: Amoxicillin-Clavulanic Acid PO was used vs. Amoxicillin PO due to availability of proper dose medications in hospital). At time of discharge, leukocytosis and symptoms of tachycardia, nausea/vomiting, and diaphoresis had resolved. Patient was advised on sterile technique for straight catheterization. # LEFT DECUBITUS PRESSURE ULCER: On admission, Mr. ___ was found to have an unstageable decubitus pressure ulcer on the left buttock. It had been increasing in size for the past ___ weeks. He was initially started on vancomycin in the ED, however this was discontinued on the floor. There was no evidence of infection of the ulcer on imaging or physical examination. Surgery evaluated ulcer and decided no surgical intervention was indicated. Wound care team was consulted and was able to remove slough via cross hatching from the ulcer to reveal a Stage 3 pressure ulcer. Throughout Mr. ___ stay, there was no evidence of infection of the ulcer. Wound care recommendations were following including keeping the wound clean and keeping pressure off the left buttock. It was noted the ulcer progression was due to a broken pressure mattress and no longer working roho cushion for his wheel chair. Before discharge, replacements for both were arranged along with evaluation for home wound care assistance. # CONSTIPATION: on arrival to the floor, the patient reported he had not had BM in several days. He was started on Polyethylene Glycol, Docusate, and Senna with good effect. He began to have regular, non-bloody stool without issue. # DEPRESSION: Mr. ___ has a history of depression and was initially noted to have a sad affect in the morning during rounds. He was evaluated by ___ who recommended considering alternative or additional medications to treat depression, which has limited his activity at home. During this stay, he was maintained on home dose of Risperidone and Bupropion. # NICOTINE USE: Given Mr. ___ history of tobacco use, he was given a nicotine Patch 14 mg TD DAILY while inpatient. # CHRONIC PAIN: Mr. ___ pain regimen was continued during his inpatient stay with OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain, Morphine SR (MS ___ 15 mg PO Q8H, and Gabapentin 800 mg PO/NG TID. TRANSITIONAL ISSUES: ===================== - UTI (enterococcus) on regimen Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H x 7 days total (Last day: ___. - Wheel chair and Mattress cushion ordered need to be delivered, ___ will help ensures this occurs - Decubitus ulcer Wound care recommendations: -- Clean with commercial wound cleanser or normal saline -- Pat tissue dry with dry gauze -- Apply thin layer of Normlgel. -- Cover with Mepilex Border -- Change every 3 days and prn -- When out of bed, limit sit time to one hour at a time and Sit on a pressure redistribution cushion- ROHO -- Elevate ___ while sitting. - Patient evaluated for depression, which appears poorly controlled currently. Please consider further evaluation for alternative or additional medicine beside wellbutrin 300mg PO daily Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion (Sustained Release) 150 mg PO BID 2. Gabapentin 800 mg PO TID 3. Morphine SR (MS ___ 15 mg PO Q8H 4. Oxybutynin 10 mg PO BID 5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 6. RISperidone 1 mg PO BID 7. Tamsulosin 0.4 mg PO QHS 8. Ascorbic Acid ___ mg PO BID 9. methenamine hippurate 1 gram oral BID Discharge Medications: 1. Ascorbic Acid ___ mg PO BID 2. BuPROPion (Sustained Release) 150 mg PO BID 3. Gabapentin 800 mg PO TID 4. Morphine SR (MS ___ 15 mg PO Q8H 5. Oxybutynin 10 mg PO BID 6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 7. RISperidone 1 mg PO BID 8. Tamsulosin 0.4 mg PO QHS 9. methenamine hippurate 1 gram oral BID 10. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth Twice a day Disp #*3 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: - Decubitus pressure ulcer - UTI Secondary: - Constipation - Depression - Chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted to ___ because of a worsening ulcer on your left buttock and symptoms suggestive of a urinary tract infection (UTI). A CT scan of your pelvis did not show evidence of infection, though the ulcer did appear worse from previous descriptions. You were seen by wound care who provided dressing recommendations to help heal. Physical therapy and case management also procured the appropriate cushion and mattress to prevent further pressure ulcer formation, they will be shipped to your house. On admission you were also found to have a urinary tract infection. You were started on IV antibiotics, and once cultures came back you were transitioned to and antibiotic called Augmentin with a plan to take for a total of 7 days (Last day ___. Roho cushion and a the proper mattress to reduce pressure ulcers are planned to be delivered to your home. These have been ordered but can take ___ weeks to arrive. It was a pleasure taking care of you during your stay at ___. We wish you the best in your ongoing recovery. If you have any questions about the care you received, please do not hesitate to ask. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "N390", "L89323", "G8220", "B952", "R32", "R112", "R61", "K5900", "F329", "F17210", "Z87440" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Decubitus pressure ulcer Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a PMH of T10 paraplegia [MASKED] GSW with chronic decubitus ulcers and history MRSA abscesses, recently seen for perirectal abscess with I+D and L ischial decubitus ulcer presenting for worsening of his decubitus ulcer. He states the ulcer has worsened over the past several weeks and the air mattress cushion device he had been using for the ulcer broke several weeks ago. He was seen in [MASKED] earlier today for this complaint and was referred to the ED for evaluation of possible infection related to his ulcer. He also describes some hot/cold sensations, although he has not checked his temperature to note a frank fever. He notes this may be similar to prior symptoms that he has with UTIs. He performs CIC and denies any recent changes in his urine or difficulty with catheterization. He denies any cough or shortness of breath. He has been eating and drinking well without significant abdominal pain. He endorses increased constipation. He endorses increased pain, at first stating 'everywhere' and then saying specifically over his decub ulcer. In the ED, initial vitals were: 97.6 90 133/81 18 100% RA - Labs were significant for WBC 20, Plt 576, lactate 3.1 - CT revealed inflammation surrounding decubitus ulcer without evidence of deep tissue infection or osteomyelitis - Surgery was consulted who did not feel that the patient required surgical management of his decub and who recommended admission to medicine for workup of leukocytosis. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward [MASKED] 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in [MASKED] 5. Recurrent sacral decubitus ulcers status post debridement in the OR on [MASKED] and [MASKED] & [MASKED] (growing MRSA) 6. Pseudomonal prostatic abscess in [MASKED] Prostatis in [MASKED] 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy [MASKED] 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in [MASKED] raised, in [MASKED], completed high school in [MASKED] and some post grad [MASKED] training. Has one son, now [MASKED] yo, who he still sees. Currently living in assisted living facility. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use [MASKED] [MASKED]. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use [MASKED] [MASKED] -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD - sister, cousin, maternal GM. Physical Exam: ***Admission Physical Exam*** VITALS: Tc: 98.5 BP: 99/57 HR: 96 RR: 18 O2 Sat: 97 RA GENERAL: lying in bed on anterior side, slightly somnolent with some mumbled responses to questions, NAD HEENT: Sclera anicteric, MMM, EOMI, PERRL NECK: Supple, JVP normal HEART: RRR, S1, S2, no r/g/m LUNGS: CTAB ABDOMEN: Soft, non-tender, non-distended, bowel sounds in all four quadrants GU: No foley EXTREMITY: WWWP, no c/c/e. Left ischial sacral decub with significant protuberance without surrounding erythema or undermining. No rectal abscess NEURO: Ox3, motor exam c/w T10 paralysis SKIN: Tattoo of gun over left chest, tribal tattoo on left forearm, scar on right shoulder s/p GSW, scars in lower spine s/p GSW ***Discharge Physical Exam*** VITALS: Tm 98.6 Tc 98.3, 123/68 (106-124/59-74), HR 93 (76-93), RR (18 ([MASKED]), 100% on RA (99-100) GENERAL: lying in bed on R side, awake and alert, pleasant, NAD HEENT: Sclera anicteric, MMM, EOMI, PERRL NECK: Supple, JVP normal HEART: RRR, S1, S2, no r/g/m LUNGS: CTAB ABDOMEN: Soft, non-tender, non-distended, bowel sounds in all four quadrants GU: No foley EXTREMITY: WWWP, no c/c/e. Left ischial sacral decub with no longer significant protuberance, no surrounding erythema or undermining. No rectal abscess. NEURO: AOx3, motor exam c/w T10 paralysis SKIN: R buttock decubitus ulcer (approx. 6cm in diameter), with granulated base, clean margins, no purulence. Tattoo of gun over left chest, tribal tattoo on left forearm, scar on right shoulder s/p GSW, scars in lower spine s/p GSW Pertinent Results: ***Admission Labs*** [MASKED] 08:12PM [MASKED] PTT-31.4 [MASKED] [MASKED] 08:07PM URINE HOURS-RANDOM [MASKED] 08:07PM URINE UHOLD-HOLD [MASKED] 08:07PM URINE COLOR-Yellow APPEAR-Hazy SP [MASKED] [MASKED] 08:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-8.0 LEUK-LG [MASKED] 08:07PM URINE RBC-2 WBC->182* BACTERIA-FEW YEAST-NONE EPI-3 [MASKED] 08:07PM URINE AMORPH-RARE [MASKED] 08:07PM URINE MUCOUS-RARE [MASKED] 08:00PM LACTATE-3.1* K+-4.1 [MASKED] 08:00PM LACTATE-3.1* K+-4.1 [MASKED] 06:35PM VoidSpec-QNS [MASKED] 06:25PM GLUCOSE-93 UREA N-14 CREAT-0.8 SODIUM-136 POTASSIUM-5.9* CHLORIDE-97 TOTAL CO2-23 ANION GAP-22* [MASKED] 06:25PM estGFR-Using this [MASKED] 06:25PM CRP-26.6* [MASKED] 06:25PM WBC-20.6*# RBC-4.36* HGB-12.7* HCT-39.7* MCV-91 MCH-29.1 MCHC-32.0 RDW-12.9 RDWSD-42.5 [MASKED] 06:25PM NEUTS-83.3* LYMPHS-6.5* MONOS-8.7 EOS-0.4* BASOS-0.4 IM [MASKED] AbsNeut-17.16* AbsLymp-1.34 AbsMono-1.79* AbsEos-0.09 AbsBaso-0.09* [MASKED] 06:25PM PLT COUNT-576*# Imaging: [MASKED] CT PELVIS Left decubitus ulcer without associated drainable fluid collection or subcutaneous emphysema. Underlying bone is unremarkable. ***Discharge Labs*** [MASKED] 04:40AM BLOOD WBC-4.3 RBC-3.71* Hgb-10.7* Hct-34.2* MCV-92 MCH-28.8 MCHC-31.3* RDW-13.2 RDWSD-44.4 Plt [MASKED] [MASKED] 04:40AM BLOOD Plt [MASKED] [MASKED] 04:40AM BLOOD Glucose-75 UreaN-8 Creat-0.7 Na-138 K-4.3 Cl-99 HCO3-30 AnGap-13 [MASKED] 04:40AM BLOOD Calcium-8.9 Phos-3.7 Mg-1. SSESSMENT & PLAN: [MASKED] with a PMH of T10 paraplegia presenting with worsened decub ulcer found to have UTI with enterococcus sensitive to ampicillin. # UTI: WBC 20.8 on admission, elevated lactate, and UA with significant WBCs consistent with UTI. Patient had no pulmonary signs (CTAB, satting weel on room air), and decubitus ulcer (discussed in section below) on exam and CT imaging showed no signs of infection. Given the patient's need for self straight catheterization, he is at risk for recurrent UTIs. He was started on CTX 1g Q24 while urine cultures pending. During this time he had one episode of nausea/vomiting, and had diaphoresis overnight. Urine cultures grew ENTEROCOCCUS SP. sensitive to ampicllin. Patient was started on Amoxicillin-Clavulanic Acid [MASKED] mg PO/NG Q12H for 7 day course. (Note: Amoxicillin-Clavulanic Acid PO was used vs. Amoxicillin PO due to availability of proper dose medications in hospital). At time of discharge, leukocytosis and symptoms of tachycardia, nausea/vomiting, and diaphoresis had resolved. Patient was advised on sterile technique for straight catheterization. # LEFT DECUBITUS PRESSURE ULCER: On admission, Mr. [MASKED] was found to have an unstageable decubitus pressure ulcer on the left buttock. It had been increasing in size for the past [MASKED] weeks. He was initially started on vancomycin in the ED, however this was discontinued on the floor. There was no evidence of infection of the ulcer on imaging or physical examination. Surgery evaluated ulcer and decided no surgical intervention was indicated. Wound care team was consulted and was able to remove slough via cross hatching from the ulcer to reveal a Stage 3 pressure ulcer. Throughout Mr. [MASKED] stay, there was no evidence of infection of the ulcer. Wound care recommendations were following including keeping the wound clean and keeping pressure off the left buttock. It was noted the ulcer progression was due to a broken pressure mattress and no longer working roho cushion for his wheel chair. Before discharge, replacements for both were arranged along with evaluation for home wound care assistance. # CONSTIPATION: on arrival to the floor, the patient reported he had not had BM in several days. He was started on Polyethylene Glycol, Docusate, and Senna with good effect. He began to have regular, non-bloody stool without issue. # DEPRESSION: Mr. [MASKED] has a history of depression and was initially noted to have a sad affect in the morning during rounds. He was evaluated by [MASKED] who recommended considering alternative or additional medications to treat depression, which has limited his activity at home. During this stay, he was maintained on home dose of Risperidone and Bupropion. # NICOTINE USE: Given Mr. [MASKED] history of tobacco use, he was given a nicotine Patch 14 mg TD DAILY while inpatient. # CHRONIC PAIN: Mr. [MASKED] pain regimen was continued during his inpatient stay with OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain, Morphine SR (MS [MASKED] 15 mg PO Q8H, and Gabapentin 800 mg PO/NG TID. TRANSITIONAL ISSUES: ===================== - UTI (enterococcus) on regimen Amoxicillin-Clavulanic Acid [MASKED] mg PO/NG Q12H x 7 days total (Last day: [MASKED]. - Wheel chair and Mattress cushion ordered need to be delivered, [MASKED] will help ensures this occurs - Decubitus ulcer Wound care recommendations: -- Clean with commercial wound cleanser or normal saline -- Pat tissue dry with dry gauze -- Apply thin layer of Normlgel. -- Cover with Mepilex Border -- Change every 3 days and prn -- When out of bed, limit sit time to one hour at a time and Sit on a pressure redistribution cushion- ROHO -- Elevate [MASKED] while sitting. - Patient evaluated for depression, which appears poorly controlled currently. Please consider further evaluation for alternative or additional medicine beside wellbutrin 300mg PO daily Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion (Sustained Release) 150 mg PO BID 2. Gabapentin 800 mg PO TID 3. Morphine SR (MS [MASKED] 15 mg PO Q8H 4. Oxybutynin 10 mg PO BID 5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 6. RISperidone 1 mg PO BID 7. Tamsulosin 0.4 mg PO QHS 8. Ascorbic Acid [MASKED] mg PO BID 9. methenamine hippurate 1 gram oral BID Discharge Medications: 1. Ascorbic Acid [MASKED] mg PO BID 2. BuPROPion (Sustained Release) 150 mg PO BID 3. Gabapentin 800 mg PO TID 4. Morphine SR (MS [MASKED] 15 mg PO Q8H 5. Oxybutynin 10 mg PO BID 6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 7. RISperidone 1 mg PO BID 8. Tamsulosin 0.4 mg PO QHS 9. methenamine hippurate 1 gram oral BID 10. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tablet(s) by mouth Twice a day Disp #*3 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: - Decubitus pressure ulcer - UTI Secondary: - Constipation - Depression - Chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] because of a worsening ulcer on your left buttock and symptoms suggestive of a urinary tract infection (UTI). A CT scan of your pelvis did not show evidence of infection, though the ulcer did appear worse from previous descriptions. You were seen by wound care who provided dressing recommendations to help heal. Physical therapy and case management also procured the appropriate cushion and mattress to prevent further pressure ulcer formation, they will be shipped to your house. On admission you were also found to have a urinary tract infection. You were started on IV antibiotics, and once cultures came back you were transitioned to and antibiotic called Augmentin with a plan to take for a total of 7 days (Last day [MASKED]. Roho cushion and a the proper mattress to reduce pressure ulcers are planned to be delivered to your home. These have been ordered but can take [MASKED] weeks to arrive. It was a pleasure taking care of you during your stay at [MASKED]. We wish you the best in your ongoing recovery. If you have any questions about the care you received, please do not hesitate to ask. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N390", "K5900", "F329", "F17210" ]
[ "N390: Urinary tract infection, site not specified", "L89323: Pressure ulcer of left buttock, stage 3", "G8220: Paraplegia, unspecified", "B952: Enterococcus as the cause of diseases classified elsewhere", "R32: Unspecified urinary incontinence", "R112: Nausea with vomiting, unspecified", "R61: Generalized hyperhidrosis", "K5900: Constipation, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z87440: Personal history of urinary (tract) infections" ]
10,038,332
23,073,151
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: Acute Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: ___ with paraplegia as a result of a GSW, neurogenic bladder with chronic intermittent straight caths, with recurrent UTIs with various organisms, now on chronic suppressive methenamine, who presented on ___ with c/o foul smelling and cloudy urine, rectal pain and burning and low bilateral back pain. He notably has a h/o prostate abscess in ___, as well as chronic sacral decubitus ulcer for which he has been treated multiple times with antibiotics including an osteomyelitis course in ___ for MRSA. Currently the wound is closed. Urine cultures in the past have grown a large range of organisms, resistant at times. He reports that the current symptoms have been ongoing for between ___ weeks. He went to the ER at an outside hospital about a week ago, and reportedly he had a UA that showed "infection," and he was given an unknown medication, which he reports was "an antibiotic that contained aspirin." He only took one dose. The symptoms progressed. He feels that this is "beyond" a usual UTI. He has had a low appetite, no N/V, no diarrhea. He endorses feeling hot/subjective fevers, but does not have a thermometer. Also endorses intermittent sweats. He denies penile discharge nor genital lesions. He has not been sexually active for several months. Of note he also states that he has a "face abscess." He noticed right facial swelling and pain around the lip and nose about a week and a half ago, and went to a dentist who felt he likely had an infection at the root of tooth #8; pt states Xray was done. He was therefore started on amoxicillin about 1.5 weeks ago and told that he needs a root canal on that tooth; the area is improved and he finished the amoxicillin. The urinary symptoms developed while on amoxicillin. Here, VS notable for mild tachycardia. He underwent CT of the abdomen/pelvis which noted cystitis and his chronic sacral decubitus; no comment on the prostate. UA showed 15 WBC, neg leuk esterase, neg nitrite. ROS: GEN: + fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: + Nausea, - Vomiting, - Diarrhea, + Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, + Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward ___ 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in ___ 5. Recurrent sacral decubitus ulcers status post debridement in the OR on ___ and ___ & ___ (growing MRSA) 6. Pseudomonal prostatic abscess in ___ Prostatis in ___ 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___ 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in ___ raised, in ___, completed high school in ___ and some post grad computer training. Has one son, now ___ yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on ___ who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use ___ ___. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use ___ ___ but was found with cocaine in his urine on this admission in ___. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION PHYSICAL EXAM: VSS: 98.3, 115/73, 78, 18, 100%RA GEN: in moderate distress, holding abdomen Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: moderate Diffuse TTP, ND, +BS, + CVAT EXT: - CCE NEURO: CAOx3, Parapalegic Discharge PE: 98.0 111 / 64 67 18 98 RA Gen: NAD, sitting comfortably in bed, EOMI, PERRLA, MMM CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, mild lower abdominal tenderness, no guarding or rebound, ND +BS Back: no CVA tenderness Ext: no c/c/e Neuro: CN II-XII intact, ___ strength upper extremities, paraplegic Psych: pleasant but bizarre comments Skin: warm, dry, chronic well healed scars on sacrum/buttocks without erythema or drainage Pertinent Results: ___ 06:54PM BLOOD WBC-22.8*# RBC-4.44* Hgb-13.9 Hct-40.4 MCV-91 MCH-31.3 MCHC-34.4 RDW-11.9 RDWSD-39.5 Plt ___ ___ 06:54PM BLOOD Neuts-82.7* Lymphs-5.5* Monos-10.8 Eos-0.0* Baso-0.3 Im ___ AbsNeut-18.82*# AbsLymp-1.26 AbsMono-2.47* AbsEos-0.01* AbsBaso-0.06 ___ 06:54PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 06:54PM BLOOD Glucose-98 UreaN-12 Creat-0.8 Na-128* K-3.9 Cl-92* HCO3-23 AnGap-17 ___ 06:54PM BLOOD ALT-14 AST-24 AlkPhos-71 TotBili-0.7 ___ 06:54PM BLOOD Lipase-14 ___ 06:54PM BLOOD Albumin-4.3 Calcium-9.7 Phos-2.9 Mg-1.8 ___ 06:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:07PM BLOOD Lactate-1.8 ___ 07:10PM URINE Color-Straw Appear-Clear Sp ___ ___ 07:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM ___ 07:10PM URINE RBC-<1 WBC-15* Bacteri-FEW Yeast-NONE Epi-<1 ___ 7:10 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. DOXYCYCLINE , Fosfomycin , AND MINOCYCLINE SENSITIVITIES TESTING PER ___ ___) ___. RESISTANT TO DOXYCYCLINE. RESISTANT TO MINOCYCLINE. SENSITIVE TO Fosfomycin. DOXYCYCLINE , MINOCYCLINE , AND Fosfomycin sensitivity testing performed by ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R CHEST (PORTABLE AP) Study Date of ___ 6:57 ___ IMPRESSION: No acute intrathoracic process. Retained bullet fragments in the mid back. CT ABD & PELVIS WITH CONTRAST Study Date of ___ 9:22 ___ IMPRESSION: 1. Chronic decubitus ulcer overlying the left ischial spine, without associated drainable fluid collection or subcutaneous air. 2. Diffuse mild urinary bladder wall thickening consistent with chronic cystitis. Discharge labs: ___ 06:40AM BLOOD WBC-4.2 RBC-4.10* Hgb-11.9* Hct-37.8* MCV-92 MCH-29.0 MCHC-31.5* RDW-11.8 RDWSD-39.8 Plt ___ ___ 06:40AM BLOOD Glucose-115* UreaN-8 Creat-0.7 Na-144 K-4.1 Cl-100 HCO3-32 AnGap-___ year old male with PMH of paraplegia, neurogenic bladder requiring intermittent straight caths, recurrent UTI, ? psychotic disorder and chronic pain presenting with fever, foul smelling urine, abdominal, back and rectal pain. # Sepsis without organ dysfunction due to E. coli acute bacterial prostatitis and UTI Febrile at home, here with low grade fevers, tachycardia and severe leukocytosis. Urinalysis showing some pyuria but not very impressive. He is complaining of significant rectal pain and prostate exam significant for tender mildly enlarged prostate. He has recently completed a 6 week course of Bactrim for possible prostatitis. Cultures growing E. Coli resistant to Bactrim and fluoroquinolones. Initially was put on Vancomycin/Ceftaz, ID was consulted. Once sensitivities returned discharged on fosfomycin for a 6 week course. His leukocytosis quickly resolved, abdominal and rectal pain improved. He was initially given opioids for the pain which was quickly weaned off. - F/u with ID as scheduled. - Continue PO fosfomycin for total 6 week course (day ___ - D/c suppressive methenamine - Tylenol, Ibuprofen for pain # Neurogenic bladder requiring straight catheterization # Spastic Bladder - Continue intermittent straight cath - Continue Oxybutinin, Tamsulosin, mirabegron # Chronic pain -Continue Suboxone, gabapentin, Tylenol and ibuprofen # Depression, possible psychotic disorder - Continue Bupropion, Risperdal # Chronic Constipation - Continue Polyethylene glycol, Colace, senna #FEN/PPX: regular, heparin SC # Full Code #Dispo: home with services Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. BuPROPion (Sustained Release) 150 mg PO BID 3. Collagenase Ointment 1 Appl TP DAILY R thigh 4. Docusate Sodium 100 mg PO BID 5. Fluticasone Propionate NASAL ___ SPRY NU DAILY 6. Gabapentin 800 mg PO TID 7. Tamsulosin 0.4 mg PO QHS 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Ascorbic Acid ___ mg PO BID 10. Ibuprofen 200 mg PO Q6H:PRN Pain - Mild 11. Methenamine Hippurate 1 gram ORAL BID 12. mirabegron 25 mg oral DAILY 13. RisperiDONE 1 mg PO QHS 14. Oxybutynin 20 mg PO DAILY 15. Morphine SR (MS ___ 15 mg PO Q12H 16. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Medications: 1. Fosfomycin Tromethamine 3 g PO ASDIR Duration: 6 Weeks Every other day for three doses then every third day RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by mouth As directed Disp #*14 Packet Refills:*0 2. Ibuprofen 800 mg PO Q6H:PRN Pain - Mild 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Ascorbic Acid ___ mg PO BID 5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 6. BuPROPion (Sustained Release) 150 mg PO BID 7. Collagenase Ointment 1 Appl TP DAILY R thigh 8. Docusate Sodium 100 mg PO BID 9. Fluticasone Propionate NASAL ___ SPRY NU DAILY 10. Gabapentin 800 mg PO TID 11. mirabegron 25 mg oral DAILY 12. Oxybutynin 10 mg PO BID 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. RisperiDONE 1 mg PO QHS 15. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Sepsis due to E. coli UTI and acute bacterial prostatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted with fevers, foul smelling urine, abdominal and rectal pain. You were found to have a urinary tract infection and a prostate infection. We are sending you on a long course of antibiotics to try to cure the infection in your prostate. Please follow-up with your primary care physician and infectious disease as scheduled. Followup Instructions: ___
[ "A4151", "G8220", "N410", "Z1623", "Z1639", "S24103D", "N319", "N39498", "N3289", "G8929", "N3020", "M549", "K5909", "F329", "F909", "F1421", "F29", "X959XXD" ]
Allergies: aspirin Chief Complaint: Acute Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with paraplegia as a result of a GSW, neurogenic bladder with chronic intermittent straight caths, with recurrent UTIs with various organisms, now on chronic suppressive methenamine, who presented on [MASKED] with c/o foul smelling and cloudy urine, rectal pain and burning and low bilateral back pain. He notably has a h/o prostate abscess in [MASKED], as well as chronic sacral decubitus ulcer for which he has been treated multiple times with antibiotics including an osteomyelitis course in [MASKED] for MRSA. Currently the wound is closed. Urine cultures in the past have grown a large range of organisms, resistant at times. He reports that the current symptoms have been ongoing for between [MASKED] weeks. He went to the ER at an outside hospital about a week ago, and reportedly he had a UA that showed "infection," and he was given an unknown medication, which he reports was "an antibiotic that contained aspirin." He only took one dose. The symptoms progressed. He feels that this is "beyond" a usual UTI. He has had a low appetite, no N/V, no diarrhea. He endorses feeling hot/subjective fevers, but does not have a thermometer. Also endorses intermittent sweats. He denies penile discharge nor genital lesions. He has not been sexually active for several months. Of note he also states that he has a "face abscess." He noticed right facial swelling and pain around the lip and nose about a week and a half ago, and went to a dentist who felt he likely had an infection at the root of tooth #8; pt states Xray was done. He was therefore started on amoxicillin about 1.5 weeks ago and told that he needs a root canal on that tooth; the area is improved and he finished the amoxicillin. The urinary symptoms developed while on amoxicillin. Here, VS notable for mild tachycardia. He underwent CT of the abdomen/pelvis which noted cystitis and his chronic sacral decubitus; no comment on the prostate. UA showed 15 WBC, neg leuk esterase, neg nitrite. ROS: GEN: + fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: + Nausea, - Vomiting, - Diarrhea, + Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, + Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward [MASKED] 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in [MASKED] 5. Recurrent sacral decubitus ulcers status post debridement in the OR on [MASKED] and [MASKED] & [MASKED] (growing MRSA) 6. Pseudomonal prostatic abscess in [MASKED] Prostatis in [MASKED] 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy [MASKED] 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in [MASKED] raised, in [MASKED], completed high school in [MASKED] and some post grad computer training. Has one son, now [MASKED] yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on [MASKED] who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use [MASKED] [MASKED]. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use [MASKED] [MASKED] but was found with cocaine in his urine on this admission in [MASKED]. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION PHYSICAL EXAM: VSS: 98.3, 115/73, 78, 18, 100%RA GEN: in moderate distress, holding abdomen Pain: [MASKED] HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: moderate Diffuse TTP, ND, +BS, + CVAT EXT: - CCE NEURO: CAOx3, Parapalegic Discharge PE: 98.0 111 / 64 67 18 98 RA Gen: NAD, sitting comfortably in bed, EOMI, PERRLA, MMM CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, mild lower abdominal tenderness, no guarding or rebound, ND +BS Back: no CVA tenderness Ext: no c/c/e Neuro: CN II-XII intact, [MASKED] strength upper extremities, paraplegic Psych: pleasant but bizarre comments Skin: warm, dry, chronic well healed scars on sacrum/buttocks without erythema or drainage Pertinent Results: [MASKED] 06:54PM BLOOD WBC-22.8*# RBC-4.44* Hgb-13.9 Hct-40.4 MCV-91 MCH-31.3 MCHC-34.4 RDW-11.9 RDWSD-39.5 Plt [MASKED] [MASKED] 06:54PM BLOOD Neuts-82.7* Lymphs-5.5* Monos-10.8 Eos-0.0* Baso-0.3 Im [MASKED] AbsNeut-18.82*# AbsLymp-1.26 AbsMono-2.47* AbsEos-0.01* AbsBaso-0.06 [MASKED] 06:54PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [MASKED] 06:54PM BLOOD Glucose-98 UreaN-12 Creat-0.8 Na-128* K-3.9 Cl-92* HCO3-23 AnGap-17 [MASKED] 06:54PM BLOOD ALT-14 AST-24 AlkPhos-71 TotBili-0.7 [MASKED] 06:54PM BLOOD Lipase-14 [MASKED] 06:54PM BLOOD Albumin-4.3 Calcium-9.7 Phos-2.9 Mg-1.8 [MASKED] 06:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 07:07PM BLOOD Lactate-1.8 [MASKED] 07:10PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 07:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [MASKED] 07:10PM URINE RBC-<1 WBC-15* Bacteri-FEW Yeast-NONE Epi-<1 [MASKED] 7:10 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. DOXYCYCLINE , Fosfomycin , AND MINOCYCLINE SENSITIVITIES TESTING PER [MASKED] [MASKED]) [MASKED]. RESISTANT TO DOXYCYCLINE. RESISTANT TO MINOCYCLINE. SENSITIVE TO Fosfomycin. DOXYCYCLINE , MINOCYCLINE , AND Fosfomycin sensitivity testing performed by [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R CHEST (PORTABLE AP) Study Date of [MASKED] 6:57 [MASKED] IMPRESSION: No acute intrathoracic process. Retained bullet fragments in the mid back. CT ABD & PELVIS WITH CONTRAST Study Date of [MASKED] 9:22 [MASKED] IMPRESSION: 1. Chronic decubitus ulcer overlying the left ischial spine, without associated drainable fluid collection or subcutaneous air. 2. Diffuse mild urinary bladder wall thickening consistent with chronic cystitis. Discharge labs: [MASKED] 06:40AM BLOOD WBC-4.2 RBC-4.10* Hgb-11.9* Hct-37.8* MCV-92 MCH-29.0 MCHC-31.5* RDW-11.8 RDWSD-39.8 Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-115* UreaN-8 Creat-0.7 Na-144 K-4.1 Cl-100 HCO3-32 AnGap-[MASKED] year old male with PMH of paraplegia, neurogenic bladder requiring intermittent straight caths, recurrent UTI, ? psychotic disorder and chronic pain presenting with fever, foul smelling urine, abdominal, back and rectal pain. # Sepsis without organ dysfunction due to E. coli acute bacterial prostatitis and UTI Febrile at home, here with low grade fevers, tachycardia and severe leukocytosis. Urinalysis showing some pyuria but not very impressive. He is complaining of significant rectal pain and prostate exam significant for tender mildly enlarged prostate. He has recently completed a 6 week course of Bactrim for possible prostatitis. Cultures growing E. Coli resistant to Bactrim and fluoroquinolones. Initially was put on Vancomycin/Ceftaz, ID was consulted. Once sensitivities returned discharged on fosfomycin for a 6 week course. His leukocytosis quickly resolved, abdominal and rectal pain improved. He was initially given opioids for the pain which was quickly weaned off. - F/u with ID as scheduled. - Continue PO fosfomycin for total 6 week course (day [MASKED] - D/c suppressive methenamine - Tylenol, Ibuprofen for pain # Neurogenic bladder requiring straight catheterization # Spastic Bladder - Continue intermittent straight cath - Continue Oxybutinin, Tamsulosin, mirabegron # Chronic pain -Continue Suboxone, gabapentin, Tylenol and ibuprofen # Depression, possible psychotic disorder - Continue Bupropion, Risperdal # Chronic Constipation - Continue Polyethylene glycol, Colace, senna #FEN/PPX: regular, heparin SC # Full Code #Dispo: home with services Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. BuPROPion (Sustained Release) 150 mg PO BID 3. Collagenase Ointment 1 Appl TP DAILY R thigh 4. Docusate Sodium 100 mg PO BID 5. Fluticasone Propionate NASAL [MASKED] SPRY NU DAILY 6. Gabapentin 800 mg PO TID 7. Tamsulosin 0.4 mg PO QHS 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Ascorbic Acid [MASKED] mg PO BID 10. Ibuprofen 200 mg PO Q6H:PRN Pain - Mild 11. Methenamine Hippurate 1 gram ORAL BID 12. mirabegron 25 mg oral DAILY 13. RisperiDONE 1 mg PO QHS 14. Oxybutynin 20 mg PO DAILY 15. Morphine SR (MS [MASKED] 15 mg PO Q12H 16. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Medications: 1. Fosfomycin Tromethamine 3 g PO ASDIR Duration: 6 Weeks Every other day for three doses then every third day RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by mouth As directed Disp #*14 Packet Refills:*0 2. Ibuprofen 800 mg PO Q6H:PRN Pain - Mild 3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 4. Ascorbic Acid [MASKED] mg PO BID 5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 6. BuPROPion (Sustained Release) 150 mg PO BID 7. Collagenase Ointment 1 Appl TP DAILY R thigh 8. Docusate Sodium 100 mg PO BID 9. Fluticasone Propionate NASAL [MASKED] SPRY NU DAILY 10. Gabapentin 800 mg PO TID 11. mirabegron 25 mg oral DAILY 12. Oxybutynin 10 mg PO BID 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. RisperiDONE 1 mg PO QHS 15. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Sepsis due to E. coli UTI and acute bacterial prostatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], You were admitted with fevers, foul smelling urine, abdominal and rectal pain. You were found to have a urinary tract infection and a prostate infection. We are sending you on a long course of antibiotics to try to cure the infection in your prostate. Please follow-up with your primary care physician and infectious disease as scheduled. Followup Instructions: [MASKED]
[]
[ "G8929", "F329" ]
[ "A4151: Sepsis due to Escherichia coli [E. coli]", "G8220: Paraplegia, unspecified", "N410: Acute prostatitis", "Z1623: Resistance to quinolones and fluoroquinolones", "Z1639: Resistance to other specified antimicrobial drug", "S24103D: Unspecified injury at T7-T10 level of thoracic spinal cord, subsequent encounter", "N319: Neuromuscular dysfunction of bladder, unspecified", "N39498: Other specified urinary incontinence", "N3289: Other specified disorders of bladder", "G8929: Other chronic pain", "N3020: Other chronic cystitis without hematuria", "M549: Dorsalgia, unspecified", "K5909: Other constipation", "F329: Major depressive disorder, single episode, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F1421: Cocaine dependence, in remission", "F29: Unspecified psychosis not due to a substance or known physiological condition", "X959XXD: Assault by unspecified firearm discharge, subsequent encounter" ]
10,038,332
23,488,593
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / lima beans Attending: ___. Chief Complaint: AMS/agitation requiring sedation/intubation Major Surgical or Invasive Procedure: Intubation Extubation History of Present Illness: ___ male with PMH of T10 paraplegia secondary to gunshot wound in ___, psychiatric history (?bipolar disorder, ?ADHD), neurogenic bladder c/b recurrent UTIs, and polysubstance use disorder who recently relapsed on cocaine and heroin who presented to the ED with confusion and altered mental status. Per report from his aunt, patient was found to be living on the streets today and was slumped over in wheelchair and brought into the ED. In the ED, his initial vitals were Temp 99.1 (Tmax 100), HR 94, BP 145/82, RR 19, SpO2 100% on RA. On arrival he was somnolent and responsive only to sternal rub with pinpoint pupils and given 0.5 mg IV narcan after which he became agitated and was yelling and combative. He required restraints and then was intubated and mechanically ventilated given agitation and started on propofol and fentanyl for sedation and analgesia. Utox positive for cocaine, opiates, and methadone (serum tox neg) and UA consistent with UTI (WBC 26, mod leuk, few bacteria) and given dose of CTX. For AMS, got CT head which did not show an acute process. CXR confirmed ET and enteric tube placement and showed left base opacity c/w atelectasis vs. aspiration. On arrival to the FICU he was intubated and sedated. His BP was 120/79 with HR 79 in NSR. ROS: ==== Unable to assess as patient intubated and sedated. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward ___ 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abscesses in neck, back, perianal 5. Recurrent sacral decubitus ulcers status post debridement in the OR on ___ and ___ & ___ (growing MRSA) 6. Pseudomonal prostatic abscess in ___ Prostatis in ___ 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___ 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation Social History: ___ Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION PHSYCIAL EXAM: VS: BP 120/79, HR 79, RR 16, SpO2 100% GENERAL: Intubated and sedated. HEENT: PERRL. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally with rhonchi bilaterally. No wheezes. ABDOMEN: Normal bowels sounds, soft, mildly distended. EXTREMITIES: No edema. SKIN: Warm, well-perfused. No rash. Stage II sacral ulcers. NEUROLOGIC: Intubated and sedated, agitated when weaned sedation DISCHARGE PHYSCIAL EXAM: 24 HR Data (last updated ___ @ 744) Temp: 98.1 (Tm 98.7), BP: 143/89 (126-143/48-89), HR: 75 (70-93), RR: 18 (___), O2 sat: 99% (93-99), O2 delivery: RA GENERAL: NAD, pleasant HEENT: Sclera anicteric and without injection. CARDIAC: RRR, no m/r/g LUNGS: CTAB ABDOMEN: Soft, NT, ND. EXTREMITIES: No edema. SKIN: Warm, well-perfused. No rash. NEUROLOGIC: Paraplegic, moving upper extremities spontaneously. Pertinent Results: ADMISSION LABS: =============== ___ 05:56PM BLOOD WBC-7.3 RBC-4.42* Hgb-12.9* Hct-40.5 MCV-92 MCH-29.2 MCHC-31.9* RDW-13.0 RDWSD-43.8 Plt ___ ___ 05:56PM BLOOD Neuts-48.7 ___ Monos-17.4* Eos-2.8 Baso-0.8 Im ___ AbsNeut-3.54 AbsLymp-2.18 AbsMono-1.26* AbsEos-0.20 AbsBaso-0.06 ___ 05:56PM BLOOD ___ PTT-34.5 ___ ___ 05:56PM BLOOD Glucose-98 UreaN-15 Creat-0.9 Na-141 K-4.2 Cl-100 HCO3-23 AnGap-18 ___ 05:56PM BLOOD ALT-26 AST-42* AlkPhos-68 TotBili-0.5 ___ 05:56PM BLOOD Albumin-4.6 Calcium-9.9 Phos-3.5 Mg-2.2 ___ 03:14AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 05:56PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 03:14AM BLOOD HCV Ab-NEG ___ 06:04PM BLOOD ___ pO2-71* pCO2-45 pH-7.38 calTCO2-28 Base XS-0 ___ 06:04PM BLOOD Lactate-1.3 IMAGING RESULTS: ================ ___ Imaging CHEST (PORTABLE AP) IMPRESSION: Endotracheal tube terminates 5 cm above the carina. Enteric tube courses below the diaphragm, out of the field of view. Mild streaky left base opacity may be due to atelectasis or aspiration, pneumonia would not be excluded in the appropriate clinical setting. ___ Imaging CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial abnormality. ___ Imaging CHEST (PORTABLE AP) IMPRESSION: Comparison to ___. The feeding tube has been pulled back. The tip now projects over the gastroesophageal junction. The repositioned the 2 in the stomach it needs to be advanced by approximately 10 cm. The right PICC line and the endotracheal tube are in stable position. Lung volumes are low and there is a new partial left lower lobe atelectasis. No pneumonia, no pulmonary edema. ___ Imaging CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial abnormalities are identified. No change from the previous study. DISCHARGE LABS ============== ___ 06:28AM BLOOD WBC-7.5 RBC-3.90* Hgb-11.4* Hct-37.0* MCV-95 MCH-29.2 MCHC-30.8* RDW-13.2 RDWSD-45.3 Plt ___ ___ 06:28AM BLOOD Plt ___ ___ 06:28AM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-140 K-4.6 Cl-98 HCO3-30 AnGap-12 ___ 06:28AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.1 Brief Hospital Course: PATIENT SUMMARY: ================= ___ male with a past medical history of T10 paraplegia secondary to a GSW in ___ and neurogenic bladder complicated by recurrent UTIs, psychiatric history (?bipolar disorder, ?ADD), and polysubstance use disorder, recently relapsed who presented to the ED with utox +cocaine/opiates and AMS that reversed with Narcan. Unfortunately, he became acutely agitated, and then required sedation and intubation. He was extubated on ___, and transferred to the medical service. He improved significantly, the care team was actively looking for a bed at a rehabilitation facility. Unfortunately, he left the hospital against medical advice, and eloped on ___ with a PICC line in place. TRANSITIONAL ISSUES: ==================== [ ] Needs Hep B immunization [ ] Consider colonoscopy as outpatient for Anemia ACUTE ISSUES: ============= # Polysubstance use disorder: Per mother, first became addicted to Percocet for chronic pain from GSW. Since ___, he has been living in different treatment facilities/houses and has had several relapses. He was most recently at ___ and was kicked out ___ weeks ago and became homeless. He uses cocaine and opiates, and urine toxicology was found to be positive in ED. He is following with Dr. ___ in addiction medicine. Addiction medicine was consulted while inpatient and made recommendations for methadone. While in the hospital, he received methadone 55 daily, clonidine 0.1 BID. We planned for him to follow up with addiction medicine as an outpatient, but unfortunately, he eloped from the hospital with PICC line in place. # Toxic metabolic encephalopathy, Resolved: # Overdose Patient was somnolent on presentation to the ER and urine toxicology was positive for cocaine, opiates and methadone. He became agitated after receiving narcan and required sedation and intubation. Extubated ___ and AAOx3 at discharge. # Neurogenic bladder: History of recurrent multi-drug resistant UTIs in setting of paraplegia and neurogenic bladder requiring intermittent straight cath. Treated most recently (___) for Enterobacter cloacae UTI resistant to bactrim and nitrofurantoin. Originally treated for UTI however Urine culture negative so d/c CTX this admission. He was discharged on oxybutynin 5 BID. # Normocytic Anemia Has known normocytic anemia and recent iron studies ___ within normal limits (ferritin 134, TIBC 267, TRF 205). Baseline Hb approximately ___.1 on presentation to ED. Repeat Fe studies ___ showing ferritin 276, TIBC 226, TRF 174. Consider colonoscopy as outpatient. CHRONIC ISSUES: =============== # Bipolar disorder #ADHD: continue Dextroamphetamine # Depression: Psychiatry note from ___ (NP ___ continued Vyvanse and increased venlafaxine dose to 150 mg daily. Unclear if pt was taking these medications. In the hospital he was continued on Venlafaxine 75, with plan to follow with psychiatry as an outpatient. # Neuropathy: Continued on Gabapentin. This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Ditropan XL (*NF*) 20 mg Other DAILY 2. Gabapentin 800 mg PO TID 3. Vyvanse (lisdexamfetamine) 50 mg oral DAILY 4. oxybutynin chloride 10 mg oral DAILY Discharge Medications: 1. CloNIDine 0.1 mg PO BID 2. Dextroamphetamine 15 mg PO DAILY 3. Famotidine 20 mg PO Q12H 4. Methadone 55 mg PO DAILY Consider prescribing naloxone at discharge 5. Nicotine Patch 14 mg/day TD DAILY 6. Venlafaxine 75 mg PO BID 7. Gabapentin 800 mg PO TID 8. oxybutynin chloride 10 mg oral DAILY 9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Polysubstance use disorder Toxic metabolic encephalopathy, Resolved Overdose Neurogenic bladder Normocytic Anemia SECONDARY DIAGNOSES: Bipolar disorder Adult Attention Deficit Hyperactivity Disorder Depression Neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were found to be very confused and not responsive. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were intubated and given medication to treat your addictions. You became stable from a medical standpoint, and the care team was actively looking for a bed at a rehabilitation facility for you. Unfortunately, you left the hospital against medical advice, and without informing your care team. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed - Please follow up with all the appointments scheduled with your doctor ___ you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
[ "T403X1A", "G92", "J9600", "F11221", "N390", "G8220", "F19121", "T401X1A", "T405X1A", "N319", "D649", "F909", "F319", "G629", "Z781", "Z87440", "S24103S", "W3400XS", "R791", "Z23", "Z993" ]
Allergies: aspirin / lima beans Chief Complaint: AMS/agitation requiring sedation/intubation Major Surgical or Invasive Procedure: Intubation Extubation History of Present Illness: [MASKED] male with PMH of T10 paraplegia secondary to gunshot wound in [MASKED], psychiatric history (?bipolar disorder, ?ADHD), neurogenic bladder c/b recurrent UTIs, and polysubstance use disorder who recently relapsed on cocaine and heroin who presented to the ED with confusion and altered mental status. Per report from his aunt, patient was found to be living on the streets today and was slumped over in wheelchair and brought into the ED. In the ED, his initial vitals were Temp 99.1 (Tmax 100), HR 94, BP 145/82, RR 19, SpO2 100% on RA. On arrival he was somnolent and responsive only to sternal rub with pinpoint pupils and given 0.5 mg IV narcan after which he became agitated and was yelling and combative. He required restraints and then was intubated and mechanically ventilated given agitation and started on propofol and fentanyl for sedation and analgesia. Utox positive for cocaine, opiates, and methadone (serum tox neg) and UA consistent with UTI (WBC 26, mod leuk, few bacteria) and given dose of CTX. For AMS, got CT head which did not show an acute process. CXR confirmed ET and enteric tube placement and showed left base opacity c/w atelectasis vs. aspiration. On arrival to the FICU he was intubated and sedated. His BP was 120/79 with HR 79 in NSR. ROS: ==== Unable to assess as patient intubated and sedated. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward [MASKED] 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abscesses in neck, back, perianal 5. Recurrent sacral decubitus ulcers status post debridement in the OR on [MASKED] and [MASKED] & [MASKED] (growing MRSA) 6. Pseudomonal prostatic abscess in [MASKED] Prostatis in [MASKED] 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy [MASKED] 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation Social History: [MASKED] Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION PHSYCIAL EXAM: VS: BP 120/79, HR 79, RR 16, SpO2 100% GENERAL: Intubated and sedated. HEENT: PERRL. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally with rhonchi bilaterally. No wheezes. ABDOMEN: Normal bowels sounds, soft, mildly distended. EXTREMITIES: No edema. SKIN: Warm, well-perfused. No rash. Stage II sacral ulcers. NEUROLOGIC: Intubated and sedated, agitated when weaned sedation DISCHARGE PHYSCIAL EXAM: 24 HR Data (last updated [MASKED] @ 744) Temp: 98.1 (Tm 98.7), BP: 143/89 (126-143/48-89), HR: 75 (70-93), RR: 18 ([MASKED]), O2 sat: 99% (93-99), O2 delivery: RA GENERAL: NAD, pleasant HEENT: Sclera anicteric and without injection. CARDIAC: RRR, no m/r/g LUNGS: CTAB ABDOMEN: Soft, NT, ND. EXTREMITIES: No edema. SKIN: Warm, well-perfused. No rash. NEUROLOGIC: Paraplegic, moving upper extremities spontaneously. Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:56PM BLOOD WBC-7.3 RBC-4.42* Hgb-12.9* Hct-40.5 MCV-92 MCH-29.2 MCHC-31.9* RDW-13.0 RDWSD-43.8 Plt [MASKED] [MASKED] 05:56PM BLOOD Neuts-48.7 [MASKED] Monos-17.4* Eos-2.8 Baso-0.8 Im [MASKED] AbsNeut-3.54 AbsLymp-2.18 AbsMono-1.26* AbsEos-0.20 AbsBaso-0.06 [MASKED] 05:56PM BLOOD [MASKED] PTT-34.5 [MASKED] [MASKED] 05:56PM BLOOD Glucose-98 UreaN-15 Creat-0.9 Na-141 K-4.2 Cl-100 HCO3-23 AnGap-18 [MASKED] 05:56PM BLOOD ALT-26 AST-42* AlkPhos-68 TotBili-0.5 [MASKED] 05:56PM BLOOD Albumin-4.6 Calcium-9.9 Phos-3.5 Mg-2.2 [MASKED] 03:14AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG [MASKED] 05:56PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 03:14AM BLOOD HCV Ab-NEG [MASKED] 06:04PM BLOOD [MASKED] pO2-71* pCO2-45 pH-7.38 calTCO2-28 Base XS-0 [MASKED] 06:04PM BLOOD Lactate-1.3 IMAGING RESULTS: ================ [MASKED] Imaging CHEST (PORTABLE AP) IMPRESSION: Endotracheal tube terminates 5 cm above the carina. Enteric tube courses below the diaphragm, out of the field of view. Mild streaky left base opacity may be due to atelectasis or aspiration, pneumonia would not be excluded in the appropriate clinical setting. [MASKED] Imaging CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial abnormality. [MASKED] Imaging CHEST (PORTABLE AP) IMPRESSION: Comparison to [MASKED]. The feeding tube has been pulled back. The tip now projects over the gastroesophageal junction. The repositioned the 2 in the stomach it needs to be advanced by approximately 10 cm. The right PICC line and the endotracheal tube are in stable position. Lung volumes are low and there is a new partial left lower lobe atelectasis. No pneumonia, no pulmonary edema. [MASKED] Imaging CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial abnormalities are identified. No change from the previous study. DISCHARGE LABS ============== [MASKED] 06:28AM BLOOD WBC-7.5 RBC-3.90* Hgb-11.4* Hct-37.0* MCV-95 MCH-29.2 MCHC-30.8* RDW-13.2 RDWSD-45.3 Plt [MASKED] [MASKED] 06:28AM BLOOD Plt [MASKED] [MASKED] 06:28AM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-140 K-4.6 Cl-98 HCO3-30 AnGap-12 [MASKED] 06:28AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.1 Brief Hospital Course: PATIENT SUMMARY: ================= [MASKED] male with a past medical history of T10 paraplegia secondary to a GSW in [MASKED] and neurogenic bladder complicated by recurrent UTIs, psychiatric history (?bipolar disorder, ?ADD), and polysubstance use disorder, recently relapsed who presented to the ED with utox +cocaine/opiates and AMS that reversed with Narcan. Unfortunately, he became acutely agitated, and then required sedation and intubation. He was extubated on [MASKED], and transferred to the medical service. He improved significantly, the care team was actively looking for a bed at a rehabilitation facility. Unfortunately, he left the hospital against medical advice, and eloped on [MASKED] with a PICC line in place. TRANSITIONAL ISSUES: ==================== [ ] Needs Hep B immunization [ ] Consider colonoscopy as outpatient for Anemia ACUTE ISSUES: ============= # Polysubstance use disorder: Per mother, first became addicted to Percocet for chronic pain from GSW. Since [MASKED], he has been living in different treatment facilities/houses and has had several relapses. He was most recently at [MASKED] and was kicked out [MASKED] weeks ago and became homeless. He uses cocaine and opiates, and urine toxicology was found to be positive in ED. He is following with Dr. [MASKED] in addiction medicine. Addiction medicine was consulted while inpatient and made recommendations for methadone. While in the hospital, he received methadone 55 daily, clonidine 0.1 BID. We planned for him to follow up with addiction medicine as an outpatient, but unfortunately, he eloped from the hospital with PICC line in place. # Toxic metabolic encephalopathy, Resolved: # Overdose Patient was somnolent on presentation to the ER and urine toxicology was positive for cocaine, opiates and methadone. He became agitated after receiving narcan and required sedation and intubation. Extubated [MASKED] and AAOx3 at discharge. # Neurogenic bladder: History of recurrent multi-drug resistant UTIs in setting of paraplegia and neurogenic bladder requiring intermittent straight cath. Treated most recently ([MASKED]) for Enterobacter cloacae UTI resistant to bactrim and nitrofurantoin. Originally treated for UTI however Urine culture negative so d/c CTX this admission. He was discharged on oxybutynin 5 BID. # Normocytic Anemia Has known normocytic anemia and recent iron studies [MASKED] within normal limits (ferritin 134, TIBC 267, TRF 205). Baseline Hb approximately [MASKED].1 on presentation to ED. Repeat Fe studies [MASKED] showing ferritin 276, TIBC 226, TRF 174. Consider colonoscopy as outpatient. CHRONIC ISSUES: =============== # Bipolar disorder #ADHD: continue Dextroamphetamine # Depression: Psychiatry note from [MASKED] (NP [MASKED] continued Vyvanse and increased venlafaxine dose to 150 mg daily. Unclear if pt was taking these medications. In the hospital he was continued on Venlafaxine 75, with plan to follow with psychiatry as an outpatient. # Neuropathy: Continued on Gabapentin. This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Ditropan XL (*NF*) 20 mg Other DAILY 2. Gabapentin 800 mg PO TID 3. Vyvanse (lisdexamfetamine) 50 mg oral DAILY 4. oxybutynin chloride 10 mg oral DAILY Discharge Medications: 1. CloNIDine 0.1 mg PO BID 2. Dextroamphetamine 15 mg PO DAILY 3. Famotidine 20 mg PO Q12H 4. Methadone 55 mg PO DAILY Consider prescribing naloxone at discharge 5. Nicotine Patch 14 mg/day TD DAILY 6. Venlafaxine 75 mg PO BID 7. Gabapentin 800 mg PO TID 8. oxybutynin chloride 10 mg oral DAILY 9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Polysubstance use disorder Toxic metabolic encephalopathy, Resolved Overdose Neurogenic bladder Normocytic Anemia SECONDARY DIAGNOSES: Bipolar disorder Adult Attention Deficit Hyperactivity Disorder Depression Neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You were found to be very confused and not responsive. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were intubated and given medication to treat your addictions. You became stable from a medical standpoint, and the care team was actively looking for a bed at a rehabilitation facility for you. Unfortunately, you left the hospital against medical advice, and without informing your care team. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please continue to take all of your medications as directed - Please follow up with all the appointments scheduled with your doctor [MASKED] you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
[]
[ "N390", "D649" ]
[ "T403X1A: Poisoning by methadone, accidental (unintentional), initial encounter", "G92: Toxic encephalopathy", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "F11221: Opioid dependence with intoxication delirium", "N390: Urinary tract infection, site not specified", "G8220: Paraplegia, unspecified", "F19121: Other psychoactive substance abuse with intoxication delirium", "T401X1A: Poisoning by heroin, accidental (unintentional), initial encounter", "T405X1A: Poisoning by cocaine, accidental (unintentional), initial encounter", "N319: Neuromuscular dysfunction of bladder, unspecified", "D649: Anemia, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F319: Bipolar disorder, unspecified", "G629: Polyneuropathy, unspecified", "Z781: Physical restraint status", "Z87440: Personal history of urinary (tract) infections", "S24103S: Unspecified injury at T7-T10 level of thoracic spinal cord, sequela", "W3400XS: Accidental discharge from unspecified firearms or gun, sequela", "R791: Abnormal coagulation profile", "Z23: Encounter for immunization", "Z993: Dependence on wheelchair" ]
10,038,332
23,550,887
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___ Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old gentleman with history of paraplegia from gun shot wound (___), neurogenic bladder, recurrent UTIs, chronic pain, hx of cocaine abuse, hx of psychosis, transferred from ___ for evaluation of syncope. Yesterday AM, patient was found by side of road by police after he fell out of his wheelchair by police. Patient reports he syncopized, unclear how long he was out for. He was brought by EMS to ___. Per notes, he had negative CT head and CT c-spine. He was evaluated by psychiatric team who recommended discharge home. However, mother endorsed concern of multiple episodes of syncope, he was transferred to ___ for syncope evaluation. Patient provides a rambling and unclear history. He says he was outside yesterday to get coffee, going uphill in his wheelchair and then lost consciousness, and fell backwards out of his chair. He also provides an incoherent history of being dragged in the mud by people he was with, and he perseverates on the fact that this dirtied his clothes and his white ___ which he normally keeps very clean. His speech is quite pressured and tangential during this part of the history. He denies cocaine use and cannot explain why his tox screen is positive. He is not able to provide meaningful details of his history of syncope. He tells me he syncopized 5x in past week. His only associated symptom is feeling "warm'--denies chest, respiratory symptoms or seizure like activity. In the ED he endorsed syncopizing up to 5x daily. There was concern for psychosis mentioned by PCP in recent note (___). Patient endorsed visual hallucinations and paranoia of government following him. There is a question of history of bipolar disorder, not currently treated. He does not follow with a psychiatrist. In the ED, initial vitals were: 99.6 90 130/85 14 99% RA - Labs notable for wbc 12.6, chem7 wnl, UA with lg leuks, 44wbc, few bac, 80 ketones, urine cocaine POS, urine opiates POS, lactate 1.7 - He was given: ___ 22:39 IV CeftriaXONE 1 gm ___ Decision was made to admit for syncope evaluation, and inpatient psych consult. On arrival to the floor, he is calm but appears altered. He has at times difficult to comprehend, rambling and pressured speech. He denies HI/SI or hallucinations currently. ROS: (+) also notable for "cloudy" urine recently. Otherwise as per HPI. (-) Full 10 point ROS negative, except as noted in HPI. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward ___ 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in ___ 5. Recurrent sacral decubitus ulcers status post debridement in the OR on ___ and ___ & ___ (growing MRSA) 6. Pseudomonal prostatic abscess in ___ Prostatis in ___ 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___ 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in ___ raised, in ___, completed high school in ___ and some post grad computer training. Has one son, now ___ yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on ___ who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use ___ ___. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use ___ ___ but was found with cocaine in his urine on this admission in ___. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION EXAM: Vital Signs: 98.2 120 / 76 81 18 100 RA General: awake but extremely somnolent, falling asleep numerous times during interview; arousable to voice HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diffusely diminished bilaterally, no crackles, Abdomen: soft, diffuse mild discomfort to deep palpation GU: No foley, no external lesions SKIN: 1x1cm superficial ulceration R gluteus, covered in clean dressing, appears non-erythematous and non-purulent Ext: Warm, non-edematous Neuro: full upper extremity muscle strength; ___ strength ___ bilaterally; Psych: denies hallucinations, HI, SI; pressured speech at times, tangentiality and circumstantiality DISCHARGE EXAM: VS: Tc 98.6 BP 105/52 HR 89 RR 18 O2 99% RA GENERAL: Awake, alert, NAD, pleasant. HEENT: Sclera anicteric, MMM, EOMI, PERRL HEART: RRR, normal S1 + S2, no m/r/g LUNGS: CTAB, no crackles ABDOMEN: Soft, non-tender, non-distended GU: No foley, no external lesions RECTAL: Prostate tender to palpation SKIN: 1x1cm superficial ulceration R gluteus, covered in clean dressing, appears non-erythematous and non-purulent EXT: Warm, non-edematous NEURO: AOx3, CNII-XII grossly intact Pertinent Results: ADMISSION LABS: ================= CHEM: ___ 08:00PM GLUCOSE-91 UREA N-8 CREAT-0.7 SODIUM-136 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-26 ANION GAP-17 ___ 08:00PM CALCIUM-9.6 PHOSPHATE-2.9 MAGNESIUM-2.2 CBC: ___ 08:00PM WBC-12.6*# RBC-4.16* HGB-12.4* HCT-37.9* MCV-91 MCH-29.8 MCHC-32.7 RDW-12.1 RDWSD-40.6 URINE: ___ 09:29PM URINE RBC-1 WBC-44* BACTERIA-FEW YEAST-NONE EPI-<1 ___ 09:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-80 BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG ___ 09:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS* cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG PERTINENT LABS: ================= ___ 07:35AM BLOOD TSH-0.16* ___ 07:45AM BLOOD Free T4-1.3 ------- MICRO: ------- ___ 9:30 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ACINETOBACTER BAUMANNII COMPLEX. >100,000 CFU/mL. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". Piperacillin/tazobactam sensitivity testing available on request. ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S LEVOFLOXACIN---------- 1 S MEROPENEM------------- 0.5 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 1 S --------- STUDIES: --------- EEG (___): - This is an abnormal continuous ICU EEG monitoring study because of a slow and poorly modulated background consistent with a mild to moderate encephalopathy. Findings were provided to the clinical team intermittently during this recording period. CT C-Spine w/o contrast ___ - No acute abnormality suspected; findings consistent with multilevel cervical spondylosis. CT Head w/o contrast ___ - No acute intracranial abnormality CXR PA/Lateral ___ - No acute cardiopulmonary process DISCHARGE LABS: ================= None, except UA, after ___ as patient was stable. CHEM: ___ 07:45AM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-141 K-4.2 Cl-102 HCO3-28 AnGap-15 CBC: ___ 07:45AM BLOOD WBC-5.1 RBC-4.45* Hgb-13.3* Hct-42.2 MCV-95 MCH-29.9 MCHC-31.5* RDW-12.5 RDWSD-43.4 Plt ___ UA: ___ 06:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Brief Hospital Course: ___ is a ___ year old male with a history of T10 paraplegia, neurogenic bladder & recurrent UTIs, recent pre-admission question of paranoia/psychosis, who presented with syncope multiple times daily. Patient reported losing consciousness up to 5x/day daily for months. All work-up was unremarkable. EEG showed mild encephalopathy but no seizures. CT head and C spine showed mild cervical spondylosis. Orthostatics negative. Telemetry without events. Patient reported that he had no episodes of syncope in the hospital and none were witnessed. Psychiatry evaluated the patient and diagnosed schizophrenia with psychosis exacerbated by drug and medication use (cocaine and Concerta) and started the patient on Risperdal. Syncope was felt to be psychiatric in nature, however history also notable for significant caffeine intake in addition to ADHD medication and severe insomnia. ACTIVE PROBLEMS: ============================ #SYNCOPE: Unclear etiology. Never witnessed by the patient's family and has not had any events during this hospitalization. No history of seizures. Question of whether this was a case of psychiatric syncope which typically presents in younger patients with psychiatric disorders, without cardiovascular or neurologic disease. Another consideration was drug/med effect from opiates, other illegal drugs given that the patient's urine tox was positive for opiates (on MS ___ and cocaine. The patient emphasized how little he sleeps (stays up late playing video games, watching TV, often only gets ___ hours of sleep a night), and somnolence secondary to this was felt to be a contributing factor as well given that the patient had no episodes in the hospital and was well rested here. Also endorsed drinking multiple caffeinated drinks daily in addition to ADHD medication. Not felt to be cardiac or neurogenic as ECG, telemetry and EEG showed nothing except for mild encephalopathy. Ultimately felt when discharged that this would continue to resolve with improved psychiatric care as outlined below. #PSYCHOSIS with suspected schizophrenia: Based upon rambling and disorganized speech in addition to delusions of the government following him confirmed by his family. He also previously endorsed paranoia and visual hallucinations. Per psych likely chronic and then triggered by cocaine (and possibly other drug) use and Concerta. UTI felt to have contributed to the patient's decompensation as well. Thyroid function appeared normal (TSH was low but barely below low normal limits and free T4 was well within normal limits) so hyperthyroidism was felt much less likely. Additionally he had no other physiologic symptoms of hyperthyroidism. The patient's morphine was tapered since he violated his narcotics contract and his home Concerta was held indefinitely. His UTI was treated as noted below and he was started on risperidone QHS per psych. ***** He recently fired his PCA on ___ (who was helping with ADLs, food, meds) because he thought she was not helping much and just taking his money. He and his son on discharge were setting up his son as his new PCA. He was also set up with a partial day psych program in order to expedite his outpatient psych care, given difficulty getting him a psychiatry appointment because of the patient's insurance. #CYSTITIS/prostatitis as below Patient reported cloudy urine. Self caths due to neurogenic bladder ___ spinal cord injury from gun shot wound. UA was grossly positive. Urine culture grew ACINETOBACTER BAUMANNII sensitive to Bactrim and ENTEROCOCCUS SP. sensitive to ampicillin. His antibiotic course was as follows: - Ampicillin PO 500 mg Q6H (___) - Bactrim DS BID (___) - Empiric ceftriaxone (___) #Acute bacterial PROSTATITIS: Tender on digital rectal exam, performed on day of discharge with concern given recurrent UTIs and reported bladder discomfort. Discharged on Bactrim x 6 weeks for prostatitis ___ - ___ given senses on initial culture. Counseled on clean self-cath routine. # L hallux ___ trauma - patient stubbed toe with skin tear. Recommend ongoing dressing changes daily and monitoring for improvement. CHRONIC/STABLE PROBLEMS: ============================ #DEPRESSION: - Continued Wellbutrin #ADHD: - Discontinued Concerta and did not resume on discharge as noted above #CHRONIC PAIN: - Continued gabapentin. - Morphine taper (15 mg twice daily from ___, then 15 mg daily from ___ the patient had diarrhea when this was initially held. Patient violated his narcotics contract prior to admission with illicit drug use. #CHRONIC ISSUES: - R gluteal wound: daily dressing changes - Neurogenic bladder: continued home tamsulosin, mirabegron, methenamine TRANSITIONAL ISSUES: ============================ - Anti-psychotic medication management (Risperdal started in the hospital) and psych follow up - Partial day psych program intake scheduled for ___ at 9 am - Gluteal wound care and left toe wound care with home ___ - Bactrim x 6 weeks for prostatitis (___) - Taper down MS ___ (15 mg twice daily from ___, then 15 mg daily from ___ because patient violated narcotics contract - Son will be patient's new personal care assistant Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. BuPROPion (Sustained Release) 150 mg PO BID 2. Collagenase Ointment 1 Appl TP DAILY R thigh 3. Fluticasone Propionate NASAL ___ SPRY NU DAILY 4. Gabapentin 800 mg PO TID 5. methenamine hippurate 1 gram oral BID 6. Concerta (methylphenidate) 27 mg oral DAILY 7. mirabegron 25 mg oral DAILY 8. Morphine SR (MS ___ 15 mg PO TID:PRN pain 9. Tamsulosin 0.4 mg PO QHS 10. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 11. Ascorbic Acid ___ mg PO BID 12. Docusate Sodium 100 mg PO BID 13. Ibuprofen 200 mg PO Q6H:PRN Pain - Mild 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. RisperiDONE 1 mg PO QHS RX *risperidone [Risperdal] 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 3. Morphine SR (MS ___ 15 mg PO Q12H 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 5. Ascorbic Acid ___ mg PO BID 6. BuPROPion (Sustained Release) 150 mg PO BID 7. Collagenase Ointment 1 Appl TP DAILY R thigh 8. Docusate Sodium 100 mg PO BID 9. Fluticasone Propionate NASAL ___ SPRY NU DAILY 10. Gabapentin 800 mg PO TID 11. Ibuprofen 200 mg PO Q6H:PRN Pain - Mild 12. Methenamine Hippurate 1 gram ORAL BID 13. mirabegron 25 mg oral DAILY 14. Oxybutynin 20 mg PO DAILY 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Psychosis NOS Cocaine Abuse Secondary Diagnosis: ADHD Depression Chronic pain from right gluteal decubitus ulcer 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. ___, Why you were here: - You were hospitalized because you were having episodes of confusion, loss of consciousness, and were found to have a urinary tract infection. What we did and found: - Urine tests which showed two types of bacteria, and cocaine - EEG (brain wave test) which did NOT show seizures - CT scan of your head and neck which showed no problems What should you do now? - Taper down MS ___ as directed in your discharge instructions - Get at least 7 hours of sleep each night and do not drink any energy drinks or coffee after noontime. - STOP taking Concerta - Continue Risperidone 1 mg nightly - It is VERY important that you follow up with the partial psych program that was arranged for you. - You can also call ___ psychiatry at ___ once you are home to set up an outpatient appointment. - Please continue to take the antibiotics for your infection for 6 weeks, until they are finished It was a pleasure meeting and taking care of you while you were in the hospital. - Your ___ Team Followup Instructions: ___
[ "N3090", "G92", "L89159", "G8220", "L89319", "F1120", "N319", "N410", "F1420", "F29", "R55", "T43615A", "T43635A", "F209", "N39498", "G4700", "F329", "F909", "F17210", "F22", "M479", "B952", "B9689", "S91109A", "W228XXA", "Y929" ]
Allergies: aspirin Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old gentleman with history of paraplegia from gun shot wound ([MASKED]), neurogenic bladder, recurrent UTIs, chronic pain, hx of cocaine abuse, hx of psychosis, transferred from [MASKED] for evaluation of syncope. Yesterday AM, patient was found by side of road by police after he fell out of his wheelchair by police. Patient reports he syncopized, unclear how long he was out for. He was brought by EMS to [MASKED]. Per notes, he had negative CT head and CT c-spine. He was evaluated by psychiatric team who recommended discharge home. However, mother endorsed concern of multiple episodes of syncope, he was transferred to [MASKED] for syncope evaluation. Patient provides a rambling and unclear history. He says he was outside yesterday to get coffee, going uphill in his wheelchair and then lost consciousness, and fell backwards out of his chair. He also provides an incoherent history of being dragged in the mud by people he was with, and he perseverates on the fact that this dirtied his clothes and his white [MASKED] which he normally keeps very clean. His speech is quite pressured and tangential during this part of the history. He denies cocaine use and cannot explain why his tox screen is positive. He is not able to provide meaningful details of his history of syncope. He tells me he syncopized 5x in past week. His only associated symptom is feeling "warm'--denies chest, respiratory symptoms or seizure like activity. In the ED he endorsed syncopizing up to 5x daily. There was concern for psychosis mentioned by PCP in recent note ([MASKED]). Patient endorsed visual hallucinations and paranoia of government following him. There is a question of history of bipolar disorder, not currently treated. He does not follow with a psychiatrist. In the ED, initial vitals were: 99.6 90 130/85 14 99% RA - Labs notable for wbc 12.6, chem7 wnl, UA with lg leuks, 44wbc, few bac, 80 ketones, urine cocaine POS, urine opiates POS, lactate 1.7 - He was given: [MASKED] 22:39 IV CeftriaXONE 1 gm [MASKED] Decision was made to admit for syncope evaluation, and inpatient psych consult. On arrival to the floor, he is calm but appears altered. He has at times difficult to comprehend, rambling and pressured speech. He denies HI/SI or hallucinations currently. ROS: (+) also notable for "cloudy" urine recently. Otherwise as per HPI. (-) Full 10 point ROS negative, except as noted in HPI. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward [MASKED] 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in [MASKED] 5. Recurrent sacral decubitus ulcers status post debridement in the OR on [MASKED] and [MASKED] & [MASKED] (growing MRSA) 6. Pseudomonal prostatic abscess in [MASKED] Prostatis in [MASKED] 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy [MASKED] 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in [MASKED] raised, in [MASKED], completed high school in [MASKED] and some post grad computer training. Has one son, now [MASKED] yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on [MASKED] who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use [MASKED] [MASKED]. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use [MASKED] [MASKED] but was found with cocaine in his urine on this admission in [MASKED]. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: ADMISSION EXAM: Vital Signs: 98.2 120 / 76 81 18 100 RA General: awake but extremely somnolent, falling asleep numerous times during interview; arousable to voice HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diffusely diminished bilaterally, no crackles, Abdomen: soft, diffuse mild discomfort to deep palpation GU: No foley, no external lesions SKIN: 1x1cm superficial ulceration R gluteus, covered in clean dressing, appears non-erythematous and non-purulent Ext: Warm, non-edematous Neuro: full upper extremity muscle strength; [MASKED] strength [MASKED] bilaterally; Psych: denies hallucinations, HI, SI; pressured speech at times, tangentiality and circumstantiality DISCHARGE EXAM: VS: Tc 98.6 BP 105/52 HR 89 RR 18 O2 99% RA GENERAL: Awake, alert, NAD, pleasant. HEENT: Sclera anicteric, MMM, EOMI, PERRL HEART: RRR, normal S1 + S2, no m/r/g LUNGS: CTAB, no crackles ABDOMEN: Soft, non-tender, non-distended GU: No foley, no external lesions RECTAL: Prostate tender to palpation SKIN: 1x1cm superficial ulceration R gluteus, covered in clean dressing, appears non-erythematous and non-purulent EXT: Warm, non-edematous NEURO: AOx3, CNII-XII grossly intact Pertinent Results: ADMISSION LABS: ================= CHEM: [MASKED] 08:00PM GLUCOSE-91 UREA N-8 CREAT-0.7 SODIUM-136 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-26 ANION GAP-17 [MASKED] 08:00PM CALCIUM-9.6 PHOSPHATE-2.9 MAGNESIUM-2.2 CBC: [MASKED] 08:00PM WBC-12.6*# RBC-4.16* HGB-12.4* HCT-37.9* MCV-91 MCH-29.8 MCHC-32.7 RDW-12.1 RDWSD-40.6 URINE: [MASKED] 09:29PM URINE RBC-1 WBC-44* BACTERIA-FEW YEAST-NONE EPI-<1 [MASKED] 09:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-TR KETONE-80 BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-LG [MASKED] 09:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS* cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG PERTINENT LABS: ================= [MASKED] 07:35AM BLOOD TSH-0.16* [MASKED] 07:45AM BLOOD Free T4-1.3 ------- MICRO: ------- [MASKED] 9:30 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ACINETOBACTER BAUMANNII COMPLEX. >100,000 CFU/mL. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". Piperacillin/tazobactam sensitivity testing available on request. ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ACINETOBACTER BAUMANNII COMPLEX | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S LEVOFLOXACIN---------- 1 S MEROPENEM------------- 0.5 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 1 S --------- STUDIES: --------- EEG ([MASKED]): - This is an abnormal continuous ICU EEG monitoring study because of a slow and poorly modulated background consistent with a mild to moderate encephalopathy. Findings were provided to the clinical team intermittently during this recording period. CT C-Spine w/o contrast [MASKED] - No acute abnormality suspected; findings consistent with multilevel cervical spondylosis. CT Head w/o contrast [MASKED] - No acute intracranial abnormality CXR PA/Lateral [MASKED] - No acute cardiopulmonary process DISCHARGE LABS: ================= None, except UA, after [MASKED] as patient was stable. CHEM: [MASKED] 07:45AM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-141 K-4.2 Cl-102 HCO3-28 AnGap-15 CBC: [MASKED] 07:45AM BLOOD WBC-5.1 RBC-4.45* Hgb-13.3* Hct-42.2 MCV-95 MCH-29.9 MCHC-31.5* RDW-12.5 RDWSD-43.4 Plt [MASKED] UA: [MASKED] 06:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Brief Hospital Course: [MASKED] is a [MASKED] year old male with a history of T10 paraplegia, neurogenic bladder & recurrent UTIs, recent pre-admission question of paranoia/psychosis, who presented with syncope multiple times daily. Patient reported losing consciousness up to 5x/day daily for months. All work-up was unremarkable. EEG showed mild encephalopathy but no seizures. CT head and C spine showed mild cervical spondylosis. Orthostatics negative. Telemetry without events. Patient reported that he had no episodes of syncope in the hospital and none were witnessed. Psychiatry evaluated the patient and diagnosed schizophrenia with psychosis exacerbated by drug and medication use (cocaine and Concerta) and started the patient on Risperdal. Syncope was felt to be psychiatric in nature, however history also notable for significant caffeine intake in addition to ADHD medication and severe insomnia. ACTIVE PROBLEMS: ============================ #SYNCOPE: Unclear etiology. Never witnessed by the patient's family and has not had any events during this hospitalization. No history of seizures. Question of whether this was a case of psychiatric syncope which typically presents in younger patients with psychiatric disorders, without cardiovascular or neurologic disease. Another consideration was drug/med effect from opiates, other illegal drugs given that the patient's urine tox was positive for opiates (on MS [MASKED] and cocaine. The patient emphasized how little he sleeps (stays up late playing video games, watching TV, often only gets [MASKED] hours of sleep a night), and somnolence secondary to this was felt to be a contributing factor as well given that the patient had no episodes in the hospital and was well rested here. Also endorsed drinking multiple caffeinated drinks daily in addition to ADHD medication. Not felt to be cardiac or neurogenic as ECG, telemetry and EEG showed nothing except for mild encephalopathy. Ultimately felt when discharged that this would continue to resolve with improved psychiatric care as outlined below. #PSYCHOSIS with suspected schizophrenia: Based upon rambling and disorganized speech in addition to delusions of the government following him confirmed by his family. He also previously endorsed paranoia and visual hallucinations. Per psych likely chronic and then triggered by cocaine (and possibly other drug) use and Concerta. UTI felt to have contributed to the patient's decompensation as well. Thyroid function appeared normal (TSH was low but barely below low normal limits and free T4 was well within normal limits) so hyperthyroidism was felt much less likely. Additionally he had no other physiologic symptoms of hyperthyroidism. The patient's morphine was tapered since he violated his narcotics contract and his home Concerta was held indefinitely. His UTI was treated as noted below and he was started on risperidone QHS per psych. ***** He recently fired his PCA on [MASKED] (who was helping with ADLs, food, meds) because he thought she was not helping much and just taking his money. He and his son on discharge were setting up his son as his new PCA. He was also set up with a partial day psych program in order to expedite his outpatient psych care, given difficulty getting him a psychiatry appointment because of the patient's insurance. #CYSTITIS/prostatitis as below Patient reported cloudy urine. Self caths due to neurogenic bladder [MASKED] spinal cord injury from gun shot wound. UA was grossly positive. Urine culture grew ACINETOBACTER BAUMANNII sensitive to Bactrim and ENTEROCOCCUS SP. sensitive to ampicillin. His antibiotic course was as follows: - Ampicillin PO 500 mg Q6H ([MASKED]) - Bactrim DS BID ([MASKED]) - Empiric ceftriaxone ([MASKED]) #Acute bacterial PROSTATITIS: Tender on digital rectal exam, performed on day of discharge with concern given recurrent UTIs and reported bladder discomfort. Discharged on Bactrim x 6 weeks for prostatitis [MASKED] - [MASKED] given senses on initial culture. Counseled on clean self-cath routine. # L hallux [MASKED] trauma - patient stubbed toe with skin tear. Recommend ongoing dressing changes daily and monitoring for improvement. CHRONIC/STABLE PROBLEMS: ============================ #DEPRESSION: - Continued Wellbutrin #ADHD: - Discontinued Concerta and did not resume on discharge as noted above #CHRONIC PAIN: - Continued gabapentin. - Morphine taper (15 mg twice daily from [MASKED], then 15 mg daily from [MASKED] the patient had diarrhea when this was initially held. Patient violated his narcotics contract prior to admission with illicit drug use. #CHRONIC ISSUES: - R gluteal wound: daily dressing changes - Neurogenic bladder: continued home tamsulosin, mirabegron, methenamine TRANSITIONAL ISSUES: ============================ - Anti-psychotic medication management (Risperdal started in the hospital) and psych follow up - Partial day psych program intake scheduled for [MASKED] at 9 am - Gluteal wound care and left toe wound care with home [MASKED] - Bactrim x 6 weeks for prostatitis ([MASKED]) - Taper down MS [MASKED] (15 mg twice daily from [MASKED], then 15 mg daily from [MASKED] because patient violated narcotics contract - Son will be patient's new personal care assistant Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. BuPROPion (Sustained Release) 150 mg PO BID 2. Collagenase Ointment 1 Appl TP DAILY R thigh 3. Fluticasone Propionate NASAL [MASKED] SPRY NU DAILY 4. Gabapentin 800 mg PO TID 5. methenamine hippurate 1 gram oral BID 6. Concerta (methylphenidate) 27 mg oral DAILY 7. mirabegron 25 mg oral DAILY 8. Morphine SR (MS [MASKED] 15 mg PO TID:PRN pain 9. Tamsulosin 0.4 mg PO QHS 10. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 11. Ascorbic Acid [MASKED] mg PO BID 12. Docusate Sodium 100 mg PO BID 13. Ibuprofen 200 mg PO Q6H:PRN Pain - Mild 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. RisperiDONE 1 mg PO QHS RX *risperidone [Risperdal] 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 3. Morphine SR (MS [MASKED] 15 mg PO Q12H 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 5. Ascorbic Acid [MASKED] mg PO BID 6. BuPROPion (Sustained Release) 150 mg PO BID 7. Collagenase Ointment 1 Appl TP DAILY R thigh 8. Docusate Sodium 100 mg PO BID 9. Fluticasone Propionate NASAL [MASKED] SPRY NU DAILY 10. Gabapentin 800 mg PO TID 11. Ibuprofen 200 mg PO Q6H:PRN Pain - Mild 12. Methenamine Hippurate 1 gram ORAL BID 13. mirabegron 25 mg oral DAILY 14. Oxybutynin 20 mg PO DAILY 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: Psychosis NOS Cocaine Abuse Secondary Diagnosis: ADHD Depression Chronic pain from right gluteal decubitus ulcer 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], Why you were here: - You were hospitalized because you were having episodes of confusion, loss of consciousness, and were found to have a urinary tract infection. What we did and found: - Urine tests which showed two types of bacteria, and cocaine - EEG (brain wave test) which did NOT show seizures - CT scan of your head and neck which showed no problems What should you do now? - Taper down MS [MASKED] as directed in your discharge instructions - Get at least 7 hours of sleep each night and do not drink any energy drinks or coffee after noontime. - STOP taking Concerta - Continue Risperidone 1 mg nightly - It is VERY important that you follow up with the partial psych program that was arranged for you. - You can also call [MASKED] psychiatry at [MASKED] once you are home to set up an outpatient appointment. - Please continue to take the antibiotics for your infection for 6 weeks, until they are finished It was a pleasure meeting and taking care of you while you were in the hospital. - Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "G4700", "F329", "F17210", "Y929" ]
[ "N3090: Cystitis, unspecified without hematuria", "G92: Toxic encephalopathy", "L89159: Pressure ulcer of sacral region, unspecified stage", "G8220: Paraplegia, unspecified", "L89319: Pressure ulcer of right buttock, unspecified stage", "F1120: Opioid dependence, uncomplicated", "N319: Neuromuscular dysfunction of bladder, unspecified", "N410: Acute prostatitis", "F1420: Cocaine dependence, uncomplicated", "F29: Unspecified psychosis not due to a substance or known physiological condition", "R55: Syncope and collapse", "T43615A: Adverse effect of caffeine, initial encounter", "T43635A: Adverse effect of methylphenidate, initial encounter", "F209: Schizophrenia, unspecified", "N39498: Other specified urinary incontinence", "G4700: Insomnia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F22: Delusional disorders", "M479: Spondylosis, unspecified", "B952: Enterococcus as the cause of diseases classified elsewhere", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "S91109A: Unspecified open wound of unspecified toe(s) without damage to nail, initial encounter", "W228XXA: Striking against or struck by other objects, initial encounter", "Y929: Unspecified place or not applicable" ]
10,038,332
27,818,008
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with PMH of history of unspecified psychotic disorder (bipolar vs schizophrenia) and significant cocaine and opioid use disorders (sober >9 mo), prostatic abscess, and T10 paraplegia ___ GSW in ___ with neurogenic bladder resulting in recurrent UTIs who presents today with flank pain and foul smelling urine. The symptoms started a week ago but have worsened over the past 2 days, prompting him to present to the ED. Over the past week the patient noticed a foul odor in his urine with purulent discharge and bilateral flank pain. These symptoms felt similar to his prior kidney infections. He describes subjective fevers and chills, neck pain, and joint pains in the small joints of his hands. He has had chronic mild abdominal tenderness that initially improved after having a bowel movement yesterday but worsened somewhat today. He is taking all his medications as prescribed but forgot to take fosfomycin over the past 2 weeks and feels this may have triggered a UTI. Of note, pt was seen in ___ clinic in ___. He had been performing straight catheterization every few hours and has noted improvement over the past several months with weekly fosfomycin therapy as the frequencies of infections has decreased. However, earlier that month he had sign/symptoms of a UTI for which he was prescribed ciprofloxacin and treated with 7 days. ROS: He denies any URI symptoms, n/v, dysuria, chest pain, dyspnea, palpitations, headache, or paresthesias. He states that he feels like is developing an ulcer in his left buttock area as well. Has had bilateral blurry vision since starting Zoloft 2 weeks ago, which prompted him to discontinue the medication. ED COURSE: Exam: NAD b/l flank pain, normal mentation, wheelchair bound Labs notable for WBC 8, UA pos for nitrites and leuks with >182 WBC and bacteria. Pt received iL NS and 1g CTX at 10:45 pm. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward ___ 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in ___ 5. Recurrent sacral decubitus ulcers status post debridement in the OR on ___ and ___ & ___ (growing MRSA) 6. Pseudomonal prostatic abscess in ___ Prostatis in ___ 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy ___ 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in ___ raised, in ___, completed high school in ___ and some post grad ___ training. Has one son, now ___ yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on ___ who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use ___ ___. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use ___ ___ but was found with cocaine in his urine on this admission in ___. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: GENERAL: Pleasant gentleman in hospital bed, in no apparent distress. EYES: PERRL, EOMI, anicteric sclerae. ENT: Ears and nose without visible erythema, masses, or trauma. Posterior oropharynx without erythema or exudate, uvula midline. CV: Regular rate and rhythm. Normal S1 S2, no S3, no S4. No murmur. No JVD. PULM: Breathing comfortably on room air. A few bibasilar crackles on chest exam. Good air movement bilaterally. GI: Bowel sounds present. Abdomen non-distended, soft, non-tender to palpation. No HSM appreciated. GU: No flank tenderness to palpation. No suprapubic fullness or tenderness to palpation. EXT: No lower extremity edema, distal extremity pulses palpable throughout. SKIN: Bilateral well healing ulcers over ischial spines, intact skin and covered. NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, bilateral lower extremities without movement (baseline) and 50% sensation. PSYCH: Pleasant, appropriate affect. Pertinent Results: RECENT LABS, MICRO, STUDIES: ___ 06:42AM BLOOD WBC-6.2 RBC-4.15* Hgb-12.0* Hct-38.4* MCV-93 MCH-28.9 MCHC-31.3* RDW-12.4 RDWSD-41.9 Plt ___ ___ 06:42AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-142 K-4.8 Cl-100 HCO3-29 AnGap-13 ___ 06:42AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0 ___ UA: hazy, +nit, 30 prot, LG leuk, 4 RBC, >182 WBC, many bacteria, 2 epithelial cells ___ 6:15 pm URINE CULTURE URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. Ertapenem AND Fosfomycin Susceptibility testing requested per ___ ___ (___) ___. Ertapenem = SENSITIVE. Fosfomycin = SENSITIVE. ______________________________ ESCHERICHIA COLI AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Mr. ___ is a ___ employee of ___ with T10 paraplegia s/p gunshot wound, neurogenic bladder (chronic self-caths) living in a sober house who is admitted for pyelonephritis. His urine culture growing multidrug-resistant E.coli. Most likely got pyelonephritis in setting of non-adherence with home suppressive fosfomycin. Final sensitivities showed sensitivity to pipercillin/tazobactam, meropenem, gentamycin, ertapenem, fosfomycin. His sober house can't manage IV antibiotics so had to be discharged to a facility to complete his antibiotics course. After initially started on ceftriaxone, when sensitivities he was switched to pip/tazo ___, per ID's suggestion; on discharge he was switched to ertapenem to complete a 7-day course (last day: ___. He was instructed to restart his home fosfomycin when he completes his IV antibiotics. While in the hospital his discomfort was treated with phenazopyridine (for dysuria), and his Suboxone was increased from daily to BID; he was discharged back on his home daily dosing. He was continued on his home dose of gabapentin for neuropathic pain. During the hospitalization his non-formulary Vyvanse for ADHD was held, and restarted at discharge. His home venlafaxine was continued. ___ PMP was checked and was appropriate. He had constipation while in the hospital, treated with miralax, senna, docusate, and prn lactulose. He was continued on his home oxybutynin and tamsulosin for neurogenic bladder and continued his normal routine of serial self-catheterization. He had constipation while in the hospital, treated with miralax, senna, docusate, and prn lactulose. He was continued on his home oxybutynin and tamsulosin for neurogenic bladder and continued his normal routine of serial self-catheterization. He also complained of neck pain and hand tingling and weakness, so MR of the c/s was done and showed djd at mult levels with cord contact and remodeling of cord without cord signal abnormality; neurosurgery was consulted and recommended that he follow up as an outpatient, no need for surgery or intervention at this time Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO TID 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 5. Oxybutynin XL (*NF*) 20 mg Other DAILY 6. Tamsulosin 0.4 mg PO BID:PRN urinary retention 7. alprostadil 20 mcg injection DAILY:PRN 8. Multivitamins 1 TAB PO DAILY 9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY 10. Naloxone Nasal Spray 4 mg IH ASDIR 11. Venlafaxine XR 75 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose give on ___ and ___, last day ___. Fosfomycin Tromethamine 3 g PO 3 G EVERY 7 DAYS Dissolve in ___ oz (90-120 mL) water and take immediately 3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 4. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 6. alprostadil 20 mcg injection DAILY:PRN 7. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 8. Gabapentin 800 mg PO TID 9. Multivitamins 1 TAB PO DAILY 10. Naloxone Nasal Spray 4 mg IH ASDIR 11. Oxybutynin XL (*NF*) 20 mg Other DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Tamsulosin 0.4 mg PO BID:PRN urinary retention 14. Venlafaxine XR 75 mg PO DAILY 15. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pyelonephritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Wheelchair/Bedbound (patient is paraplegic). Discharge Instructions: You were admitted for a kidney infection (pyelonephritis), probably related to not taking your fosfomycin. We treated you with fluids and antibiotics. Your infection is resistant to many antibiotics, requiring treatment with IV antibiotics instead of oral ones. You are being discharged to complete your IV antibiotics at a facility. Afterward, please restart your fosfomycin to help prevent future infections like this. Followup Instructions: ___
[ "N10", "B9620", "Z1624", "T368X6A", "Z91138", "Y9289", "F1120", "G8220", "N319", "R338", "S24103S", "W3400XS", "F29", "K5900", "M47812", "M792", "F1421", "F17290", "Z993" ]
Allergies: aspirin Chief Complaint: Pyelonephritis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with PMH of history of unspecified psychotic disorder (bipolar vs schizophrenia) and significant cocaine and opioid use disorders (sober >9 mo), prostatic abscess, and T10 paraplegia [MASKED] GSW in [MASKED] with neurogenic bladder resulting in recurrent UTIs who presents today with flank pain and foul smelling urine. The symptoms started a week ago but have worsened over the past 2 days, prompting him to present to the ED. Over the past week the patient noticed a foul odor in his urine with purulent discharge and bilateral flank pain. These symptoms felt similar to his prior kidney infections. He describes subjective fevers and chills, neck pain, and joint pains in the small joints of his hands. He has had chronic mild abdominal tenderness that initially improved after having a bowel movement yesterday but worsened somewhat today. He is taking all his medications as prescribed but forgot to take fosfomycin over the past 2 weeks and feels this may have triggered a UTI. Of note, pt was seen in [MASKED] clinic in [MASKED]. He had been performing straight catheterization every few hours and has noted improvement over the past several months with weekly fosfomycin therapy as the frequencies of infections has decreased. However, earlier that month he had sign/symptoms of a UTI for which he was prescribed ciprofloxacin and treated with 7 days. ROS: He denies any URI symptoms, n/v, dysuria, chest pain, dyspnea, palpitations, headache, or paresthesias. He states that he feels like is developing an ulcer in his left buttock area as well. Has had bilateral blurry vision since starting Zoloft 2 weeks ago, which prompted him to discontinue the medication. ED COURSE: Exam: NAD b/l flank pain, normal mentation, wheelchair bound Labs notable for WBC 8, UA pos for nitrites and leuks with >182 WBC and bacteria. Pt received iL NS and 1g CTX at 10:45 pm. Past Medical History: 1. Paraplegia after gun shout wound from T10 level downward [MASKED] 2. Chronic back pain 3. Partial right lung resection for GSW 4. Recurrent MRSA skin abcesses in neck, back, perianal (recently admitted in [MASKED] 5. Recurrent sacral decubitus ulcers status post debridement in the OR on [MASKED] and [MASKED] & [MASKED] (growing MRSA) 6. Pseudomonal prostatic abscess in [MASKED] Prostatis in [MASKED] 7. Recurrent UTI: Past cultures have grown enterococcus, morganella, pseudomonas 8. Cocaine use with history of perforated nasal septum 9. Urinary incontinence: chronically self-catheterizes 10. Grade 1 internal hemorrhoids seen on sigmoidoscopy [MASKED] 11. Chronic Constipation 12. Depression 13. ADHD 14. G6PD mutation -Diagnoses: Depression, add, no hx.o psychosis prior to what is described in HPI -Prior Hospitalizations: 1x this month as per HPI. -History of assaultive behaviors: Denies -History of suicide attempts or self-injurious behavior: Denies -Prior med trials: Report being on wellbutrin/concerta longstanding. Has tried ritalin Social History: Born in [MASKED] raised, in [MASKED], completed high school in [MASKED] and some post grad [MASKED] training. Has one son, now [MASKED] yo, who he still sees. Currently living in assisted living facility. ***Recently fired his PCA on [MASKED] who was taking care of assistance with his ADLs, food and meds. Now in the process of hiring his son as his new PCA. SUBSTANCE ABUSE HISTORY: -ETOH: Denies -Tobacco: denies -MJ/LSD/Ecstasy/Mushrooms: report last MJ use [MASKED] [MASKED]. -Cocaine/Crack/Amphetamines: Has significant history of cocaine dependence, now in remission, c/b perforated septum, reports last use [MASKED] [MASKED] but was found with cocaine in his urine on this admission in [MASKED]. -Opiates: Denies IVDU, on opioids for pain, question of misuse of prescriptions. -Benzos: Denies Family History: Notable for BPAD and schizophrenia - sister, cousin, maternal GM Physical Exam: GENERAL: Pleasant gentleman in hospital bed, in no apparent distress. EYES: PERRL, EOMI, anicteric sclerae. ENT: Ears and nose without visible erythema, masses, or trauma. Posterior oropharynx without erythema or exudate, uvula midline. CV: Regular rate and rhythm. Normal S1 S2, no S3, no S4. No murmur. No JVD. PULM: Breathing comfortably on room air. A few bibasilar crackles on chest exam. Good air movement bilaterally. GI: Bowel sounds present. Abdomen non-distended, soft, non-tender to palpation. No HSM appreciated. GU: No flank tenderness to palpation. No suprapubic fullness or tenderness to palpation. EXT: No lower extremity edema, distal extremity pulses palpable throughout. SKIN: Bilateral well healing ulcers over ischial spines, intact skin and covered. NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, bilateral lower extremities without movement (baseline) and 50% sensation. PSYCH: Pleasant, appropriate affect. Pertinent Results: RECENT LABS, MICRO, STUDIES: [MASKED] 06:42AM BLOOD WBC-6.2 RBC-4.15* Hgb-12.0* Hct-38.4* MCV-93 MCH-28.9 MCHC-31.3* RDW-12.4 RDWSD-41.9 Plt [MASKED] [MASKED] 06:42AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-142 K-4.8 Cl-100 HCO3-29 AnGap-13 [MASKED] 06:42AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0 [MASKED] UA: hazy, +nit, 30 prot, LG leuk, 4 RBC, >182 WBC, many bacteria, 2 epithelial cells [MASKED] 6:15 pm URINE CULTURE URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. Ertapenem AND Fosfomycin Susceptibility testing requested per [MASKED] [MASKED] ([MASKED]) [MASKED]. Ertapenem = SENSITIVE. Fosfomycin = SENSITIVE. [MASKED] ESCHERICHIA COLI AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Mr. [MASKED] is a [MASKED] employee of [MASKED] with T10 paraplegia s/p gunshot wound, neurogenic bladder (chronic self-caths) living in a sober house who is admitted for pyelonephritis. His urine culture growing multidrug-resistant E.coli. Most likely got pyelonephritis in setting of non-adherence with home suppressive fosfomycin. Final sensitivities showed sensitivity to pipercillin/tazobactam, meropenem, gentamycin, ertapenem, fosfomycin. His sober house can't manage IV antibiotics so had to be discharged to a facility to complete his antibiotics course. After initially started on ceftriaxone, when sensitivities he was switched to pip/tazo [MASKED], per ID's suggestion; on discharge he was switched to ertapenem to complete a 7-day course (last day: [MASKED]. He was instructed to restart his home fosfomycin when he completes his IV antibiotics. While in the hospital his discomfort was treated with phenazopyridine (for dysuria), and his Suboxone was increased from daily to BID; he was discharged back on his home daily dosing. He was continued on his home dose of gabapentin for neuropathic pain. During the hospitalization his non-formulary Vyvanse for ADHD was held, and restarted at discharge. His home venlafaxine was continued. [MASKED] PMP was checked and was appropriate. He had constipation while in the hospital, treated with miralax, senna, docusate, and prn lactulose. He was continued on his home oxybutynin and tamsulosin for neurogenic bladder and continued his normal routine of serial self-catheterization. He had constipation while in the hospital, treated with miralax, senna, docusate, and prn lactulose. He was continued on his home oxybutynin and tamsulosin for neurogenic bladder and continued his normal routine of serial self-catheterization. He also complained of neck pain and hand tingling and weakness, so MR of the c/s was done and showed djd at mult levels with cord contact and remodeling of cord without cord signal abnormality; neurosurgery was consulted and recommended that he follow up as an outpatient, no need for surgery or intervention at this time Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 800 mg PO TID 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 5. Oxybutynin XL (*NF*) 20 mg Other DAILY 6. Tamsulosin 0.4 mg PO BID:PRN urinary retention 7. alprostadil 20 mcg injection DAILY:PRN 8. Multivitamins 1 TAB PO DAILY 9. Vyvanse (lisdexamfetamine) 50 mg oral DAILY 10. Naloxone Nasal Spray 4 mg IH ASDIR 11. Venlafaxine XR 75 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose give on [MASKED] and [MASKED], last day [MASKED]. Fosfomycin Tromethamine 3 g PO 3 G EVERY 7 DAYS Dissolve in [MASKED] oz (90-120 mL) water and take immediately 3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 4. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 6. alprostadil 20 mcg injection DAILY:PRN 7. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL DAILY 8. Gabapentin 800 mg PO TID 9. Multivitamins 1 TAB PO DAILY 10. Naloxone Nasal Spray 4 mg IH ASDIR 11. Oxybutynin XL (*NF*) 20 mg Other DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Tamsulosin 0.4 mg PO BID:PRN urinary retention 14. Venlafaxine XR 75 mg PO DAILY 15. Vyvanse (lisdexamfetamine) 50 mg oral DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Pyelonephritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Wheelchair/Bedbound (patient is paraplegic). Discharge Instructions: You were admitted for a kidney infection (pyelonephritis), probably related to not taking your fosfomycin. We treated you with fluids and antibiotics. Your infection is resistant to many antibiotics, requiring treatment with IV antibiotics instead of oral ones. You are being discharged to complete your IV antibiotics at a facility. Afterward, please restart your fosfomycin to help prevent future infections like this. Followup Instructions: [MASKED]
[]
[ "K5900" ]
[ "N10: Acute pyelonephritis", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z1624: Resistance to multiple antibiotics", "T368X6A: Underdosing of other systemic antibiotics, initial encounter", "Z91138: Patient's unintentional underdosing of medication regimen for other reason", "Y9289: Other specified places as the place of occurrence of the external cause", "F1120: Opioid dependence, uncomplicated", "G8220: Paraplegia, unspecified", "N319: Neuromuscular dysfunction of bladder, unspecified", "R338: Other retention of urine", "S24103S: Unspecified injury at T7-T10 level of thoracic spinal cord, sequela", "W3400XS: Accidental discharge from unspecified firearms or gun, sequela", "F29: Unspecified psychosis not due to a substance or known physiological condition", "K5900: Constipation, unspecified", "M47812: Spondylosis without myelopathy or radiculopathy, cervical region", "M792: Neuralgia and neuritis, unspecified", "F1421: Cocaine dependence, in remission", "F17290: Nicotine dependence, other tobacco product, uncomplicated", "Z993: Dependence on wheelchair" ]
10,038,688
25,926,997
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Post cardiac arrest Major Surgical or Invasive Procedure: Intubation History of Present Illness: ___ hepatitis B and C, cirrhosis w/ portal HTN, bipolar 2, depression, osteo, BKA right, craniectomy, who was found down in a public restroom with drug paraphernalia. Bystander CPR was performed, initial rhythm asystole to PEA, epi x 5, 4 mg narcan, with ROSC, with an estimated total CPR time of 22 minutes. Patient was transferred to ___, intubated, and started on chilled saline, norepinephrine. CT imaging included a normal CT head, and a torso with R upper lobe consolidations c/f aspiration, and GB wall thickening c/f cholecystitis, as well as e/o cirrhosis with portal HTN. EKG with Afib w/ RVR, STD in I, II, V3-V6 w/ recriprocal STE in AVR. Given 4L NS and clindamycin. Reportedly having some purposeful movements prior to transfer. No fever on presentation. ___ labs: cr 1.0 pH:pH 7.06/65/539/18.5 lactate 9.5; EtOH 194. Trop <0.02 Lytes w/ Na 145, K 4.0, bicarb 23, Cr 1.0 Patient transferred to ___ for post-arrest care. In the ED, initial vitals: 97.8 114 119/68 22 100% intub On exam pt was: RLE BKA, not following commands Labs were significant for: urine +109 wbc but no leuks tox screen: neg for barbs, cocaine, amphet, methadone 7.25/29/203/13 (VBG) on vbg Na 141 k 3.8 cl 112 gluc 71 cal 0.96 lactate 7.5 hgb 12.3 Imaging was significant for: CT C spine - no fracture, degenerative changes. nodular opacities RUL, likely aspiration vs pneumonia CXR: ETT in place, OGT in place, pulm vasc congestion, no frank pulm edema or infiltrate (our read) EKG: NSR rate 115, qtc 505, normal axis, PVC x1, no STEs, no q waves, TW flattening in V1 Consults: post cardiac arrest team recommended ongoing cooling given absence of mental status (goal temp 34-36), EEG to be ordered on arrival to the MICU. Cardiology fellow: no e/o STE, no indication for cath, no indication for CCU. GIVEN: fentanyl gtt at 50/hr, midazolam gtt, norepi at 0.12, 1L IVF Past Medical History: Hep B+C bipolar/ depression craniectomy (unclear indication) h/o MRSA R BKA for osteomyelitis Drug abuse/dependence HTN Seizure Bilateral clubbed feet s/p multiple surgeries as child Social History: ___ Family History: Lung cancer in Father, DM in ___ grandfather. No hx heart disease or stroke. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: 98.1 119/78 119/sinus 22 100%/vent @ CMV ___ GENERAL: intubated, sedated HEENT: Intubated, NGT in place. No craniotomy scar visible NECK: supple LUNGS: Reasonably clear to auscultation on anterior exam, nont breathing over vent CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-distended, no appreciable bowel sounds GU: Foley in place EXT: Warm, well perfused, 2+ pulse; BKA on R SKIN: Rash on RLE at knee, multiple tattoos NEURO: Sedated ACCESS: ___ radial A-line PHYSICAL EXAM ON DATE OF EXPIRATION (___) Absent breath and heart sounds Absent pulses No withdrawal to painful stimuli Fixed pupils Pertinent Results: ADMISSION LABS ============== ___ 07:10AM BLOOD WBC-9.9 RBC-2.96* Hgb-10.2* Hct-32.5* MCV-110* MCH-34.5* MCHC-31.4* RDW-14.7 RDWSD-60.6* Plt Ct-59* ___ 07:10AM BLOOD Neuts-89.5* Lymphs-3.1* Monos-6.6 Eos-0.0* Baso-0.1 Im ___ AbsNeut-8.87* AbsLymp-0.31* AbsMono-0.65 AbsEos-0.00* AbsBaso-0.01 ___ 07:10AM BLOOD ___ PTT-41.6* ___ ___ 10:20AM BLOOD ___ ___ 07:10AM BLOOD Glucose-70 UreaN-17 Creat-1.0 Na-141 K-4.0 Cl-107 HCO3-11* AnGap-27* ___ 07:10AM BLOOD ALT-202* AST-555* AlkPhos-227* TotBili-1.6* ___ 07:10AM BLOOD Lipase-62* ___ 07:10AM BLOOD cTropnT-0.57* ___ 10:20AM BLOOD Calcium-6.6* Phos-4.1 Mg-1.4* ___ 07:10AM BLOOD ASA-NEG Ethanol-89* Acetmnp-NEG Bnzodzp-POS* Barbitr-NEG Tricycl-NEG ___ 05:57AM BLOOD ___ pO2-203* pCO2-29* pH-7.25* calTCO2-13* Base XS--12 ___ 05:57AM BLOOD Glucose-71 Lactate-7.5* Na-141 K-3.8 Cl-112* ___ 05:57AM BLOOD Hgb-12.3* calcHCT-37 O2 Sat-99 COHgb-1 MetHgb-0 ___ 05:48AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05:48AM URINE Blood-MOD Nitrite-NEG Protein-300 Glucose-70 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 05:48AM URINE RBC-65* WBC-109* Bacteri-FEW Yeast-NONE Epi-0 ___ 05:48AM URINE CastGr-29* ___ 05:48AM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG PERTINENT LABS ============== ___ 04:10AM BLOOD WBC-13.0* RBC-2.92* Hgb-10.0* Hct-31.0* MCV-106* MCH-34.2* MCHC-32.3 RDW-15.4 RDWSD-59.7* Plt Ct-82* ___ 05:35AM BLOOD ALT-495* AST-1115* LD(LDH)-461* AlkPhos-130 TotBili-2.0* ___ 10:20AM BLOOD ALT-188* AST-512* CK(CPK)-1484* AlkPhos-190* TotBili-1.4 ___ 07:48AM BLOOD CK(CPK)-1020* ___ 04:33PM BLOOD cTropnT-0.44* ___ 04:10AM BLOOD cTropnT-0.25* ___ 04:33PM BLOOD VitB12-689 ___ 10:20AM BLOOD Hapto-<10* ___ 01:36PM BLOOD HBV VL-NOT DETECT HCV VL-5.2* ___ 01:36PM BLOOD QUANTIFERON-TB GOLD-Test INDETERMINATE MICROBIOLOGY ============ All Cultures No Growth: ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ URINE URINE CULTURE-FINAL ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ URINE URINE CULTURE-FINAL ___ MRSA SCREEN MRSA SCREEN-FINAL ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL ___ URINE URINE CULTURE-FINAL ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ BLOOD CULTURE Blood Culture, Routine-FINAL ___ URINE URINE CULTURE-FINAL IMAGING ======= ___ CT C-SPINE: 1. No evidence of fracture or malalignment. 2. Multilevel multifactorial degenerative changes with spinal canal and neural foraminal narrowing at multiple levels. 3. Partially imaged nodular opacities with the left right upper lobe, better demonstrated on the chest CT with the same date, likely representing aspiration or pneumonia. ___ RUQ U/S: Cirrhotic liver without discrete focal lesion. Splenomegaly with small volume ascites. No cholelithiasis or gallbladder wall edema. Kidneys were not visualized. ___ CT HEAD: 1. Symmetric loss of gray-white matter differentiation involving the deep gray structures (thalami, basal ganglia), and subtle suggestion of early loss of gray-white matter differentiation involving the cerebral hemispheres with sulcal effacement, overall concerning for developing sequelae of anoxic brain injury. 2. No acute intracranial hemorrhage. No herniation. 3. There is a well corticated expansile tubular structure within the left sphenoid medial to the left foramen ovale extending anteriorly just lateral to the foramen rotundum. There is appearance of dehiscence of the lateral wall of the foramen rotundum. Recommend MRI skullbase for further evaluation to exclude meningocele/encephalocele, if there are no contraindications. This could also represent an asymmetric venous structure such as an enlarged sphenoidal emissary vein. ___ CT HEAD: 1. As seen on the study from ___, symmetric loss of gray-white matter differentiation in the deep gray matter structures and early loss of gray-white matter differentiation in the cerebral hemispheres is concerning for sequelae of anoxic brain injury. 2. No evidence of hemorrhage. ___ LENIS: No evidence of deep venous thrombosis in the left lower extremity veins. ___ CT HEAD: Nearly complete loss of gray-white matter differentiation supratentorially consistent with anoxic brain injury. There is mild worsening of diffuse brain swelling, without evidence of herniation. There is no hemorrhage. EEG === ___: This telemetry captured no pushbutton activations but showed an extremely suppressed background throughout, with some very low voltage continuous theta activity emerging after midnight. The suppressed background indicates a severe encephalopathy. There were no epileptiform features, and there were no electrographic seizures. ___: This is an abnormal continuous video EEG due to severe background suppression without any clear discernible cerebral activity, consistent with a severe encephalopathy, which could be seen with sedative medications, severe toxic/metabolic disturbances, infections, and anoxic injury. There are no epileptiform discharges or electrographic seizures in this recording. ___: This is an abnormal continuous ICU EEG monitoring study because of an extremely suppressed background consistent with a severe encephalopathy. No focal or epileptiform features were seen. No epileptiform activity was seen with the two pushbutton activations identified. ___: This is an abnormal continuous ICU EEG monitoring study because of an extremely suppressed background consistent with a severe encephalopathy. No focal or epileptiform features were seen. No epileptiform activity was seen with the one pushbutton activation identified Brief Hospital Course: ___ hepatitis B and C, cirrhosis w/ portal HTN, bipolar 2, depression, osteo, BKA right, craniectomy, who was found down in a public restroom with drug paraphernalia and found to be in PEA arrest, transferred to MICU for post-arrest cooling. #s/p PEA arrest #Anoxic brain injury with cerebral edema Given that he was found surrounded by drug paraphernalia, likely PEA arrest secondary to hypoxemia in setting of respiratory arrest from opioid overdose. s/p 22 min of CPR with absent mental status post-arrest. EKG at OSH with afib w/ STD in anterolateral leads w/ recriprocal changes; EKG here with resolution of STDs. TTM (with continuous EEG monitoring) completed 10pm ___, sedation was subsequently weaned. Neurology consult was obtained for prognostication. Brain MRI was not able to be obtained due to metal in the body. However, CT head non-contrast with multiple repeats showed findings consistent anoxic brain injury with worsening cerebral edema. EEG monitoring showed severe encephalopathy. Blood pressure control with labetalol intermittently used to maintain systolic pressures <200. Family meeting held ___. Confirmed DNR status. Patient was previously DNR/DNI but because he was already intubated, family meetings were held to discuss options regarding trach/PEG vs extubation/comfort care. Given his poor prognosis, his family decided to have him extubated and to transition him to comfort measures only. Patient passed away on ___. #Aspiration vs pneumonitis #Pneumonia #Fevers Pattern of RUL consolidation unusual for aspiration. Given social hx, there was concern for possible mTB infection, with indeterminate Quant Gold. Had repeat fever on ___. He was treated for ventilator-associated pneumonia with broad spectrum antibiotics (vancomycin, zosyn 8 day course). Culture data was unrevealing. Flu was negative. Sputum Gram stain 2+ budding yeast, sparse growth on culture x2. He continued to spike fevers without an infectious source identified. DVT was ruled out by ultrasound. Central fevers were thought to be a likely cause, vs medication effect. #Hypoxemic respiratory failure: Intubated post cardiac arrest, possible pneumonia vs. central apnea. Respiratory support was maintained with target pCO2 35-45, goal Pplat <30, weaned FiO2 to maintain SpO2 >94% using lowest possible FiO2. Post-cooling protocol, patient was maintained on pressure support. #Acidemia: pH 7.06 on admission, 7.25 on VBG on arrival. Likely lactic acidosis in setting of cardiac arrest. Lactate resolved s/p 4 L IVF. #Coffee ground emesis #Macrocytic Anemia #Thrombocytopenia #Coagulopathy Hb 9.0 (MCV 107) w/ platelets 40 on admission, INR 1.7 from unclear baseline. ___ be ___ cirrhosis, EtOH abuse, poor nutrition. On folate but no B12 supplementation. Serum B12 level WNL. Had some coffee ground emesis through NG. He received 10mg IV vit K, 1u FFP on admission with no further episodes. #hx Hep B+C #Transaminitis #Cirrhosis: Noted to have stigmata of cirrhosis on CT abdomen. On Lasix/spironolactone at home. Not on viral treatment per OSH PAML or medication history tab. HBV not detected. HCV viral load 5.2 million. DF 43. Right upper quadrant U/s was obtained ___ due to transaminitis. This did not show obstruction, and liver enzymes downtrended. Lactulose, Rifaximin were started. Spironolactone was held. Lasix with albumin was employed to achieve euvolemia. He was not given steroids for alcoholic hepatitis due to the possibility of infectious etiology. #h/o IV drug/EtOH use: Unclear when last drink was. Received thiamine 500mg IV TID x3d (___), then 100IV daily, folic acid IV. Did not receive phenobarbital as he did not appear to be withdrawing. #HTN: Not on any antihypertensives on OSH PAML or medications tab. #Hx seizure: reported in medical records, not on antiseizure meds per OSH PAML or medications tab. Monitored with EEG during cooling/rewarming, but no electrographic seizures seen. #Loose stools in setting of lactulose, Tube Feeds: continued lactulose, discontinued Colace. #Hypernatremia: Free water deficit calculated at 2.8L. Increased free water flushes to 300cc q4h, although still elevated despite. Corrected with D5W x 1L #HTN: not on any antihypertensives on OSH PAML or medications tab. Received labetalol as above. #Groin rash: likely fungal, treated with Miconazole powder. # Communication/HCP: ___ ___ ___, daughter ___ ___, sister, ___ ___, brother in ___ ___ ___, sister ___ ___, daughter's mother ___ (wrong number) Medications on Admission: Expired on ___ Discharge Medications: Expired on ___ Discharge Disposition: Expired Discharge Diagnosis: Expired on ___ Discharge Condition: Expired on ___ Discharge Instructions: Expired on ___ Followup Instructions: ___
[ "J9601", "G936", "R579", "K7200", "G9340", "J189", "G931", "D689", "N179", "J95851", "K766", "E870", "E872", "B1910", "F3181", "F1920", "K7460", "B1920", "D539", "D696", "F1010", "F17210", "B356", "Z8614", "Z781", "Z89511", "Z66", "Z515", "Z590", "Y848", "Y92230" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Post cardiac arrest Major Surgical or Invasive Procedure: Intubation History of Present Illness: [MASKED] hepatitis B and C, cirrhosis w/ portal HTN, bipolar 2, depression, osteo, BKA right, craniectomy, who was found down in a public restroom with drug paraphernalia. Bystander CPR was performed, initial rhythm asystole to PEA, epi x 5, 4 mg narcan, with ROSC, with an estimated total CPR time of 22 minutes. Patient was transferred to [MASKED], intubated, and started on chilled saline, norepinephrine. CT imaging included a normal CT head, and a torso with R upper lobe consolidations c/f aspiration, and GB wall thickening c/f cholecystitis, as well as e/o cirrhosis with portal HTN. EKG with Afib w/ RVR, STD in I, II, V3-V6 w/ recriprocal STE in AVR. Given 4L NS and clindamycin. Reportedly having some purposeful movements prior to transfer. No fever on presentation. [MASKED] labs: cr 1.0 pH:pH 7.06/65/539/18.5 lactate 9.5; EtOH 194. Trop <0.02 Lytes w/ Na 145, K 4.0, bicarb 23, Cr 1.0 Patient transferred to [MASKED] for post-arrest care. In the ED, initial vitals: 97.8 114 119/68 22 100% intub On exam pt was: RLE BKA, not following commands Labs were significant for: urine +109 wbc but no leuks tox screen: neg for barbs, cocaine, amphet, methadone 7.25/29/203/13 (VBG) on vbg Na 141 k 3.8 cl 112 gluc 71 cal 0.96 lactate 7.5 hgb 12.3 Imaging was significant for: CT C spine - no fracture, degenerative changes. nodular opacities RUL, likely aspiration vs pneumonia CXR: ETT in place, OGT in place, pulm vasc congestion, no frank pulm edema or infiltrate (our read) EKG: NSR rate 115, qtc 505, normal axis, PVC x1, no STEs, no q waves, TW flattening in V1 Consults: post cardiac arrest team recommended ongoing cooling given absence of mental status (goal temp 34-36), EEG to be ordered on arrival to the MICU. Cardiology fellow: no e/o STE, no indication for cath, no indication for CCU. GIVEN: fentanyl gtt at 50/hr, midazolam gtt, norepi at 0.12, 1L IVF Past Medical History: Hep B+C bipolar/ depression craniectomy (unclear indication) h/o MRSA R BKA for osteomyelitis Drug abuse/dependence HTN Seizure Bilateral clubbed feet s/p multiple surgeries as child Social History: [MASKED] Family History: Lung cancer in Father, DM in [MASKED] grandfather. No hx heart disease or stroke. Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: 98.1 119/78 119/sinus 22 100%/vent @ CMV [MASKED] GENERAL: intubated, sedated HEENT: Intubated, NGT in place. No craniotomy scar visible NECK: supple LUNGS: Reasonably clear to auscultation on anterior exam, nont breathing over vent CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-distended, no appreciable bowel sounds GU: Foley in place EXT: Warm, well perfused, 2+ pulse; BKA on R SKIN: Rash on RLE at knee, multiple tattoos NEURO: Sedated ACCESS: [MASKED] radial A-line PHYSICAL EXAM ON DATE OF EXPIRATION ([MASKED]) Absent breath and heart sounds Absent pulses No withdrawal to painful stimuli Fixed pupils Pertinent Results: ADMISSION LABS ============== [MASKED] 07:10AM BLOOD WBC-9.9 RBC-2.96* Hgb-10.2* Hct-32.5* MCV-110* MCH-34.5* MCHC-31.4* RDW-14.7 RDWSD-60.6* Plt Ct-59* [MASKED] 07:10AM BLOOD Neuts-89.5* Lymphs-3.1* Monos-6.6 Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-8.87* AbsLymp-0.31* AbsMono-0.65 AbsEos-0.00* AbsBaso-0.01 [MASKED] 07:10AM BLOOD [MASKED] PTT-41.6* [MASKED] [MASKED] 10:20AM BLOOD [MASKED] [MASKED] 07:10AM BLOOD Glucose-70 UreaN-17 Creat-1.0 Na-141 K-4.0 Cl-107 HCO3-11* AnGap-27* [MASKED] 07:10AM BLOOD ALT-202* AST-555* AlkPhos-227* TotBili-1.6* [MASKED] 07:10AM BLOOD Lipase-62* [MASKED] 07:10AM BLOOD cTropnT-0.57* [MASKED] 10:20AM BLOOD Calcium-6.6* Phos-4.1 Mg-1.4* [MASKED] 07:10AM BLOOD ASA-NEG Ethanol-89* Acetmnp-NEG Bnzodzp-POS* Barbitr-NEG Tricycl-NEG [MASKED] 05:57AM BLOOD [MASKED] pO2-203* pCO2-29* pH-7.25* calTCO2-13* Base XS--12 [MASKED] 05:57AM BLOOD Glucose-71 Lactate-7.5* Na-141 K-3.8 Cl-112* [MASKED] 05:57AM BLOOD Hgb-12.3* calcHCT-37 O2 Sat-99 COHgb-1 MetHgb-0 [MASKED] 05:48AM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 05:48AM URINE Blood-MOD Nitrite-NEG Protein-300 Glucose-70 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 05:48AM URINE RBC-65* WBC-109* Bacteri-FEW Yeast-NONE Epi-0 [MASKED] 05:48AM URINE CastGr-29* [MASKED] 05:48AM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG PERTINENT LABS ============== [MASKED] 04:10AM BLOOD WBC-13.0* RBC-2.92* Hgb-10.0* Hct-31.0* MCV-106* MCH-34.2* MCHC-32.3 RDW-15.4 RDWSD-59.7* Plt Ct-82* [MASKED] 05:35AM BLOOD ALT-495* AST-1115* LD(LDH)-461* AlkPhos-130 TotBili-2.0* [MASKED] 10:20AM BLOOD ALT-188* AST-512* CK(CPK)-1484* AlkPhos-190* TotBili-1.4 [MASKED] 07:48AM BLOOD CK(CPK)-1020* [MASKED] 04:33PM BLOOD cTropnT-0.44* [MASKED] 04:10AM BLOOD cTropnT-0.25* [MASKED] 04:33PM BLOOD VitB12-689 [MASKED] 10:20AM BLOOD Hapto-<10* [MASKED] 01:36PM BLOOD HBV VL-NOT DETECT HCV VL-5.2* [MASKED] 01:36PM BLOOD QUANTIFERON-TB GOLD-Test INDETERMINATE MICROBIOLOGY ============ All Cultures No Growth: [MASKED] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL [MASKED] URINE URINE CULTURE-FINAL [MASKED] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL [MASKED] URINE URINE CULTURE-FINAL [MASKED] MRSA SCREEN MRSA SCREEN-FINAL [MASKED] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL [MASKED] URINE URINE CULTURE-FINAL [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL [MASKED] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL [MASKED] URINE URINE CULTURE-FINAL IMAGING ======= [MASKED] CT C-SPINE: 1. No evidence of fracture or malalignment. 2. Multilevel multifactorial degenerative changes with spinal canal and neural foraminal narrowing at multiple levels. 3. Partially imaged nodular opacities with the left right upper lobe, better demonstrated on the chest CT with the same date, likely representing aspiration or pneumonia. [MASKED] RUQ U/S: Cirrhotic liver without discrete focal lesion. Splenomegaly with small volume ascites. No cholelithiasis or gallbladder wall edema. Kidneys were not visualized. [MASKED] CT HEAD: 1. Symmetric loss of gray-white matter differentiation involving the deep gray structures (thalami, basal ganglia), and subtle suggestion of early loss of gray-white matter differentiation involving the cerebral hemispheres with sulcal effacement, overall concerning for developing sequelae of anoxic brain injury. 2. No acute intracranial hemorrhage. No herniation. 3. There is a well corticated expansile tubular structure within the left sphenoid medial to the left foramen ovale extending anteriorly just lateral to the foramen rotundum. There is appearance of dehiscence of the lateral wall of the foramen rotundum. Recommend MRI skullbase for further evaluation to exclude meningocele/encephalocele, if there are no contraindications. This could also represent an asymmetric venous structure such as an enlarged sphenoidal emissary vein. [MASKED] CT HEAD: 1. As seen on the study from [MASKED], symmetric loss of gray-white matter differentiation in the deep gray matter structures and early loss of gray-white matter differentiation in the cerebral hemispheres is concerning for sequelae of anoxic brain injury. 2. No evidence of hemorrhage. [MASKED] LENIS: No evidence of deep venous thrombosis in the left lower extremity veins. [MASKED] CT HEAD: Nearly complete loss of gray-white matter differentiation supratentorially consistent with anoxic brain injury. There is mild worsening of diffuse brain swelling, without evidence of herniation. There is no hemorrhage. EEG === [MASKED]: This telemetry captured no pushbutton activations but showed an extremely suppressed background throughout, with some very low voltage continuous theta activity emerging after midnight. The suppressed background indicates a severe encephalopathy. There were no epileptiform features, and there were no electrographic seizures. [MASKED]: This is an abnormal continuous video EEG due to severe background suppression without any clear discernible cerebral activity, consistent with a severe encephalopathy, which could be seen with sedative medications, severe toxic/metabolic disturbances, infections, and anoxic injury. There are no epileptiform discharges or electrographic seizures in this recording. [MASKED]: This is an abnormal continuous ICU EEG monitoring study because of an extremely suppressed background consistent with a severe encephalopathy. No focal or epileptiform features were seen. No epileptiform activity was seen with the two pushbutton activations identified. [MASKED]: This is an abnormal continuous ICU EEG monitoring study because of an extremely suppressed background consistent with a severe encephalopathy. No focal or epileptiform features were seen. No epileptiform activity was seen with the one pushbutton activation identified Brief Hospital Course: [MASKED] hepatitis B and C, cirrhosis w/ portal HTN, bipolar 2, depression, osteo, BKA right, craniectomy, who was found down in a public restroom with drug paraphernalia and found to be in PEA arrest, transferred to MICU for post-arrest cooling. #s/p PEA arrest #Anoxic brain injury with cerebral edema Given that he was found surrounded by drug paraphernalia, likely PEA arrest secondary to hypoxemia in setting of respiratory arrest from opioid overdose. s/p 22 min of CPR with absent mental status post-arrest. EKG at OSH with afib w/ STD in anterolateral leads w/ recriprocal changes; EKG here with resolution of STDs. TTM (with continuous EEG monitoring) completed 10pm [MASKED], sedation was subsequently weaned. Neurology consult was obtained for prognostication. Brain MRI was not able to be obtained due to metal in the body. However, CT head non-contrast with multiple repeats showed findings consistent anoxic brain injury with worsening cerebral edema. EEG monitoring showed severe encephalopathy. Blood pressure control with labetalol intermittently used to maintain systolic pressures <200. Family meeting held [MASKED]. Confirmed DNR status. Patient was previously DNR/DNI but because he was already intubated, family meetings were held to discuss options regarding trach/PEG vs extubation/comfort care. Given his poor prognosis, his family decided to have him extubated and to transition him to comfort measures only. Patient passed away on [MASKED]. #Aspiration vs pneumonitis #Pneumonia #Fevers Pattern of RUL consolidation unusual for aspiration. Given social hx, there was concern for possible mTB infection, with indeterminate Quant Gold. Had repeat fever on [MASKED]. He was treated for ventilator-associated pneumonia with broad spectrum antibiotics (vancomycin, zosyn 8 day course). Culture data was unrevealing. Flu was negative. Sputum Gram stain 2+ budding yeast, sparse growth on culture x2. He continued to spike fevers without an infectious source identified. DVT was ruled out by ultrasound. Central fevers were thought to be a likely cause, vs medication effect. #Hypoxemic respiratory failure: Intubated post cardiac arrest, possible pneumonia vs. central apnea. Respiratory support was maintained with target pCO2 35-45, goal Pplat <30, weaned FiO2 to maintain SpO2 >94% using lowest possible FiO2. Post-cooling protocol, patient was maintained on pressure support. #Acidemia: pH 7.06 on admission, 7.25 on VBG on arrival. Likely lactic acidosis in setting of cardiac arrest. Lactate resolved s/p 4 L IVF. #Coffee ground emesis #Macrocytic Anemia #Thrombocytopenia #Coagulopathy Hb 9.0 (MCV 107) w/ platelets 40 on admission, INR 1.7 from unclear baseline. [MASKED] be [MASKED] cirrhosis, EtOH abuse, poor nutrition. On folate but no B12 supplementation. Serum B12 level WNL. Had some coffee ground emesis through NG. He received 10mg IV vit K, 1u FFP on admission with no further episodes. #hx Hep B+C #Transaminitis #Cirrhosis: Noted to have stigmata of cirrhosis on CT abdomen. On Lasix/spironolactone at home. Not on viral treatment per OSH PAML or medication history tab. HBV not detected. HCV viral load 5.2 million. DF 43. Right upper quadrant U/s was obtained [MASKED] due to transaminitis. This did not show obstruction, and liver enzymes downtrended. Lactulose, Rifaximin were started. Spironolactone was held. Lasix with albumin was employed to achieve euvolemia. He was not given steroids for alcoholic hepatitis due to the possibility of infectious etiology. #h/o IV drug/EtOH use: Unclear when last drink was. Received thiamine 500mg IV TID x3d ([MASKED]), then 100IV daily, folic acid IV. Did not receive phenobarbital as he did not appear to be withdrawing. #HTN: Not on any antihypertensives on OSH PAML or medications tab. #Hx seizure: reported in medical records, not on antiseizure meds per OSH PAML or medications tab. Monitored with EEG during cooling/rewarming, but no electrographic seizures seen. #Loose stools in setting of lactulose, Tube Feeds: continued lactulose, discontinued Colace. #Hypernatremia: Free water deficit calculated at 2.8L. Increased free water flushes to 300cc q4h, although still elevated despite. Corrected with D5W x 1L #HTN: not on any antihypertensives on OSH PAML or medications tab. Received labetalol as above. #Groin rash: likely fungal, treated with Miconazole powder. # Communication/HCP: [MASKED] [MASKED] [MASKED], daughter [MASKED] [MASKED], sister, [MASKED] [MASKED], brother in [MASKED] [MASKED] [MASKED], sister [MASKED] [MASKED], daughter's mother [MASKED] (wrong number) Medications on Admission: Expired on [MASKED] Discharge Medications: Expired on [MASKED] Discharge Disposition: Expired Discharge Diagnosis: Expired on [MASKED] Discharge Condition: Expired on [MASKED] Discharge Instructions: Expired on [MASKED] Followup Instructions: [MASKED]
[]
[ "J9601", "N179", "E872", "D696", "F17210", "Z66", "Z515", "Y92230" ]
[ "J9601: Acute respiratory failure with hypoxia", "G936: Cerebral edema", "R579: Shock, unspecified", "K7200: Acute and subacute hepatic failure without coma", "G9340: Encephalopathy, unspecified", "J189: Pneumonia, unspecified organism", "G931: Anoxic brain damage, not elsewhere classified", "D689: Coagulation defect, unspecified", "N179: Acute kidney failure, unspecified", "J95851: Ventilator associated pneumonia", "K766: Portal hypertension", "E870: Hyperosmolality and hypernatremia", "E872: Acidosis", "B1910: Unspecified viral hepatitis B without hepatic coma", "F3181: Bipolar II disorder", "F1920: Other psychoactive substance dependence, uncomplicated", "K7460: Unspecified cirrhosis of liver", "B1920: Unspecified viral hepatitis C without hepatic coma", "D539: Nutritional anemia, unspecified", "D696: Thrombocytopenia, unspecified", "F1010: Alcohol abuse, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "B356: Tinea cruris", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection", "Z781: Physical restraint status", "Z89511: Acquired absence of right leg below knee", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "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" ]
10,038,992
24,745,425
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: lisinopril / shellfish derived Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: ___ Aortic valve replacement with a 25 mm ___ Biocor Epic tissue valve. History of Present Illness: Mr. ___ is a ___ year old man with a history of aortic insufficiency, chronic kidney disease, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, sleep apnea, and tricuspid regurgitation. He has noted dyspnea on exertion while ambulating to the bathroom. He has been on Lasix for diuresis in the past without improvement in his symptoms and was recently changed to Torsemide 100 mg daily with mild improvement. An echocardiogram in ___ demonstrated a depressed ejection fraction, severe aortic insufficiency, dilated aortic root, and moderate tricuspid regurgitation. Cardiac catheterization revealed elevated filling pressure without obstructive coronary artery disease. He was referred to Dr. ___ surgical consultation. He presents today for routine PAT's. Since his last office visit, there has been no clinical change in his condition. Past Medical History: Aortic Insufficiency s/p Aortic valve replacement Past medical history: Anemia Chronic Kidney Disease (Cre 1.76-2.08) - Single kidney Renal atrophy Chronic Obstructive Pulmonary Disease Depression Gout Hyperlipidemia Hypertension Hypothyroid Non-Ischemic Cardiomyopathy Obesity Pulmonary Hypertension Seizure Sleep Apnea, CPAP recommended but patient declined Tricuspid Regurgitation Appendectomy Social History: ___ Family History: No premature coronary artery disease Father had an MI in his early ___. Mother without heart disease. Brother with CABG in his ___. Physical Exam: Vital Signs sheet entries for ___: BP: 140/85 (left arm ). Heart Rate: 80. O2 Saturation%: 94 (room air ). Resp. Rate: 17. Pain Score: 0. Height: 72" Weight: 198lb General: NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Decreased at bases bilaterally Heart: RRR, II/VI diastolic, I/VI systolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] 2+ ___ Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 ___ Right:1 Left:1 Radial Right:2 Left:2 Carotid Bruit: None appreciated Discharge exam General: NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Decreased at bases bilaterally Heart: RRR Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] trace ___ Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 ___ Right:1 Left:1 Radial Right:2 Left:2 Carotid Bruit: None appreciated Pertinent Results: Echo ___: PRE-BYPASS: The left atrium is markedly dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is dilated. Overall left ventricular systolic function is severely depressed (LVEF= ___ %). with mild to moderate global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are three aortic valve leaflets. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The severity of aortic regurgitation may be underestimated. The aortic regurgitation jet is eccentric. Physiologic mitral regurgitation is seen (within normal limits). There is trace TR with a tricuspid annulus of 38mm. There is a small pericardial effusion. POST-BYPASS: The patient is AV paced on low dose epi gtt. A well seated bioprosthetic valve is visualized in the aortic position with normal moving leaflets. There is no AI. Pk and mean pressure gradient across the valve is 15mmHg and 7mmHg respectively with a SV of 57cc. The remaining valves are unchanged. LV function remains unchanged. RV function is borderline on epi gtt. Aorta remains intact s/ p decannulation. . ___ 06:10AM BLOOD WBC-10.6* RBC-2.59* Hgb-7.8* Hct-24.8* MCV-96 MCH-30.1 MCHC-31.5* RDW-15.0 RDWSD-52.5* Plt ___ ___ 09:00AM BLOOD WBC-17.5* RBC-2.95* Hgb-9.1* Hct-28.9* MCV-98 MCH-30.8 MCHC-31.5* RDW-15.8* RDWSD-56.6* Plt ___ ___ 09:00AM BLOOD ___ ___ 06:10AM BLOOD Glucose-96 UreaN-39* Creat-1.5* Na-136 K-4.0 Cl-98 HCO3-25 AnGap-17 ___ 06:00AM BLOOD Glucose-93 UreaN-53* Creat-2.0* Na-139 K-4.1 Cl-100 HCO3-26 AnGap-17 ___ 10:45AM BLOOD Glucose-127* UreaN-55* Creat-2.3* Na-139 K-4.2 Cl-102 HCO3-26 AnGap-15 Brief Hospital Course: Mr. ___ was a same day admit and on ___ was brought directly to the operating room where he underwent an aortic valve replacement. Please see operative note for surgical details. Following surgery he was transferred to the ___ for invasive monitoring in stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated. On postoperative day one he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight with a modest increase in his creat. His baseline creat was 1.9 and he peaked at 2.3. He was maintained on Lasix for diuresis and his creat was followed closely- At the time of discharge his creat was below his baseline at 1.5. His chest tubes and epicardial wires were removed per protocol. The physical therapy service was consulted for assistance with his strength and mobility. Rehab was recommended. By the time of discharge he was ambulating with assist and a rolling walker. The wound was healing well. All instructions and appointments were advised. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO QPM 2. Carvedilol 25 mg PO BID 3. FLUoxetine 20 mg PO QPM 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Losartan Potassium 100 mg PO QHS 6. Simvastatin 40 mg PO QPM 7. Torsemide 100 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Vitamin E 400 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0 2. Docusate Sodium 100 mg PO BID hold for loose stool 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 4. Ranitidine 150 mg PO DAILY 5. Sarna Lotion 1 Appl TP QID:PRN itching 6. Carvedilol 12.5 mg PO BID 7. Losartan Potassium 25 mg PO QHS 8. Allopurinol ___ mg PO QPM 9. Aspirin 81 mg PO DAILY 10. FLUoxetine 20 mg PO QPM 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Simvastatin 40 mg PO QPM 13. Torsemide 100 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Vitamin E 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Aortic Insufficiency s/p Aortic valve replacement Past medical history: Anemia Chronic Kidney Disease (Cre 1.76-2.08) - Single kidney Renal atrophy Chronic Obstructive Pulmonary Disease Depression Gout Hyperlipidemia Hypertension Hypothyroid Non-Ischemic Cardiomyopathy Obesity Pulmonary Hypertension Seizure Sleep Apnea, CPAP recommended but patient declined Tricuspid Regurgitation Appendectomy Discharge Condition: Alert and oriented x3 non-focal Ambulating, deconditioned Incisional pain managed with oral analgesics Incisions: Sternal - 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 ___ **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
[ "I082", "I428", "D696", "I272", "I130", "N183", "I5022", "I471", "D62", "J449", "E785", "G4733", "M109", "E039", "E669", "Z87891", "Z6829" ]
Allergies: lisinopril / shellfish derived Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [MASKED] Aortic valve replacement with a 25 mm [MASKED] Biocor Epic tissue valve. History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with a history of aortic insufficiency, chronic kidney disease, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, sleep apnea, and tricuspid regurgitation. He has noted dyspnea on exertion while ambulating to the bathroom. He has been on Lasix for diuresis in the past without improvement in his symptoms and was recently changed to Torsemide 100 mg daily with mild improvement. An echocardiogram in [MASKED] demonstrated a depressed ejection fraction, severe aortic insufficiency, dilated aortic root, and moderate tricuspid regurgitation. Cardiac catheterization revealed elevated filling pressure without obstructive coronary artery disease. He was referred to Dr. [MASKED] surgical consultation. He presents today for routine PAT's. Since his last office visit, there has been no clinical change in his condition. Past Medical History: Aortic Insufficiency s/p Aortic valve replacement Past medical history: Anemia Chronic Kidney Disease (Cre 1.76-2.08) - Single kidney Renal atrophy Chronic Obstructive Pulmonary Disease Depression Gout Hyperlipidemia Hypertension Hypothyroid Non-Ischemic Cardiomyopathy Obesity Pulmonary Hypertension Seizure Sleep Apnea, CPAP recommended but patient declined Tricuspid Regurgitation Appendectomy Social History: [MASKED] Family History: No premature coronary artery disease Father had an MI in his early [MASKED]. Mother without heart disease. Brother with CABG in his [MASKED]. Physical Exam: Vital Signs sheet entries for [MASKED]: BP: 140/85 (left arm ). Heart Rate: 80. O2 Saturation%: 94 (room air ). Resp. Rate: 17. Pain Score: 0. Height: 72" Weight: 198lb General: NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Decreased at bases bilaterally Heart: RRR, II/VI diastolic, I/VI systolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] 2+ [MASKED] Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 [MASKED] Right:1 Left:1 Radial Right:2 Left:2 Carotid Bruit: None appreciated Discharge exam General: NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Decreased at bases bilaterally Heart: RRR Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] trace [MASKED] Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 [MASKED] Right:1 Left:1 Radial Right:2 Left:2 Carotid Bruit: None appreciated Pertinent Results: Echo [MASKED]: PRE-BYPASS: The left atrium is markedly dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is dilated. Overall left ventricular systolic function is severely depressed (LVEF= [MASKED] %). with mild to moderate global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are three aortic valve leaflets. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The severity of aortic regurgitation may be underestimated. The aortic regurgitation jet is eccentric. Physiologic mitral regurgitation is seen (within normal limits). There is trace TR with a tricuspid annulus of 38mm. There is a small pericardial effusion. POST-BYPASS: The patient is AV paced on low dose epi gtt. A well seated bioprosthetic valve is visualized in the aortic position with normal moving leaflets. There is no AI. Pk and mean pressure gradient across the valve is 15mmHg and 7mmHg respectively with a SV of 57cc. The remaining valves are unchanged. LV function remains unchanged. RV function is borderline on epi gtt. Aorta remains intact s/ p decannulation. . [MASKED] 06:10AM BLOOD WBC-10.6* RBC-2.59* Hgb-7.8* Hct-24.8* MCV-96 MCH-30.1 MCHC-31.5* RDW-15.0 RDWSD-52.5* Plt [MASKED] [MASKED] 09:00AM BLOOD WBC-17.5* RBC-2.95* Hgb-9.1* Hct-28.9* MCV-98 MCH-30.8 MCHC-31.5* RDW-15.8* RDWSD-56.6* Plt [MASKED] [MASKED] 09:00AM BLOOD [MASKED] [MASKED] 06:10AM BLOOD Glucose-96 UreaN-39* Creat-1.5* Na-136 K-4.0 Cl-98 HCO3-25 AnGap-17 [MASKED] 06:00AM BLOOD Glucose-93 UreaN-53* Creat-2.0* Na-139 K-4.1 Cl-100 HCO3-26 AnGap-17 [MASKED] 10:45AM BLOOD Glucose-127* UreaN-55* Creat-2.3* Na-139 K-4.2 Cl-102 HCO3-26 AnGap-15 Brief Hospital Course: Mr. [MASKED] was a same day admit and on [MASKED] was brought directly to the operating room where he underwent an aortic valve replacement. Please see operative note for surgical details. Following surgery he was transferred to the [MASKED] for invasive monitoring in stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated. On postoperative day one he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight with a modest increase in his creat. His baseline creat was 1.9 and he peaked at 2.3. He was maintained on Lasix for diuresis and his creat was followed closely- At the time of discharge his creat was below his baseline at 1.5. His chest tubes and epicardial wires were removed per protocol. The physical therapy service was consulted for assistance with his strength and mobility. Rehab was recommended. By the time of discharge he was ambulating with assist and a rolling walker. The wound was healing well. All instructions and appointments were advised. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO QPM 2. Carvedilol 25 mg PO BID 3. FLUoxetine 20 mg PO QPM 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Losartan Potassium 100 mg PO QHS 6. Simvastatin 40 mg PO QPM 7. Torsemide 100 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Vitamin E 400 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0 2. Docusate Sodium 100 mg PO BID hold for loose stool 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 4. Ranitidine 150 mg PO DAILY 5. Sarna Lotion 1 Appl TP QID:PRN itching 6. Carvedilol 12.5 mg PO BID 7. Losartan Potassium 25 mg PO QHS 8. Allopurinol [MASKED] mg PO QPM 9. Aspirin 81 mg PO DAILY 10. FLUoxetine 20 mg PO QPM 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Simvastatin 40 mg PO QPM 13. Torsemide 100 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Vitamin E 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Aortic Insufficiency s/p Aortic valve replacement Past medical history: Anemia Chronic Kidney Disease (Cre 1.76-2.08) - Single kidney Renal atrophy Chronic Obstructive Pulmonary Disease Depression Gout Hyperlipidemia Hypertension Hypothyroid Non-Ischemic Cardiomyopathy Obesity Pulmonary Hypertension Seizure Sleep Apnea, CPAP recommended but patient declined Tricuspid Regurgitation Appendectomy Discharge Condition: Alert and oriented x3 non-focal Ambulating, deconditioned Incisional pain managed with oral analgesics Incisions: Sternal - 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] **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
[]
[ "D696", "I130", "D62", "J449", "E785", "G4733", "M109", "E039", "E669", "Z87891" ]
[ "I082: Rheumatic disorders of both aortic and tricuspid valves", "I428: Other cardiomyopathies", "D696: Thrombocytopenia, unspecified", "I272: Other secondary pulmonary hypertension", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "I5022: Chronic systolic (congestive) heart failure", "I471: Supraventricular tachycardia", "D62: Acute posthemorrhagic anemia", "J449: Chronic obstructive pulmonary disease, unspecified", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M109: Gout, unspecified", "E039: Hypothyroidism, unspecified", "E669: Obesity, unspecified", "Z87891: Personal history of nicotine dependence", "Z6829: Body mass index [BMI] 29.0-29.9, adult" ]
10,038,999
27,189,241
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: abdominal pain, found to have pericardial effusion Major Surgical or Invasive Procedure: pericardiocentesis intubation bronchoscopy History of Present Illness: This is a ___ yoM with a PMH significant for developmental mental delay, seizure disorder, and blindness who is being admitted to the CCU following pericardial drainage for a moderate to large pericardial effusion. He lives ___ a group home and he has been complaining of abdominal pain for about a week. He went to his PCP ___ ___, who was unable to examine him due to agitation. He then went to ___ ED on ___ with the same complaints and his vitals at the time were Afebrile, HR 110s-120s, SBP 130s, 91% RA. He was acutely agitated and required Haldol 5 mg IM, Haldol 5 mg IV, Ativan 2 mg IM, and dilaudid 0.5 mg IV. He then got a CT abdomen to evaluate his abdominal pain and it showed a moderate to large pericardial effusion, small bilateral pleural effusions, and no significant intra-abdominal process. He then received a bedside echocardiogram that showed RV collapse, he was given 2 L NS, and he was transferred to BID ED. ___ the ED here, his BP was 143/104, HR 128, RR 24, and 93% room air. Labs significant for wbc 10.8 (72% poly, 14% lymph), hgb 9.2, INR 1.3, K 5.7, Cr 0.8. An echocardiogram ___ the ED showed the IVC was non-collapsible, but the RA was not invaginating with diastole. EKG showed NSR, tachycardia, with PR depression ___ I/II, elevation ___ AVR, decreased voltages, no electrical alternans. He was acutely agitated and required intubation (fentanyl, versed). He was then taken to the cath lab to have a pericardial drain placed, but prior to the procedure his pulse was nonpalpable with a dropping BP, and he required 20 seconds of chest compressions with ROSC. He then received a pericardial drain without complications and ~400 mL of bloody fluid was drained. He only received about 300 mL of IVF ___ the cath lab. On arrival to the CCU: T 98.8, BP 98/64, HR 103, on volume-controlled CMV with FiO2 50%, PEEP 5, set RR 20, set Vt 400 mL, 93% saturation. He is on fentanyl and versed gtt. Past Medical History: Blindness Mental delay Seizure disorder Social History: ___ Family History: Unknown Physical Exam: ADMISSION: ========== Vitals: T 98.8, BP 98/64, HR 103, on volume-controlled CMV with FiO2 50%, PEEP 5, set RR 20, set Vt 400 mL, 93% saturation. He is on fentanyl and versed gtt. GENERAL: Intubated and sedated, ET tube ___ place HEENT: Normocephalic atraumatic. NECK: Supple. No appreciable JVP, but difficult to tell. CARDIAC: Tachycardia, normal S1, S2, no m,r,g LUNGS: Mechanical breath sounds bilaterally, no appreciable rales ABDOMEN: Distended, but soft without masses EXTREMITIES: Cool arms, non-pitting edema ___ bilateral lower extremities up to mid tibia. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. ACCESS: Left AC 18 and right AC 20. DISCHARGE: ========== Pertinent physical: GENERAL: NAD, awake HEENT: Normocephalic atraumatic. NECK: Supple. No appreciable JVP, but difficult to tell. CARDIAC: Tachycardia, normal S1, S2, no m,r,g LUNGS: Slight rales bilateral bases, poor effort ABDOMEN: Distended, but soft without masses, NTTP EXTREMITIES: No pedal edema SKIN: Rashes from EKG leads on chest. PULSES: Distal pulses palpable and symmetric. ACCESS: None Pertinent Results: ADMISSION LABS: =============== ___ 09:00PM BLOOD WBC-10.8* RBC-3.66* Hgb-9.2* Hct-30.0* MCV-82 MCH-25.1* MCHC-30.7* RDW-15.2 RDWSD-45.4 Plt ___ ___ 09:00PM BLOOD Neuts-72.4* Lymphs-14.9* Monos-11.5 Eos-0.3* Baso-0.3 Im ___ AbsNeut-7.84* AbsLymp-1.61 AbsMono-1.25* AbsEos-0.03* AbsBaso-0.03 ___ 09:00PM BLOOD Plt ___ ___ 09:00PM BLOOD ___ PTT-27.7 ___ ___ 09:00PM BLOOD Glucose-123* UreaN-17 Creat-0.8 Na-136 K-5.7* Cl-102 HCO3-22 AnGap-18 ___ 10:45PM BLOOD CK(CPK)-258 ___ 04:54AM BLOOD ALT-54* AST-27 AlkPhos-95 TotBili-0.5 ___ 09:00PM BLOOD cTropnT-<0.01 ___ 10:45PM BLOOD Calcium-7.8* Phos-4.3 Mg-2.2 ___ 10:45PM BLOOD TSH-7.4* ___ 09:11PM BLOOD ___ pO2-47* pCO2-47* pH-7.32* calTCO2-25 Base XS--2 Intubat-INTUBATED Comment-PERIPHERAL ___ 09:11PM BLOOD Lactate-2.1* ___ 09:11PM BLOOD O2 Sat-77 ___ 11:55PM BLOOD freeCa-1.02* ___ 09:59PM BLOOD SED RATE-Test ___ CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: PERICARDIAL FLUID DIAGNOSIS: PERICARDIAL FLUID: NEGATIVE FOR MALIGNANT CELLS. OTHER PERTINENT LABS: ===================== ___ 06:29PM BLOOD WBC-11.5* RBC-3.92* Hgb-9.8* Hct-31.1* MCV-79* MCH-25.0* MCHC-31.5* RDW-15.1 RDWSD-43.6 Plt ___ ___ 05:08AM BLOOD WBC-9.3 RBC-3.47* Hgb-8.6* Hct-27.9* MCV-80* MCH-24.8* MCHC-30.8* RDW-14.9 RDWSD-43.6 Plt ___ ___ 04:54AM BLOOD Glucose-64* UreaN-15 Creat-0.8 Na-139 K-4.3 Cl-99 HCO3-26 AnGap-18 ___ 06:29PM BLOOD calTIBC-264 VitB12-683 Folate-18.9 Hapto-474* Ferritn-457* TRF-203 ___ 04:44PM BLOOD calTIBC-234* VitB12-1087* Folate->20 Ferritn-529* TRF-180* ___ 06:29PM BLOOD T4-4.5* T3-67* ___ 06:38AM BLOOD Free T4-1.1 ___ 04:44PM BLOOD Free T4-0.9* ___ 09:28AM BLOOD ANCA-NEGATIVE B ___ 06:29PM BLOOD RheuFac-15* CRP->300.0* ___ 09:59PM BLOOD ___ ___ 06:38AM BLOOD CRP-327.1* ___ 09:28AM BLOOD IgG-1087 ___ 02:56AM BLOOD C3-180 C4-27 ___ 09:28AM BLOOD HIV Ab-Negative ___ 05:21AM BLOOD Type-ART pO2-98 pCO2-51* pH-7.41 calTCO2-33* Base XS-5 Intubat-INTUBATED ___ 02:30PM BLOOD Type-ART FiO2-40 pO2-93 pCO2-57* pH-7.41 calTCO2-37* Base XS-8 ___ 12:20PM BLOOD Lactate-1.5 ___ Page 1 of 2 CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: PERICARDIAL FLUID, Collected @ 16:45 DIAGNOSIS: PERICARDIAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Blood only. ___ CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: BRONCHIAL LAVAGE DIAGNOSIS: BRONCHIAL LAVAGE: NEGATIVE FOR MALIGNANT CELLS. Bronchial epithelial cells and pulmonary macrophages ___ a background of numerous inflammatory cells including neutrophils, histiocytes and lymphocytes. MICROBIOLOGY: ============= ___ 10:06 pm FLUID,OTHER r/o coxsackievirus (types A and B) . Enterovirus Culture (Final ___: No Enterovirus isolated. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final ___: Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED ___ 6:25 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: GEMELLA SPECIES. PRESUMPTIVE IDENTIFICATION. Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ ON ___ AT ___. GRAM POSITIVE COCCI ___ CLUSTERS. ___ 9:46 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 9:46 pm 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. ___ 9:46 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. RESPIRATORY CULTURE (Final ___: HEAVY GROWTH Commensal Respiratory Flora. ___ 8:42 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final ___: NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ 8:42 am BRONCHIAL WASHINGS BRONCHIAL WASH. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final ___: NO LEGIONELLA ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ 8:42 am Rapid Respiratory Viral Screen & Culture BRONCHIAL WASH . **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Less than 60 columnar epithelial cells;. Inadequate specimen for DFA detection of respiratory viruses.. Interpret all negative DFA and/or culture results from this specimen with caution.. Negative results should not be used to discontinue precautions.. Recommend new sample be submitted for confirmation.. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. Reported to and read back by ___ ___ ___ AT 14:44. ___ 2:30 pm Immunology (CMV) Source: Line-a. **FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use ___ the ___ patient population. ___ 8:38 am PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): Blood Cultures (___): No growth final Urine Cultures (___): No growth final IMAGING: ======== TTE ___: The left atrium is normal ___ size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The right ventricular cavity is unusually small. with normal free wall contractility. There is a large pericardial effusion. The effusion appears circumferential. Stranding is visualized within the pericardial space c/w organization. The pericardium appears thickened. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Large circumferential pericardial effusion. Thickened parietal pericardium. No echocardiographic evidence of tamponade. Normal LV function. Small RV cavity size with normal function. CXR (AP Portable) ___: IMPRESSION: Evidence for bilateral pleural effusions and consolidation or atelectasis ___ the left lower lobe. Prominent cardiac silhouette. TTE ___: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is significantly depressed. The apical The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. There is a small-moderate sized pericardial effusion ___ the apical views the fluid is all echodense and there does appear to be tagging of the RV wall to the pericardium raising question of constriction. ___ those views the effusion is small, all < 1.0cm, and the fluid is echodense. The subcostal windows are quite limited, but the posterolateral pocket may be a little bigger there measuring up to 1.3cm. It is hard to make out whether any of that fluid is simple, but I suspect it is also echodense like the rest of the pericardial fluid. There are no echocardiographic signs of tamponade. IMPRESSION: Small to moderate sized echodense circumferential pericardial effusion. Pleural effusion. No 2D echo evidence of tamponade. Depressed global right ventricular systolic function. The images and the report from ___ are not available for review CTA Chest ___: IMPRESSION: 1. No evidence of pulmonary embolism within limitations of the study limited by patient motion. 2. There is a large nonhemorrhagic pericardial effusion with pericardial drain ___ place. There is associated leftward interventricular septal bowing and contrast reflux into the hepatic veins suggestive of right ventricular strain. 3. Bilateral nonhemorrhagic pleural effusions are larger compared to ___. 4. Bilateral compressive atelectasis with collapse of the left lower lobe and posterior basal segment of the right lower lobe. There is also linear atelectasis ___ the left upper lobe. CXR (AP Portable) ___: IMPRESSION: 1. Central pulmonary vascular congestion with new mild edema since the ___ examination. 2. The lung volumes remain low. Unchanged pleural effusions and bibasilar atelectasis. CT Chest w/ Contrast ___: IMPRESSION: Decrease ___ size of pericardial effusion. Extensive mediastinal lymphadenopathy is unchanged, the lymph nodes are borderline, likely reactive. Large bilateral layering pleural effusions associated with adjacent atelectasis are stable. No definitive new lung abnormalities are detected. TTE ___: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF = 75%). Right ventricular chamber size and free wall motion are normal. There is a moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. However, ___ the presence of a non-free-flowing pericardial effusion, these signs may be absent despite impairment of right ventricular filling. Compared with the prior study (images reviewed) of ___ the pericardial effusion is larger. TTE ___: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is a small to moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. However, there is significant, accentuated respiratory variation ___ mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of ___ the effusion appears smaller. CXR ___: IMPRESSION: Compared to chest radiographs ___ through ___. Previous pulmonary vascular congestion has resolved, but moderate enlargement of the cardiac silhouette remains, exaggerated by very low lung volumes. There is no mediastinal venous engorgement to suggest elevated central venous pressure. Pleural effusions are likely, but not large. No pneumothorax. DISCHARGE LABS (most recent since discharge): ============================================== ___ 11:10AM BLOOD WBC-7.0 RBC-4.24* Hgb-10.1* Hct-33.6* MCV-79* MCH-23.8* MCHC-30.1* RDW-15.3 RDWSD-43.6 Plt ___ ___ 11:10AM BLOOD ___ PTT-31.8 ___ ___ 11:10AM BLOOD Glucose-92 UreaN-20 Creat-0.7 Na-138 K-4.4 Cl-101 HCO3-21* AnGap-20 ___ 11:10AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ y/o man with history of developmental delay who presented to an OSH with abdominal pain was found to have a large pericardial effusion on CT Abd/Pelvis, transferred to ___ for further management. #Pericardial effusion/Pericarditis: Patient initially presented with abdominal pain with finding of pericardial effusion as incidental finding. Unclear if symptoms are related to effusion, however, as patient with limited ability to express himself clearly due to developmental delay. He underwent pericardiocentesis with findings consistent with inflammatory/bloody output. Serial TTE post-procedure showed persistent, but much improved and stable pericardial fluid as well as possible constrictive physiology. He also had positive inflammatory markers (CRP/ESR). Extensive work-up did not reveal clear etiology with work-up negative for TB, thyroid dysfunction, malignancy, and infection intrinsic to pericardial fluid. Most likely explanation would be that patient had pneumonia (as below), triggering para-pneumonic pericarditis and effusion with subsequent heart failure as a result of effusion and possible constriction. He was diuresed intermittently with Lasix while ___ the CCU and started on colchicine therapy for planned 90 days. He was evaluated by c-surg and after discussion with patient's guardian (mother) and essential return to baseline functional status, it was decided not to pursue any invasive procedures such as pericardial stripping vs. window. After evaluation and treatment with physical therapy, he was discharged back to his home facility. #Hypervolemia: Patient had low albumin, constrictive physiology and lower extremity edema, bilateral pleural effusions, and elevated CVP on admission. This was felt to be due to acute inflammation (leading to low albumin) and effusive/constrictive physiology, treated with Lasix while ___ the ICU. He was euvolemic at discharge off any maintenance diuretics. #Pleural effusions: Given extensive work-up (detailed above), patient was noticed to have large pleural effusions likely due to para-pneumonic inflammation and volume overload. He underwent U/S guided drainage of his left-sided effusion (exudative) without clear signs of infection with ___ during this admission and improvement noted on subsequent imaging. #HCAP: Patient was admitted with fever and pulmonary infiltrates, and overall picture that was felt to be consistent with pneumonia. He was treated with course of vancomycin/cefepime/azithro as such. Unfortunately, only positive growth from BAL and cultures from multiple sources was Gamella from blood (per ID felt to be likely contaminant). His respiratory status improved to baseline at time of discharge. #Rash: During this admission, patient noted to have rash on back from b/l shoulders to top of iliac crests, diffuse erythematous plaques and papules with poorly demarcated borders covering most of back; no sloughing, vesicles or purpura, blanchable ___ nature. This was felt to be possible heat rash or possible drug effect. However, no concerning findings c/w SJS/TEN or significant eosinophilia on lab work. This self resolved with mobilization from the bed, prior to discharge. #Hypoxic respiratory failure: The patient was initially intubated and sedated prior to admission due to report of hypoxia and agitation, which would have potentially complicated pericardial drainage. He was found as above to have pneumonia, pleural effusions, pericardial effusion, and atelectasis/incomplete collapse of bilateral lower lobes. CTA chest also showed no signs of PE. He was extubated with treatment of his multiple conditions as above on ___ and quickly was weaned to room air prior to discharge. #Bradycardia: While intubated, patient had multiple episodes of bradycardia with possible junctional rhythm, never lasting more than seconds to a minute. These were all felt to be vagal ___ nature as they occurred ___ the setting of bladder scan, trach adjustment, and ventilation changes. He was monitor closely on tele without further episodes post-discharge. #Anemia: Baseline H/H 13.2-___-40. Iron studies c/w slight anemia of chronic disease. Has been low likely because of hemodilution ___ the setting of IVF. His H&H improved with supportive care. #Malnutrition: He had low albumin possibly due to acute inflammation/illness and prolonged intubation. He did receive tube feeds while intubated and was quickly restarted on regular diet prior to discharge. #Coagulopathy: INR 1.2 on admission, today 1.7. Unknown etiology. ___ malnutrition, liver dysfunction, medication induced. This was most likely due to malnutrition and vitamin K dysfunction as INR improved quickly after initiation of nutrition. #Seizures (chronic): Continued on home Depakote 500 mg BID #Developmental delay/behavioral issues (chronic): Continued during hospitalization on home Seroquel, trazodone, and celexa. TRANSITIONAL ISSUES: - Colchicine for 3 month course for possible pericarditis (Day 1 - ___ - Outpatient cards f/u ___ ___ weeks - Repeat TTE ___ ___ weeks before cardiology appointment to assess for pericardial fluid reaccumulation - Decision made not to pursue pericardial stripping vs. pericardial window placement given ability to return to baseline functional status. Can consider ___ the future if recurrent pericardial effusion -During work-up for cause of pericardial effusion, patient had negative Quantiferon Gold assay for TB CODE STATUS: FULL CODE CONTACT: ___ (mother) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. QUEtiapine Fumarate 300 mg PO QHS 2. Divalproex (DELayed Release) 500 mg PO BID 3. Citalopram 40 mg PO DAILY 4. QUEtiapine Fumarate 150 mg PO QAM 5. TraZODone 100 mg PO QHS 6. TraZODone 50 mg PO QAM 7. Vitamin D ___ UNIT PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg) oral DAILY 10. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID Discharge Medications: 1. Colchicine 0.6 mg PO BID Duration: 90 Days Please continue for 90 days. Day 1 = ___. RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 2. Citalopram 40 mg PO DAILY 3. Divalproex (DELayed Release) 500 mg PO BID 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg) oral DAILY 6. QUEtiapine Fumarate 150 mg PO QAM 7. QUEtiapine Fumarate 300 mg PO QHS 8. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID 9. TraZODone 100 mg PO QHS 10. TraZODone 50 mg PO QAM 11. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Pericarditis Pericardial Effusion Health Care Associated Pneumonia Pleural Effusion Hyperkalemia Hypoxic Respiratory Failure SECONDARY DIAGNOSES: Developmental Delay Seizure disorder Discharge Condition: Mental Status: Confused - sometimes. At baseline the patient is AOx1 and he has returned to baseline on discharge. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Patient is legally blind so requires assistance at baseline. Discharge Instructions: Dear Mr. ___, You came to ___ because you were having stomach pain and it was discovered that you had fluid around your heart. What was found ___ the hospital? - Your had fluid around your heart, called a pericardial effusion. - Your had fluid ___ your lungs, called a pleural effusion. - You had an infection ___ your lungs, called pneumonia. - You had high levels of potassium ___ your blood, called hyperkalemia. - You had difficulty breathing and were on a mechanical ventilator for 1 week. What was done for you ___ the hospital? - The fluid around your heart was causing problems with pumping. You went to the catheterization lab. A drain was placed to remove fluid. After two days, most of the fluid was gone and the drain was pulled out. The fluid was sent for laboratory studies to look for a cause like infection or disease, but no cause was found. We continued to monitor your heart with pictures (transthoracic echocardiograms and chest xrays). You were given oral medications to keep the combat the inflammation around your heart. The fluid did not reaccumulate and you are safe to go home with follow-up with your doctor. - Samples of the fluid ___ your lungs were taken by two methods. The first was a bronchoscopy, where a tube with a video camera was placed down your throat to look inside your lungs. The second method was a pleurocentesis, where a needle was put ___ your side and the fluid was pulled off. These samples were sent to the laboratory for studies to look for a cause. We found indicators of infection, but no specific bacterium that was likely to cause it. You had chest x-rays to watch for reaccumulation, and that did not happen. - For your infection, you were see by specialists from the infectious diseases and pulmonary divisions. You most likely had a pneumonia. You received antibiotics for several days. You had a fever with this infection. You received acetaminophen. You had your intake and output monitored to make sure you did not become dehydrated. Your symptoms improved and you are safe to go home. - Initial laboratory studies showed that you had high levels of potassium ___ your blood. You received fluids and diuresis at different points during your hospitalization. You had frequent electrocardiograms and laboratory studies to monitor for effects of high potassium. Your potassium level returned to normal. - You came to ___ on a mechanical ventilator to help your breathing while you were sick. You were on the ventilator for several days. You showed us you could breathe on your own, so we stopped the ventilator and you were able to breathe on your own. You did not require re-intubation. What should you do when you go home? - For the fluid around the heart, you should take a new medicine, called colchicine, described below. - Follow-up with your primary care doctor. - Ask your primary care doctor to schedule follow-up appointment and transthoracic echocardiogram with a cardiologist. NEW MEDICATIONS - Colchicine 0.6 mg by mouth ___ the morning and at night, every day. This medication is for your pericarditis. You should take it for 3 months, last dose ___. Otherwise, you can continue taking the medications you had taken at home before coming to the hospital. Followup Instructions: ___
[ "J189", "R570", "I314", "J918", "D688", "E46", "J9691", "I313", "J9811", "I319", "G40909", "H540", "R21", "I509", "D649", "E875", "R001" ]
Allergies: No Allergies/ADRs on File Chief Complaint: abdominal pain, found to have pericardial effusion Major Surgical or Invasive Procedure: pericardiocentesis intubation bronchoscopy History of Present Illness: This is a [MASKED] yoM with a PMH significant for developmental mental delay, seizure disorder, and blindness who is being admitted to the CCU following pericardial drainage for a moderate to large pericardial effusion. He lives [MASKED] a group home and he has been complaining of abdominal pain for about a week. He went to his PCP [MASKED] [MASKED], who was unable to examine him due to agitation. He then went to [MASKED] ED on [MASKED] with the same complaints and his vitals at the time were Afebrile, HR 110s-120s, SBP 130s, 91% RA. He was acutely agitated and required Haldol 5 mg IM, Haldol 5 mg IV, Ativan 2 mg IM, and dilaudid 0.5 mg IV. He then got a CT abdomen to evaluate his abdominal pain and it showed a moderate to large pericardial effusion, small bilateral pleural effusions, and no significant intra-abdominal process. He then received a bedside echocardiogram that showed RV collapse, he was given 2 L NS, and he was transferred to BID ED. [MASKED] the ED here, his BP was 143/104, HR 128, RR 24, and 93% room air. Labs significant for wbc 10.8 (72% poly, 14% lymph), hgb 9.2, INR 1.3, K 5.7, Cr 0.8. An echocardiogram [MASKED] the ED showed the IVC was non-collapsible, but the RA was not invaginating with diastole. EKG showed NSR, tachycardia, with PR depression [MASKED] I/II, elevation [MASKED] AVR, decreased voltages, no electrical alternans. He was acutely agitated and required intubation (fentanyl, versed). He was then taken to the cath lab to have a pericardial drain placed, but prior to the procedure his pulse was nonpalpable with a dropping BP, and he required 20 seconds of chest compressions with ROSC. He then received a pericardial drain without complications and ~400 mL of bloody fluid was drained. He only received about 300 mL of IVF [MASKED] the cath lab. On arrival to the CCU: T 98.8, BP 98/64, HR 103, on volume-controlled CMV with FiO2 50%, PEEP 5, set RR 20, set Vt 400 mL, 93% saturation. He is on fentanyl and versed gtt. Past Medical History: Blindness Mental delay Seizure disorder Social History: [MASKED] Family History: Unknown Physical Exam: ADMISSION: ========== Vitals: T 98.8, BP 98/64, HR 103, on volume-controlled CMV with FiO2 50%, PEEP 5, set RR 20, set Vt 400 mL, 93% saturation. He is on fentanyl and versed gtt. GENERAL: Intubated and sedated, ET tube [MASKED] place HEENT: Normocephalic atraumatic. NECK: Supple. No appreciable JVP, but difficult to tell. CARDIAC: Tachycardia, normal S1, S2, no m,r,g LUNGS: Mechanical breath sounds bilaterally, no appreciable rales ABDOMEN: Distended, but soft without masses EXTREMITIES: Cool arms, non-pitting edema [MASKED] bilateral lower extremities up to mid tibia. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. ACCESS: Left AC 18 and right AC 20. DISCHARGE: ========== Pertinent physical: GENERAL: NAD, awake HEENT: Normocephalic atraumatic. NECK: Supple. No appreciable JVP, but difficult to tell. CARDIAC: Tachycardia, normal S1, S2, no m,r,g LUNGS: Slight rales bilateral bases, poor effort ABDOMEN: Distended, but soft without masses, NTTP EXTREMITIES: No pedal edema SKIN: Rashes from EKG leads on chest. PULSES: Distal pulses palpable and symmetric. ACCESS: None Pertinent Results: ADMISSION LABS: =============== [MASKED] 09:00PM BLOOD WBC-10.8* RBC-3.66* Hgb-9.2* Hct-30.0* MCV-82 MCH-25.1* MCHC-30.7* RDW-15.2 RDWSD-45.4 Plt [MASKED] [MASKED] 09:00PM BLOOD Neuts-72.4* Lymphs-14.9* Monos-11.5 Eos-0.3* Baso-0.3 Im [MASKED] AbsNeut-7.84* AbsLymp-1.61 AbsMono-1.25* AbsEos-0.03* AbsBaso-0.03 [MASKED] 09:00PM BLOOD Plt [MASKED] [MASKED] 09:00PM BLOOD [MASKED] PTT-27.7 [MASKED] [MASKED] 09:00PM BLOOD Glucose-123* UreaN-17 Creat-0.8 Na-136 K-5.7* Cl-102 HCO3-22 AnGap-18 [MASKED] 10:45PM BLOOD CK(CPK)-258 [MASKED] 04:54AM BLOOD ALT-54* AST-27 AlkPhos-95 TotBili-0.5 [MASKED] 09:00PM BLOOD cTropnT-<0.01 [MASKED] 10:45PM BLOOD Calcium-7.8* Phos-4.3 Mg-2.2 [MASKED] 10:45PM BLOOD TSH-7.4* [MASKED] 09:11PM BLOOD [MASKED] pO2-47* pCO2-47* pH-7.32* calTCO2-25 Base XS--2 Intubat-INTUBATED Comment-PERIPHERAL [MASKED] 09:11PM BLOOD Lactate-2.1* [MASKED] 09:11PM BLOOD O2 Sat-77 [MASKED] 11:55PM BLOOD freeCa-1.02* [MASKED] 09:59PM BLOOD SED RATE-Test [MASKED] CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: PERICARDIAL FLUID DIAGNOSIS: PERICARDIAL FLUID: NEGATIVE FOR MALIGNANT CELLS. OTHER PERTINENT LABS: ===================== [MASKED] 06:29PM BLOOD WBC-11.5* RBC-3.92* Hgb-9.8* Hct-31.1* MCV-79* MCH-25.0* MCHC-31.5* RDW-15.1 RDWSD-43.6 Plt [MASKED] [MASKED] 05:08AM BLOOD WBC-9.3 RBC-3.47* Hgb-8.6* Hct-27.9* MCV-80* MCH-24.8* MCHC-30.8* RDW-14.9 RDWSD-43.6 Plt [MASKED] [MASKED] 04:54AM BLOOD Glucose-64* UreaN-15 Creat-0.8 Na-139 K-4.3 Cl-99 HCO3-26 AnGap-18 [MASKED] 06:29PM BLOOD calTIBC-264 VitB12-683 Folate-18.9 Hapto-474* Ferritn-457* TRF-203 [MASKED] 04:44PM BLOOD calTIBC-234* VitB12-1087* Folate->20 Ferritn-529* TRF-180* [MASKED] 06:29PM BLOOD T4-4.5* T3-67* [MASKED] 06:38AM BLOOD Free T4-1.1 [MASKED] 04:44PM BLOOD Free T4-0.9* [MASKED] 09:28AM BLOOD ANCA-NEGATIVE B [MASKED] 06:29PM BLOOD RheuFac-15* CRP->300.0* [MASKED] 09:59PM BLOOD [MASKED] [MASKED] 06:38AM BLOOD CRP-327.1* [MASKED] 09:28AM BLOOD IgG-1087 [MASKED] 02:56AM BLOOD C3-180 C4-27 [MASKED] 09:28AM BLOOD HIV Ab-Negative [MASKED] 05:21AM BLOOD Type-ART pO2-98 pCO2-51* pH-7.41 calTCO2-33* Base XS-5 Intubat-INTUBATED [MASKED] 02:30PM BLOOD Type-ART FiO2-40 pO2-93 pCO2-57* pH-7.41 calTCO2-37* Base XS-8 [MASKED] 12:20PM BLOOD Lactate-1.5 [MASKED] Page 1 of 2 CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: PERICARDIAL FLUID, Collected @ 16:45 DIAGNOSIS: PERICARDIAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Blood only. [MASKED] CYTOLOGY REPORT - Final SPECIMEN(S) SUBMITTED: BRONCHIAL LAVAGE DIAGNOSIS: BRONCHIAL LAVAGE: NEGATIVE FOR MALIGNANT CELLS. Bronchial epithelial cells and pulmonary macrophages [MASKED] a background of numerous inflammatory cells including neutrophils, histiocytes and lymphocytes. MICROBIOLOGY: ============= [MASKED] 10:06 pm FLUID,OTHER r/o coxsackievirus (types A and B) . Enterovirus Culture (Final [MASKED]: No Enterovirus isolated. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final [MASKED]: Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED [MASKED] 6:25 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: GEMELLA SPECIES. PRESUMPTIVE IDENTIFICATION. Anaerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED]. [MASKED] ON [MASKED] AT [MASKED]. GRAM POSITIVE COCCI [MASKED] CLUSTERS. [MASKED] 9:46 pm URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 9:46 pm 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] 9:46 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. RESPIRATORY CULTURE (Final [MASKED]: HEAVY GROWTH Commensal Respiratory Flora. [MASKED] 8:42 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final [MASKED]: NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [MASKED]: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [MASKED] 8:42 am BRONCHIAL WASHINGS BRONCHIAL WASH. GRAM STAIN (Final [MASKED]: 3+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final [MASKED]: NO LEGIONELLA ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [MASKED] 8:42 am Rapid Respiratory Viral Screen & Culture BRONCHIAL WASH . **FINAL REPORT [MASKED] Respiratory Viral Culture (Final [MASKED]: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [MASKED] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [MASKED]: Less than 60 columnar epithelial cells;. Inadequate specimen for DFA detection of respiratory viruses.. Interpret all negative DFA and/or culture results from this specimen with caution.. Negative results should not be used to discontinue precautions.. Recommend new sample be submitted for confirmation.. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. Reported to and read back by [MASKED] [MASKED] [MASKED] AT 14:44. [MASKED] 2:30 pm Immunology (CMV) Source: Line-a. **FINAL REPORT [MASKED] CMV Viral Load (Final [MASKED]: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use [MASKED] the [MASKED] patient population. [MASKED] 8:38 am PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [MASKED]: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): Blood Cultures ([MASKED]): No growth final Urine Cultures ([MASKED]): No growth final IMAGING: ======== TTE [MASKED]: The left atrium is normal [MASKED] size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The right ventricular cavity is unusually small. with normal free wall contractility. There is a large pericardial effusion. The effusion appears circumferential. Stranding is visualized within the pericardial space c/w organization. The pericardium appears thickened. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Large circumferential pericardial effusion. Thickened parietal pericardium. No echocardiographic evidence of tamponade. Normal LV function. Small RV cavity size with normal function. CXR (AP Portable) [MASKED]: IMPRESSION: Evidence for bilateral pleural effusions and consolidation or atelectasis [MASKED] the left lower lobe. Prominent cardiac silhouette. TTE [MASKED]: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is significantly depressed. The apical The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. There is a small-moderate sized pericardial effusion [MASKED] the apical views the fluid is all echodense and there does appear to be tagging of the RV wall to the pericardium raising question of constriction. [MASKED] those views the effusion is small, all < 1.0cm, and the fluid is echodense. The subcostal windows are quite limited, but the posterolateral pocket may be a little bigger there measuring up to 1.3cm. It is hard to make out whether any of that fluid is simple, but I suspect it is also echodense like the rest of the pericardial fluid. There are no echocardiographic signs of tamponade. IMPRESSION: Small to moderate sized echodense circumferential pericardial effusion. Pleural effusion. No 2D echo evidence of tamponade. Depressed global right ventricular systolic function. The images and the report from [MASKED] are not available for review CTA Chest [MASKED]: IMPRESSION: 1. No evidence of pulmonary embolism within limitations of the study limited by patient motion. 2. There is a large nonhemorrhagic pericardial effusion with pericardial drain [MASKED] place. There is associated leftward interventricular septal bowing and contrast reflux into the hepatic veins suggestive of right ventricular strain. 3. Bilateral nonhemorrhagic pleural effusions are larger compared to [MASKED]. 4. Bilateral compressive atelectasis with collapse of the left lower lobe and posterior basal segment of the right lower lobe. There is also linear atelectasis [MASKED] the left upper lobe. CXR (AP Portable) [MASKED]: IMPRESSION: 1. Central pulmonary vascular congestion with new mild edema since the [MASKED] examination. 2. The lung volumes remain low. Unchanged pleural effusions and bibasilar atelectasis. CT Chest w/ Contrast [MASKED]: IMPRESSION: Decrease [MASKED] size of pericardial effusion. Extensive mediastinal lymphadenopathy is unchanged, the lymph nodes are borderline, likely reactive. Large bilateral layering pleural effusions associated with adjacent atelectasis are stable. No definitive new lung abnormalities are detected. TTE [MASKED]: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF = 75%). Right ventricular chamber size and free wall motion are normal. There is a moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. However, [MASKED] the presence of a non-free-flowing pericardial effusion, these signs may be absent despite impairment of right ventricular filling. Compared with the prior study (images reviewed) of [MASKED] the pericardial effusion is larger. TTE [MASKED]: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is a small to moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. However, there is significant, accentuated respiratory variation [MASKED] mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of [MASKED] the effusion appears smaller. CXR [MASKED]: IMPRESSION: Compared to chest radiographs [MASKED] through [MASKED]. Previous pulmonary vascular congestion has resolved, but moderate enlargement of the cardiac silhouette remains, exaggerated by very low lung volumes. There is no mediastinal venous engorgement to suggest elevated central venous pressure. Pleural effusions are likely, but not large. No pneumothorax. DISCHARGE LABS (most recent since discharge): ============================================== [MASKED] 11:10AM BLOOD WBC-7.0 RBC-4.24* Hgb-10.1* Hct-33.6* MCV-79* MCH-23.8* MCHC-30.1* RDW-15.3 RDWSD-43.6 Plt [MASKED] [MASKED] 11:10AM BLOOD [MASKED] PTT-31.8 [MASKED] [MASKED] 11:10AM BLOOD Glucose-92 UreaN-20 Creat-0.7 Na-138 K-4.4 Cl-101 HCO3-21* AnGap-20 [MASKED] 11:10AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0 Brief Hospital Course: Mr. [MASKED] is a [MASKED] y/o man with history of developmental delay who presented to an OSH with abdominal pain was found to have a large pericardial effusion on CT Abd/Pelvis, transferred to [MASKED] for further management. #Pericardial effusion/Pericarditis: Patient initially presented with abdominal pain with finding of pericardial effusion as incidental finding. Unclear if symptoms are related to effusion, however, as patient with limited ability to express himself clearly due to developmental delay. He underwent pericardiocentesis with findings consistent with inflammatory/bloody output. Serial TTE post-procedure showed persistent, but much improved and stable pericardial fluid as well as possible constrictive physiology. He also had positive inflammatory markers (CRP/ESR). Extensive work-up did not reveal clear etiology with work-up negative for TB, thyroid dysfunction, malignancy, and infection intrinsic to pericardial fluid. Most likely explanation would be that patient had pneumonia (as below), triggering para-pneumonic pericarditis and effusion with subsequent heart failure as a result of effusion and possible constriction. He was diuresed intermittently with Lasix while [MASKED] the CCU and started on colchicine therapy for planned 90 days. He was evaluated by c-surg and after discussion with patient's guardian (mother) and essential return to baseline functional status, it was decided not to pursue any invasive procedures such as pericardial stripping vs. window. After evaluation and treatment with physical therapy, he was discharged back to his home facility. #Hypervolemia: Patient had low albumin, constrictive physiology and lower extremity edema, bilateral pleural effusions, and elevated CVP on admission. This was felt to be due to acute inflammation (leading to low albumin) and effusive/constrictive physiology, treated with Lasix while [MASKED] the ICU. He was euvolemic at discharge off any maintenance diuretics. #Pleural effusions: Given extensive work-up (detailed above), patient was noticed to have large pleural effusions likely due to para-pneumonic inflammation and volume overload. He underwent U/S guided drainage of his left-sided effusion (exudative) without clear signs of infection with [MASKED] during this admission and improvement noted on subsequent imaging. #HCAP: Patient was admitted with fever and pulmonary infiltrates, and overall picture that was felt to be consistent with pneumonia. He was treated with course of vancomycin/cefepime/azithro as such. Unfortunately, only positive growth from BAL and cultures from multiple sources was Gamella from blood (per ID felt to be likely contaminant). His respiratory status improved to baseline at time of discharge. #Rash: During this admission, patient noted to have rash on back from b/l shoulders to top of iliac crests, diffuse erythematous plaques and papules with poorly demarcated borders covering most of back; no sloughing, vesicles or purpura, blanchable [MASKED] nature. This was felt to be possible heat rash or possible drug effect. However, no concerning findings c/w SJS/TEN or significant eosinophilia on lab work. This self resolved with mobilization from the bed, prior to discharge. #Hypoxic respiratory failure: The patient was initially intubated and sedated prior to admission due to report of hypoxia and agitation, which would have potentially complicated pericardial drainage. He was found as above to have pneumonia, pleural effusions, pericardial effusion, and atelectasis/incomplete collapse of bilateral lower lobes. CTA chest also showed no signs of PE. He was extubated with treatment of his multiple conditions as above on [MASKED] and quickly was weaned to room air prior to discharge. #Bradycardia: While intubated, patient had multiple episodes of bradycardia with possible junctional rhythm, never lasting more than seconds to a minute. These were all felt to be vagal [MASKED] nature as they occurred [MASKED] the setting of bladder scan, trach adjustment, and ventilation changes. He was monitor closely on tele without further episodes post-discharge. #Anemia: Baseline H/H 13.2-[MASKED]-40. Iron studies c/w slight anemia of chronic disease. Has been low likely because of hemodilution [MASKED] the setting of IVF. His H&H improved with supportive care. #Malnutrition: He had low albumin possibly due to acute inflammation/illness and prolonged intubation. He did receive tube feeds while intubated and was quickly restarted on regular diet prior to discharge. #Coagulopathy: INR 1.2 on admission, today 1.7. Unknown etiology. [MASKED] malnutrition, liver dysfunction, medication induced. This was most likely due to malnutrition and vitamin K dysfunction as INR improved quickly after initiation of nutrition. #Seizures (chronic): Continued on home Depakote 500 mg BID #Developmental delay/behavioral issues (chronic): Continued during hospitalization on home Seroquel, trazodone, and celexa. TRANSITIONAL ISSUES: - Colchicine for 3 month course for possible pericarditis (Day 1 - [MASKED] - Outpatient cards f/u [MASKED] [MASKED] weeks - Repeat TTE [MASKED] [MASKED] weeks before cardiology appointment to assess for pericardial fluid reaccumulation - Decision made not to pursue pericardial stripping vs. pericardial window placement given ability to return to baseline functional status. Can consider [MASKED] the future if recurrent pericardial effusion -During work-up for cause of pericardial effusion, patient had negative Quantiferon Gold assay for TB CODE STATUS: FULL CODE CONTACT: [MASKED] (mother) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. QUEtiapine Fumarate 300 mg PO QHS 2. Divalproex (DELayed Release) 500 mg PO BID 3. Citalopram 40 mg PO DAILY 4. QUEtiapine Fumarate 150 mg PO QAM 5. TraZODone 100 mg PO QHS 6. TraZODone 50 mg PO QAM 7. Vitamin D [MASKED] UNIT PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg) oral DAILY 10. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID Discharge Medications: 1. Colchicine 0.6 mg PO BID Duration: 90 Days Please continue for 90 days. Day 1 = [MASKED]. RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 2. Citalopram 40 mg PO DAILY 3. Divalproex (DELayed Release) 500 mg PO BID 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg) oral DAILY 6. QUEtiapine Fumarate 150 mg PO QAM 7. QUEtiapine Fumarate 300 mg PO QHS 8. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID 9. TraZODone 100 mg PO QHS 10. TraZODone 50 mg PO QAM 11. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Pericarditis Pericardial Effusion Health Care Associated Pneumonia Pleural Effusion Hyperkalemia Hypoxic Respiratory Failure SECONDARY DIAGNOSES: Developmental Delay Seizure disorder Discharge Condition: Mental Status: Confused - sometimes. At baseline the patient is AOx1 and he has returned to baseline on discharge. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Patient is legally blind so requires assistance at baseline. Discharge Instructions: Dear Mr. [MASKED], You came to [MASKED] because you were having stomach pain and it was discovered that you had fluid around your heart. What was found [MASKED] the hospital? - Your had fluid around your heart, called a pericardial effusion. - Your had fluid [MASKED] your lungs, called a pleural effusion. - You had an infection [MASKED] your lungs, called pneumonia. - You had high levels of potassium [MASKED] your blood, called hyperkalemia. - You had difficulty breathing and were on a mechanical ventilator for 1 week. What was done for you [MASKED] the hospital? - The fluid around your heart was causing problems with pumping. You went to the catheterization lab. A drain was placed to remove fluid. After two days, most of the fluid was gone and the drain was pulled out. The fluid was sent for laboratory studies to look for a cause like infection or disease, but no cause was found. We continued to monitor your heart with pictures (transthoracic echocardiograms and chest xrays). You were given oral medications to keep the combat the inflammation around your heart. The fluid did not reaccumulate and you are safe to go home with follow-up with your doctor. - Samples of the fluid [MASKED] your lungs were taken by two methods. The first was a bronchoscopy, where a tube with a video camera was placed down your throat to look inside your lungs. The second method was a pleurocentesis, where a needle was put [MASKED] your side and the fluid was pulled off. These samples were sent to the laboratory for studies to look for a cause. We found indicators of infection, but no specific bacterium that was likely to cause it. You had chest x-rays to watch for reaccumulation, and that did not happen. - For your infection, you were see by specialists from the infectious diseases and pulmonary divisions. You most likely had a pneumonia. You received antibiotics for several days. You had a fever with this infection. You received acetaminophen. You had your intake and output monitored to make sure you did not become dehydrated. Your symptoms improved and you are safe to go home. - Initial laboratory studies showed that you had high levels of potassium [MASKED] your blood. You received fluids and diuresis at different points during your hospitalization. You had frequent electrocardiograms and laboratory studies to monitor for effects of high potassium. Your potassium level returned to normal. - You came to [MASKED] on a mechanical ventilator to help your breathing while you were sick. You were on the ventilator for several days. You showed us you could breathe on your own, so we stopped the ventilator and you were able to breathe on your own. You did not require re-intubation. What should you do when you go home? - For the fluid around the heart, you should take a new medicine, called colchicine, described below. - Follow-up with your primary care doctor. - Ask your primary care doctor to schedule follow-up appointment and transthoracic echocardiogram with a cardiologist. NEW MEDICATIONS - Colchicine 0.6 mg by mouth [MASKED] the morning and at night, every day. This medication is for your pericarditis. You should take it for 3 months, last dose [MASKED]. Otherwise, you can continue taking the medications you had taken at home before coming to the hospital. Followup Instructions: [MASKED]
[]
[ "D649" ]
[ "J189: Pneumonia, unspecified organism", "R570: Cardiogenic shock", "I314: Cardiac tamponade", "J918: Pleural effusion in other conditions classified elsewhere", "D688: Other specified coagulation defects", "E46: Unspecified protein-calorie malnutrition", "J9691: Respiratory failure, unspecified with hypoxia", "I313: Pericardial effusion (noninflammatory)", "J9811: Atelectasis", "I319: Disease of pericardium, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "H540: Blindness, both eyes", "R21: Rash and other nonspecific skin eruption", "I509: Heart failure, unspecified", "D649: Anemia, unspecified", "E875: Hyperkalemia", "R001: Bradycardia, unspecified" ]
10,038,999
29,026,789
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Valium Attending: ___. Chief Complaint: right ankle pain Major Surgical or Invasive Procedure: right tibial intramedullary nail History of Present Illness: ___ hx of developmental mental delay, seizure disorder, and blindness resides at a group home and while at day care had a witnessed fall. No head strike per staff. Refused to bear weight to right lower extremity. Significant swelling and tenderness to right lower extremity, outside hospital images showed right ankle fracture, transferred to ___ for higher level care. Past Medical History: Blindness Mental delay Seizure disorder Social History: ___ Family History: Unknown Physical Exam: Exam on discharge: VS: Consistently tachycardic, oAVSS General: Unlabored breathing on RA RLE: -Leg in aircast boot, wrapped in ACE bandage -> dressing changed today, incisions clean/dry/intact, staples in place -Exam limited by patient cooperation: wiggles toes, attempts to dorsi/plantarflex ankle, sensation intact over dorsum and plantar aspects of forefoot as testable, -Foot warm and well perfused No acute distress Unlabored breathing Abdomen soft, non-tender, non-distended Incision clean/dry/intact with no erythema or discharge, minimal ecchymosis Splint in place, clean, dry, and intact Aircast boot in place Right lower extremity - leg in aircast boot, ACE dressing clean/dry/intact, intact toe flexion/extension, no pain with toe range of motion, sensation intact over dorsum and plantar aspects of forefoot as testable, foot warm and well perfused Pertinent Results: ___ 01:00PM BLOOD WBC-7.7 RBC-4.59* Hgb-11.4* Hct-36.7* MCV-80* MCH-24.8* MCHC-31.1* RDW-15.0 RDWSD-43.6 Plt ___ ___ 11:50PM BLOOD Glucose-108* UreaN-20 Creat-0.7 Na-141 K-4.2 Cl-101 ___ AnGap-17* 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 tibial and right fibular fractures and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for a right tibial intramedullary nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications 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 his rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is partial weight-bearing in an aircast boot in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient and his caretakers 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 and his caretakers were also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient and his caretakers expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 30 mg PO QHS 2. QUEtiapine Fumarate 150 mg PO QAM 3. QUEtiapine Fumarate 300 mg PO QHS 4. TraZODone 100 mg PO QHS 5. TraZODone 50 mg PO QAM 6. Divalproex (DELayed Release) 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO DAILY 3. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain Do not drive while taking narcotics. Hold RR<12. RX *oxycodone 5 mg 1 tablet by mouth every six (6) hours Disp #*15 Tablet Refills:*0 5. Citalopram 30 mg PO QHS 6. Divalproex (DELayed Release) 500 mg PO BID 7. QUEtiapine Fumarate 150 mg PO QAM 8. QUEtiapine Fumarate 300 mg PO QHS 9. TraZODone 50 mg PO QAM 10. TraZODone 100 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right tibia fracture and right fibula fracture 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: 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: - partial weight-bearing right lower extremity in aircast boot 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 daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Aircast boot must be left on until follow up appointment unless otherwise instructed 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 FOLLOW UP: Please follow up with Dr. ___ in the ___ Trauma Clinic ___ days post-operation for evaluation. Please call ___ to schedule appointment. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: partial weight-bearing right lower extremity in aircast boot Treatments Frequency: -dressing change as needed -staples remain until follow up visit Followup Instructions: ___
[ "S82251A", "F09", "G40909", "H548", "W1830XA", "Y92199" ]
Allergies: Valium Chief Complaint: right ankle pain Major Surgical or Invasive Procedure: right tibial intramedullary nail History of Present Illness: [MASKED] hx of developmental mental delay, seizure disorder, and blindness resides at a group home and while at day care had a witnessed fall. No head strike per staff. Refused to bear weight to right lower extremity. Significant swelling and tenderness to right lower extremity, outside hospital images showed right ankle fracture, transferred to [MASKED] for higher level care. Past Medical History: Blindness Mental delay Seizure disorder Social History: [MASKED] Family History: Unknown Physical Exam: Exam on discharge: VS: Consistently tachycardic, oAVSS General: Unlabored breathing on RA RLE: -Leg in aircast boot, wrapped in ACE bandage -> dressing changed today, incisions clean/dry/intact, staples in place -Exam limited by patient cooperation: wiggles toes, attempts to dorsi/plantarflex ankle, sensation intact over dorsum and plantar aspects of forefoot as testable, -Foot warm and well perfused No acute distress Unlabored breathing Abdomen soft, non-tender, non-distended Incision clean/dry/intact with no erythema or discharge, minimal ecchymosis Splint in place, clean, dry, and intact Aircast boot in place Right lower extremity - leg in aircast boot, ACE dressing clean/dry/intact, intact toe flexion/extension, no pain with toe range of motion, sensation intact over dorsum and plantar aspects of forefoot as testable, foot warm and well perfused Pertinent Results: [MASKED] 01:00PM BLOOD WBC-7.7 RBC-4.59* Hgb-11.4* Hct-36.7* MCV-80* MCH-24.8* MCHC-31.1* RDW-15.0 RDWSD-43.6 Plt [MASKED] [MASKED] 11:50PM BLOOD Glucose-108* UreaN-20 Creat-0.7 Na-141 K-4.2 Cl-101 [MASKED] AnGap-17* 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 tibial and right fibular fractures and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for a right tibial intramedullary nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications 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 his rehab was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is partial weight-bearing in an aircast boot in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient and his caretakers 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 and his caretakers were also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient and his caretakers expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 30 mg PO QHS 2. QUEtiapine Fumarate 150 mg PO QAM 3. QUEtiapine Fumarate 300 mg PO QHS 4. TraZODone 100 mg PO QHS 5. TraZODone 50 mg PO QAM 6. Divalproex (DELayed Release) 500 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO DAILY 3. Enoxaparin Sodium 40 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain Do not drive while taking narcotics. Hold RR<12. RX *oxycodone 5 mg 1 tablet by mouth every six (6) hours Disp #*15 Tablet Refills:*0 5. Citalopram 30 mg PO QHS 6. Divalproex (DELayed Release) 500 mg PO BID 7. QUEtiapine Fumarate 150 mg PO QAM 8. QUEtiapine Fumarate 300 mg PO QHS 9. TraZODone 50 mg PO QAM 10. TraZODone 100 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: right tibia fracture and right fibula fracture 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: 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: - partial weight-bearing right lower extremity in aircast boot 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 daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Aircast boot must be left on until follow up appointment unless otherwise instructed 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 FOLLOW UP: Please follow up with Dr. [MASKED] in the [MASKED] Trauma Clinic [MASKED] days post-operation for evaluation. Please call [MASKED] to schedule appointment. Please follow up with your primary care doctor regarding this admission within [MASKED] weeks and for and any new medications/refills. Physical Therapy: partial weight-bearing right lower extremity in aircast boot Treatments Frequency: -dressing change as needed -staples remain until follow up visit Followup Instructions: [MASKED]
[]
[]
[ "S82251A: Displaced comminuted fracture of shaft of right tibia, initial encounter for closed fracture", "F09: Unspecified mental disorder due to known physiological condition", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "H548: Legal blindness, as defined in USA", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92199: Unspecified place in other specified residential institution as the place of occurrence of the external cause" ]
10,039,110
20,528,136
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Diflucan Attending: ___ Chief Complaint: Vaginal bleeding Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a ___ y/o G6P2 with a history of known fibroid uterus, history of anemia, history of PE on Eliquis (___), who presents with vaginal bleeding. LMP started ___ - has been much heavier than her prior periods. Changing "more than one pad" per hour, having dizziness, palpitations, SOB as well. Mild cramping. She is followed by Dr. ___ office for her fibroid uterus. Started Lupron (test dose ___, first dose ___ - 11.25 mg with plan for Q3 month injections). Had been advised to get ferraheme injections for anemia, baseline Hct ___, but did not keep appointments. She underwent an endometrial biopsy in ___, which returned as proliferative endometrium and benign endocervix. Patient states she has discussed hysterectomy with Dr. ___ but was "waiting for her blood counts to come up." Past Medical History: OB History: - TAB x 4 - LTCS x 2 GYN History: - LMP ___ - last pap smear ___ NILM HPV- - fibroid uterus, as per above PMH: - anemia - "fatty liver" - PE (___) on Eliquis Surgical History: - (___) prim LTCS - (___) open MMY - (___) rpt LTCS - (___) laparoscopic hiatal hernia repair, Roux-En-Y, LOA Social History: ___ Family History: No history of ovarian, uterine, breast, or colon cancer. Physical Exam: Vitals: Stable and within normal limits General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, non-tender, uterus palpable ~5 cm above umbilicus GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally Pertinent Results: ___ 05:00AM BLOOD WBC-8.1 RBC-4.42 Hgb-7.1* Hct-26.1* MCV-59* MCH-16.1* MCHC-27.2* RDW-22.2* RDWSD-43.2 Plt ___ ___ 11:02AM BLOOD WBC-6.3 RBC-3.47* Hgb-5.6* Hct-20.5* MCV-59* MCH-16.1* MCHC-27.3* RDW-21.9* RDWSD-43.4 Plt ___ ___ 12:35AM BLOOD WBC-6.0 RBC-3.99 Hgb-8.4* Hct-27.6* MCV-69* MCH-21.1* MCHC-30.4* RDW-29.4* RDWSD-67.8* Plt ___ ___ 05:00AM BLOOD Neuts-66.9 Lymphs-18.9* Monos-7.6 Eos-5.3 Baso-0.9 Im ___ AbsNeut-5.45 AbsLymp-1.54 AbsMono-0.62 AbsEos-0.43 AbsBaso-0.07 ___ 07:25AM BLOOD Neuts-60.0 ___ Monos-9.7 Eos-4.9 Baso-0.5 Im ___ AbsNeut-3.29 AbsLymp-1.34 AbsMono-0.53 AbsEos-0.27 AbsBaso-0.03 ___ 05:00AM BLOOD Glucose-74 UreaN-13 Creat-1.1 Na-139 K-4.1 Cl-107 HCO3-20* AnGap-12 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after presenting with vaginal bleeding secondary to known fibroid uterus, with possible additional Lupron effect. Her Hct on initial presentation was 20.5. On HD#1 she received 2 units packed RBCs with a rise in her Hct to 23.7. She was also started on Provera 10 mg daily. ___ was consulted and planned for uterine artery embolization. On HD#2 her Hct was 22.1 and she received an additional two units packed RBCs with appropriate response of her hematocrit to 27.6 and subjective improvement in her symptoms. Her Provera was also increased to 10 mg twice daily. By HD #3, she had minimal ongoing vaginal bleeding and was overall feeling better. She elected to defer UAE during this admission and requested to be discharged home. Her foley catheter was removed and she voided spontaneously. She had minimal pain, was ambulating independently, and continued on regular diet. She was discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Apixaban 5 mg PO BID Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. MedroxyPROGESTERone Acetate 10 mg PO BID RX *medroxyprogesterone [Provera] 10 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Apixaban 5 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Vaginal bleeding secondary to known fibroid uterus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service to manage your vaginal bleeding. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * You may eat a regular diet. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain, headache, or difficulty breathing To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
[ "N938", "D259", "D649", "Z86711", "Z7902" ]
Allergies: Diflucan Chief Complaint: Vaginal bleeding Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a [MASKED] y/o G6P2 with a history of known fibroid uterus, history of anemia, history of PE on Eliquis ([MASKED]), who presents with vaginal bleeding. LMP started [MASKED] - has been much heavier than her prior periods. Changing "more than one pad" per hour, having dizziness, palpitations, SOB as well. Mild cramping. She is followed by Dr. [MASKED] office for her fibroid uterus. Started Lupron (test dose [MASKED], first dose [MASKED] - 11.25 mg with plan for Q3 month injections). Had been advised to get ferraheme injections for anemia, baseline Hct [MASKED], but did not keep appointments. She underwent an endometrial biopsy in [MASKED], which returned as proliferative endometrium and benign endocervix. Patient states she has discussed hysterectomy with Dr. [MASKED] but was "waiting for her blood counts to come up." Past Medical History: OB History: - TAB x 4 - LTCS x 2 GYN History: - LMP [MASKED] - last pap smear [MASKED] NILM HPV- - fibroid uterus, as per above PMH: - anemia - "fatty liver" - PE ([MASKED]) on Eliquis Surgical History: - ([MASKED]) prim LTCS - ([MASKED]) open MMY - ([MASKED]) rpt LTCS - ([MASKED]) laparoscopic hiatal hernia repair, Roux-En-Y, LOA Social History: [MASKED] Family History: No history of ovarian, uterine, breast, or colon cancer. Physical Exam: Vitals: Stable and within normal limits General: NAD, comfortable CV: RRR Lungs: CTAB Abdomen: soft, non-distended, non-tender, uterus palpable ~5 cm above umbilicus GU: pad with minimal spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally Pertinent Results: [MASKED] 05:00AM BLOOD WBC-8.1 RBC-4.42 Hgb-7.1* Hct-26.1* MCV-59* MCH-16.1* MCHC-27.2* RDW-22.2* RDWSD-43.2 Plt [MASKED] [MASKED] 11:02AM BLOOD WBC-6.3 RBC-3.47* Hgb-5.6* Hct-20.5* MCV-59* MCH-16.1* MCHC-27.3* RDW-21.9* RDWSD-43.4 Plt [MASKED] [MASKED] 12:35AM BLOOD WBC-6.0 RBC-3.99 Hgb-8.4* Hct-27.6* MCV-69* MCH-21.1* MCHC-30.4* RDW-29.4* RDWSD-67.8* Plt [MASKED] [MASKED] 05:00AM BLOOD Neuts-66.9 Lymphs-18.9* Monos-7.6 Eos-5.3 Baso-0.9 Im [MASKED] AbsNeut-5.45 AbsLymp-1.54 AbsMono-0.62 AbsEos-0.43 AbsBaso-0.07 [MASKED] 07:25AM BLOOD Neuts-60.0 [MASKED] Monos-9.7 Eos-4.9 Baso-0.5 Im [MASKED] AbsNeut-3.29 AbsLymp-1.34 AbsMono-0.53 AbsEos-0.27 AbsBaso-0.03 [MASKED] 05:00AM BLOOD Glucose-74 UreaN-13 Creat-1.1 Na-139 K-4.1 Cl-107 HCO3-20* AnGap-12 Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after presenting with vaginal bleeding secondary to known fibroid uterus, with possible additional Lupron effect. Her Hct on initial presentation was 20.5. On HD#1 she received 2 units packed RBCs with a rise in her Hct to 23.7. She was also started on Provera 10 mg daily. [MASKED] was consulted and planned for uterine artery embolization. On HD#2 her Hct was 22.1 and she received an additional two units packed RBCs with appropriate response of her hematocrit to 27.6 and subjective improvement in her symptoms. Her Provera was also increased to 10 mg twice daily. By HD #3, she had minimal ongoing vaginal bleeding and was overall feeling better. She elected to defer UAE during this admission and requested to be discharged home. Her foley catheter was removed and she voided spontaneously. She had minimal pain, was ambulating independently, and continued on regular diet. She was discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Apixaban 5 mg PO BID Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild/Fever 2. MedroxyPROGESTERone Acetate 10 mg PO BID RX *medroxyprogesterone [Provera] 10 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Apixaban 5 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Vaginal bleeding secondary to known fibroid uterus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the gynecology service to manage your vaginal bleeding. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. [MASKED] office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * You may eat a regular diet. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain, headache, or difficulty breathing To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]
[]
[ "D649", "Z7902" ]
[ "N938: Other specified abnormal uterine and vaginal bleeding", "D259: Leiomyoma of uterus, unspecified", "D649: Anemia, unspecified", "Z86711: Personal history of pulmonary embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,039,110
25,345,103
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Diflucan Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ year old woman with history of dysfunctional uterine bleeding, iron deficiency anemia, and polysubstance abuse including crack cocaine presenting with chest pain. Notably, she was seen the ED on ___ for chest and abdominal pain worsened with inspiration. She underwent CT abd/pelvis and was diagnosed with a right lower lobe pneumonia based on that CT, and was discharged on azithromycin. She initially felt better, but then the day prior to this admission developed left-sided chest pressure, constant, worse with deep breathing. She also reported dyspnea on exertion. She denied any nausea, vomiting, diaphoresis, or exertional component to the pain. She denied any unilateral leg pain, history of blood clots, or recent surgeries. She did report a flight to ___ 2 weeks prior (12 hours). She is a daily smoker. Not on OCPs. In the ED: Initial vital signs were notable for: 99.0 92 155/70 16 99% RA Labs were notable for: - D-Dimer ___ - Trop < 0.01 - BNP 113 - Lactate 0.7 - Hb 6.8 (has been ___ since ___ Studies performed include: ___ CTA CHEST 1. Segmental and subsegmental pulmonary emboli in the lingula, right middle lobe and bilateral lower lobes. Upper lobes are not particularly well assessed due to motion. No evidence of right heart strain. 2. Findings compatible with a pulmonary infarct in the lingula. Areas of atelectasis at the lung bases with suspected right basilar infarct as well. 3. Small right and trace left pleural effusions. 4. The rounded 1.5 cm lesion in the upper and slightly outer right breast which likely correlates with lesion worked up by prior ultrasound in ___. Patient was given: ___ 09:06 PO Acetaminophen 1000 mg ___ 12:14 PO Ibuprofen 600 mg ___ 13:42 IVF NS 1000 mL ___ 14:11 IV Heparin 6900 UNIT ___ 14:11 IV Heparin Started 1550 units/hr ___ 16:15 PO Ibuprofen 600 mg Upon arrival to the floor, patient reports story as above. She reports continued left chest pain with inspiration and dyspnea with activity, but this has improved since initiation of the heparin gtt. She notes dysfunctional uterine bleeding and a history of anemia. We discussed blood transfusion given Hb < 7, although I relayed that this is chronic and she does not need urgent transfusion at this time. She preferred to think about it overnight. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: PMH 1. hypertension 2. genital herpes 3. fatty liver by ultrasound study PSH 1. S/P C-section x ___ and ___ 2. S/P multiple myomectomy for fibroids in ___ Social History: ___ Family History: Her family history is noted for hyperlipidemia and father living age ___ and diabetes in her mother living age ___. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 98.2PO 152/77 86 18 98Ra GENERAL: Alert and interactive. HEENT: NCAT. CARDIAC: Regular rhythm, normal rate. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords. SKIN: Warm. No rash. NEUROLOGIC: CN2-12 intact. AOx3. ============================= DISCHARGE PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 946) Temp: pt refused v/s (Tm 98.2), BP: 136/82 (136-152/77-82), HR: 78 (78-86), RR: 18, O2 sat: 98%, O2 delivery: Ra, Wt: 190.7 lb/86.5 kg GENERAL: Alert and interactive. HEENT: NCAT. CARDIAC: Regular rhythm, normal rate. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords. SKIN: Warm. No rash. NEUROLOGIC: CN2-12 intact. AOx3. Pertinent Results: ADMISSION LABS: ___ 09:08AM BLOOD WBC-10.4* RBC-4.36 Hgb-6.8* Hct-25.2* MCV-58* MCH-15.6* MCHC-27.0* RDW-22.3* RDWSD-42.5 Plt ___ ___ 09:08AM BLOOD Glucose-86 UreaN-10 Creat-1.0 Na-142 K-4.2 Cl-104 HCO3-23 AnGap-15 ___ 09:08AM BLOOD ___ 09:08AM BLOOD cTropnT-<0.01 ___ 09:08AM BLOOD proBNP-113 ___ 09:08AM BLOOD Iron-15* ___ 09:08AM BLOOD calTIBC-529* Ferritn-29 TRF-407* ___ 09:12AM BLOOD Lactate-0.7 DISCHARGE LABS: ___ 06:35AM BLOOD WBC-10.3* RBC-4.00 Hgb-6.3* Hct-23.3* MCV-58* MCH-15.8* MCHC-27.0* RDW-22.3* RDWSD-42.8 Plt ___ ___ 06:35AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-140 K-4.2 Cl-104 HCO3-23 ___ CXR: IMPRESSION: Perhaps minimal residual opacity at the right costophrenic angle as seen on prior CT. No new consolidation. ___ CHEST CTA: IMPRESSION: 1. Segmental and subsegmental pulmonary emboli in the lingula, right middle lobe and bilateral lower lobes. Upper lobes are not particularly well assessed due to motion. No evidence of right heart strain. 2. Findings compatible with a pulmonary infarct in the lingula. Areas of atelectasis at the lung bases with suspected right basilar infarct as well. 3. Small right and trace left pleural effusions. 4. The rounded 1.5 cm lesion in the upper and slightly outer right breast which likely correlates with lesion worked up by prior ultrasound in ___. ___ TTE: IMPRESSION: LVEF 69%. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Brief Hospital Course: Ms. ___ is a ___ year old woman with history of dysfunctional uterine bleeding, iron deficiency anemia, and polysubstance abuse including crack cocaine presenting with chest pain, found to have a pulmonary embolism. # Non-submassive PE: Pt presented with a week of worsening dyspnea and left sided chest pain. ___ chest CTA notable for segmental PE in lingual, RML, b/l lower lobes with pulmonary infarct in lingual and suspected R. basilar infarct. She was hemodynamically stable. ___ TTE was obtained: LVEF 69%, there was no e/o R heart strain, but TTE notable for mild symmetric LVH with regional biventricular function, mild mitral regurg and mild pulm HTN. Risk factors include smoking (7 cig/day), recent ~12 hr flight from ___. She was started on a hep gtt and transitioned to PO Eliquis 10mg bid x7 days followed by 5mg bid. For her pain, she was given standing Tylenol ___ q8h + PRN ibuprofen. # Dysfunctional uterine bleeding # Iron deficiency anemia: Reports Hgb ___ since ___ im the setting of fibroids and dysfunctional uterine bleeding. She has undergone intermittent iron infusions. This admission Hb 6.8 (baseline), with most recent ferritin 6.8 in ___. Her Hgb was 6.3 on ___, but she was asymptomatic. Previously, she repeatedly refused blood transfusions, but was amenable to receiving 1U pRBC prior to being discharged. She was adamant about being discharged on ___, as she had to go home to take care of her two younger boys. She indicated she would present to the ED if she noticed any active bleeding or become symptomatic. She has an outpatient OBGYN appointment on ___ and said she would contact her PCP for an appointment. # Polysubstance use: Pt with active EtOH use ___ drinker daily) and daily crack cocaine inhalation. She was seen by addiction psychiatry in ___, started on acamprosate, and referred to social work. She stopped taking this medication and missed her most recent social work appointment. SW was initially consulted; however, pt did not seem amenable to meeting with them. She denied any illicit drug use after admission. Will suggest she f/u with outpatient PCP ___ Psychiatry regarding substance use. ==================== MEDICATION CHANGES ==================== []Started Eliquis 10mg bid x7 days (last day ___ followed by 5mg bid. ==================== TRANSITIONAL ISSUES ==================== [] Re-check H/H at next clinic visit, within 1 week of discharge. Continue to monitor for active bleeding. [] She has a f/u scheduled with OBGYN on ___. Please assess for vaginal bleeding at that time, as she was recently started on Eliquis for PE. [] She denied a history of polysubstance abuse during this admission. Please re-address possible illicit drug use either with PCP or ___. []Consider EGD to evaluate for anastamosis, colonoscopy for Fe-deficiency anemia. []s/p Roux-en-Y bypass. Consider multivitamin, Fe supplements, B12, vitamin D and calcium supplementation. # CONTACT: Husband, ___, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg two tablet(s) by mouth every 8 hours as needed for pain Disp #*30 Tablet Refills:*0 2. Apixaban 5 mg PO BID Take 10mg twice daily for a total of 7 days (until ___, then 5mg twice daily thereafter. RX *apixaban [Eliquis] 5 mg one tablet(s) by mouth twice daily Disp #*30 Tablet Refills:*2 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild RX *ibuprofen 400 mg one tablet(s) by mouth every 8 hours as needed for pain Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pulmonary embolism Iron-deficiency Anemia Polysubstance use Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital for a blood clot in your lungs. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received blood for your anemia. - We gave you an IV blood thinner for your lung clot (called heparin). We switched this to oral tablets called Eliquis (apixaban). WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - You are now on a blood thinner that increases your risk of bleeding. Please go to your nearest Emergency Department if you experience any of the following: vaginal bleeding or bleeding elsewhere, chest pain, palpitations (rapid heart beats), shortness of breath, lightheadedness. - Please follow up with your primary care doctor within 5 days of being discharged. You will need to continue taking the Eliquis (apixaban) for your lung clot. - Take your Eliquis (apixaban) as directed: ___: Take 10mg in the morning + 10mg in the evening for a total of 7 days. ___: Take 5mg in the morning + 5mg in the evening. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "I2699", "R042", "D509", "F17210", "F1490", "N938" ]
Allergies: Diflucan Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. [MASKED] is a [MASKED] year old woman with history of dysfunctional uterine bleeding, iron deficiency anemia, and polysubstance abuse including crack cocaine presenting with chest pain. Notably, she was seen the ED on [MASKED] for chest and abdominal pain worsened with inspiration. She underwent CT abd/pelvis and was diagnosed with a right lower lobe pneumonia based on that CT, and was discharged on azithromycin. She initially felt better, but then the day prior to this admission developed left-sided chest pressure, constant, worse with deep breathing. She also reported dyspnea on exertion. She denied any nausea, vomiting, diaphoresis, or exertional component to the pain. She denied any unilateral leg pain, history of blood clots, or recent surgeries. She did report a flight to [MASKED] 2 weeks prior (12 hours). She is a daily smoker. Not on OCPs. In the ED: Initial vital signs were notable for: 99.0 92 155/70 16 99% RA Labs were notable for: - D-Dimer [MASKED] - Trop < 0.01 - BNP 113 - Lactate 0.7 - Hb 6.8 (has been [MASKED] since [MASKED] Studies performed include: [MASKED] CTA CHEST 1. Segmental and subsegmental pulmonary emboli in the lingula, right middle lobe and bilateral lower lobes. Upper lobes are not particularly well assessed due to motion. No evidence of right heart strain. 2. Findings compatible with a pulmonary infarct in the lingula. Areas of atelectasis at the lung bases with suspected right basilar infarct as well. 3. Small right and trace left pleural effusions. 4. The rounded 1.5 cm lesion in the upper and slightly outer right breast which likely correlates with lesion worked up by prior ultrasound in [MASKED]. Patient was given: [MASKED] 09:06 PO Acetaminophen 1000 mg [MASKED] 12:14 PO Ibuprofen 600 mg [MASKED] 13:42 IVF NS 1000 mL [MASKED] 14:11 IV Heparin 6900 UNIT [MASKED] 14:11 IV Heparin Started 1550 units/hr [MASKED] 16:15 PO Ibuprofen 600 mg Upon arrival to the floor, patient reports story as above. She reports continued left chest pain with inspiration and dyspnea with activity, but this has improved since initiation of the heparin gtt. She notes dysfunctional uterine bleeding and a history of anemia. We discussed blood transfusion given Hb < 7, although I relayed that this is chronic and she does not need urgent transfusion at this time. She preferred to think about it overnight. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: PMH 1. hypertension 2. genital herpes 3. fatty liver by ultrasound study PSH 1. S/P C-section x [MASKED] and [MASKED] 2. S/P multiple myomectomy for fibroids in [MASKED] Social History: [MASKED] Family History: Her family history is noted for hyperlipidemia and father living age [MASKED] and diabetes in her mother living age [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 98.2PO 152/77 86 18 98Ra GENERAL: Alert and interactive. HEENT: NCAT. CARDIAC: Regular rhythm, normal rate. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords. SKIN: Warm. No rash. NEUROLOGIC: CN2-12 intact. AOx3. ============================= DISCHARGE PHYSICAL EXAM: VITALS: 24 HR Data (last updated [MASKED] @ 946) Temp: pt refused v/s (Tm 98.2), BP: 136/82 (136-152/77-82), HR: 78 (78-86), RR: 18, O2 sat: 98%, O2 delivery: Ra, Wt: 190.7 lb/86.5 kg GENERAL: Alert and interactive. HEENT: NCAT. CARDIAC: Regular rhythm, normal rate. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No clubbing, cyanosis, or edema. No palpable cords. SKIN: Warm. No rash. NEUROLOGIC: CN2-12 intact. AOx3. Pertinent Results: ADMISSION LABS: [MASKED] 09:08AM BLOOD WBC-10.4* RBC-4.36 Hgb-6.8* Hct-25.2* MCV-58* MCH-15.6* MCHC-27.0* RDW-22.3* RDWSD-42.5 Plt [MASKED] [MASKED] 09:08AM BLOOD Glucose-86 UreaN-10 Creat-1.0 Na-142 K-4.2 Cl-104 HCO3-23 AnGap-15 [MASKED] 09:08AM BLOOD [MASKED] 09:08AM BLOOD cTropnT-<0.01 [MASKED] 09:08AM BLOOD proBNP-113 [MASKED] 09:08AM BLOOD Iron-15* [MASKED] 09:08AM BLOOD calTIBC-529* Ferritn-29 TRF-407* [MASKED] 09:12AM BLOOD Lactate-0.7 DISCHARGE LABS: [MASKED] 06:35AM BLOOD WBC-10.3* RBC-4.00 Hgb-6.3* Hct-23.3* MCV-58* MCH-15.8* MCHC-27.0* RDW-22.3* RDWSD-42.8 Plt [MASKED] [MASKED] 06:35AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-140 K-4.2 Cl-104 HCO3-23 [MASKED] CXR: IMPRESSION: Perhaps minimal residual opacity at the right costophrenic angle as seen on prior CT. No new consolidation. [MASKED] CHEST CTA: IMPRESSION: 1. Segmental and subsegmental pulmonary emboli in the lingula, right middle lobe and bilateral lower lobes. Upper lobes are not particularly well assessed due to motion. No evidence of right heart strain. 2. Findings compatible with a pulmonary infarct in the lingula. Areas of atelectasis at the lung bases with suspected right basilar infarct as well. 3. Small right and trace left pleural effusions. 4. The rounded 1.5 cm lesion in the upper and slightly outer right breast which likely correlates with lesion worked up by prior ultrasound in [MASKED]. [MASKED] TTE: IMPRESSION: LVEF 69%. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with history of dysfunctional uterine bleeding, iron deficiency anemia, and polysubstance abuse including crack cocaine presenting with chest pain, found to have a pulmonary embolism. # Non-submassive PE: Pt presented with a week of worsening dyspnea and left sided chest pain. [MASKED] chest CTA notable for segmental PE in lingual, RML, b/l lower lobes with pulmonary infarct in lingual and suspected R. basilar infarct. She was hemodynamically stable. [MASKED] TTE was obtained: LVEF 69%, there was no e/o R heart strain, but TTE notable for mild symmetric LVH with regional biventricular function, mild mitral regurg and mild pulm HTN. Risk factors include smoking (7 cig/day), recent ~12 hr flight from [MASKED]. She was started on a hep gtt and transitioned to PO Eliquis 10mg bid x7 days followed by 5mg bid. For her pain, she was given standing Tylenol [MASKED] q8h + PRN ibuprofen. # Dysfunctional uterine bleeding # Iron deficiency anemia: Reports Hgb [MASKED] since [MASKED] im the setting of fibroids and dysfunctional uterine bleeding. She has undergone intermittent iron infusions. This admission Hb 6.8 (baseline), with most recent ferritin 6.8 in [MASKED]. Her Hgb was 6.3 on [MASKED], but she was asymptomatic. Previously, she repeatedly refused blood transfusions, but was amenable to receiving 1U pRBC prior to being discharged. She was adamant about being discharged on [MASKED], as she had to go home to take care of her two younger boys. She indicated she would present to the ED if she noticed any active bleeding or become symptomatic. She has an outpatient OBGYN appointment on [MASKED] and said she would contact her PCP for an appointment. # Polysubstance use: Pt with active EtOH use [MASKED] drinker daily) and daily crack cocaine inhalation. She was seen by addiction psychiatry in [MASKED], started on acamprosate, and referred to social work. She stopped taking this medication and missed her most recent social work appointment. SW was initially consulted; however, pt did not seem amenable to meeting with them. She denied any illicit drug use after admission. Will suggest she f/u with outpatient PCP [MASKED] Psychiatry regarding substance use. ==================== MEDICATION CHANGES ==================== []Started Eliquis 10mg bid x7 days (last day [MASKED] followed by 5mg bid. ==================== TRANSITIONAL ISSUES ==================== [] Re-check H/H at next clinic visit, within 1 week of discharge. Continue to monitor for active bleeding. [] She has a f/u scheduled with OBGYN on [MASKED]. Please assess for vaginal bleeding at that time, as she was recently started on Eliquis for PE. [] She denied a history of polysubstance abuse during this admission. Please re-address possible illicit drug use either with PCP or [MASKED]. []Consider EGD to evaluate for anastamosis, colonoscopy for Fe-deficiency anemia. []s/p Roux-en-Y bypass. Consider multivitamin, Fe supplements, B12, vitamin D and calcium supplementation. # CONTACT: Husband, [MASKED], [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg two tablet(s) by mouth every 8 hours as needed for pain Disp #*30 Tablet Refills:*0 2. Apixaban 5 mg PO BID Take 10mg twice daily for a total of 7 days (until [MASKED], then 5mg twice daily thereafter. RX *apixaban [Eliquis] 5 mg one tablet(s) by mouth twice daily Disp #*30 Tablet Refills:*2 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild RX *ibuprofen 400 mg one tablet(s) by mouth every 8 hours as needed for pain Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pulmonary embolism Iron-deficiency Anemia Polysubstance use Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were in the hospital for a blood clot in your lungs. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received blood for your anemia. - We gave you an IV blood thinner for your lung clot (called heparin). We switched this to oral tablets called Eliquis (apixaban). WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - You are now on a blood thinner that increases your risk of bleeding. Please go to your nearest Emergency Department if you experience any of the following: vaginal bleeding or bleeding elsewhere, chest pain, palpitations (rapid heart beats), shortness of breath, lightheadedness. - Please follow up with your primary care doctor within 5 days of being discharged. You will need to continue taking the Eliquis (apixaban) for your lung clot. - Take your Eliquis (apixaban) as directed: [MASKED]: Take 10mg in the morning + 10mg in the evening for a total of 7 days. [MASKED]: Take 5mg in the morning + 5mg in the evening. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "D509", "F17210" ]
[ "I2699: Other pulmonary embolism without acute cor pulmonale", "R042: Hemoptysis", "D509: Iron deficiency anemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1490: Cocaine use, unspecified, uncomplicated", "N938: Other specified abnormal uterine and vaginal bleeding" ]
10,039,110
25,441,215
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Symptomatic fibroid uterus Major Surgical or Invasive Procedure: Total abdominal hysterectomy, Bilateral salpingectomy History of Present Illness: ___ is a ___ gravida 7 ___ who returns to discuss further future hysterectomy and bilateral salpingectomy. On ___, endometrial biopsy showed proliferative endometrium and benign endocervix. She has a history of an enlarged uterus, excessive uterine bleeding. And chronic/acute blood loss anemia for which she has received IV iron therapy. In addition, in efforts to decrease her uterine fibroid burden and decrease her excessive bleeding she has been on IM Lupron therapy. Since initiating Lupron therapy she has had no further vaginal bleeding. She will get a 3-month dose today. She has a history of thrombosis/pulmonary embolism and has been treated with Eliquis. She has an appointment with Dr. ___ ___, heme-onc for recommendations in regard to perioperative anticoagulation therapy. Past Medical History: OB History: - TAB x 4 - LTCS x 2 GYN History: - LMP ___ - last pap smear ___ NILM HPV- - fibroid uterus, as per above PMH: - anemia - "fatty liver" - PE (___) on Eliquis Surgical History: - (___) prim LTCS - (___) open MMY - (___) rpt LTCS - (___) laparoscopic hiatal hernia repair, Roux-En-Y, LOA Social History: ___ Family History: No history of ovarian, uterine, breast, or colon cancer. Physical Exam: On day of discharge: Pertinent Results: ___ 10:25AM BLOOD WBC-7.1 RBC-5.03 Hgb-11.0* Hct-36.1 MCV-72* MCH-21.9* MCHC-30.5* RDW-16.6* RDWSD-42.7 Plt ___ Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after undergoing the procedures listed below. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and a TAP block. She was transitioned to lovenox 12 hours post-operatively given her history of provoked PE. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone, tylenol. By post-operative day 2 she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Apixaban 2.5mg BID Leuprolide Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hrs RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*2 2. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth Two times per day Disp #*56 Tablet Refills:*2 3. Docusate Sodium 100 mg PO BID Hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice per day Disp #*60 Capsule Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate ___ cause sedation. Do not drink or drive. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Fibroid uterus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___ ___ were admitted to the gynecology service after your procedure. ___ have recovered well and the team believes ___ are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking opioids (e.g. oxycodone, hydromorphone) * Take a stool softener such as colace while taking opioids to prevent constipation. * Do not combine opioid and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * ___ may eat a regular diet. * ___ may walk up and down stairs. Incision care: * ___ may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Leave the steri-strips in place. They will fall off on their own. If they have not fallen off by 7 days post-op, ___ may remove them. * If ___ have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where ___ are unable to keep down fluids/food or your medication 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 ___ are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
[ "D259", "Z86718", "Z86711", "Z7902" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Symptomatic fibroid uterus Major Surgical or Invasive Procedure: Total abdominal hysterectomy, Bilateral salpingectomy History of Present Illness: [MASKED] is a [MASKED] gravida 7 [MASKED] who returns to discuss further future hysterectomy and bilateral salpingectomy. On [MASKED], endometrial biopsy showed proliferative endometrium and benign endocervix. She has a history of an enlarged uterus, excessive uterine bleeding. And chronic/acute blood loss anemia for which she has received IV iron therapy. In addition, in efforts to decrease her uterine fibroid burden and decrease her excessive bleeding she has been on IM Lupron therapy. Since initiating Lupron therapy she has had no further vaginal bleeding. She will get a 3-month dose today. She has a history of thrombosis/pulmonary embolism and has been treated with Eliquis. She has an appointment with Dr. [MASKED] [MASKED], heme-onc for recommendations in regard to perioperative anticoagulation therapy. Past Medical History: OB History: - TAB x 4 - LTCS x 2 GYN History: - LMP [MASKED] - last pap smear [MASKED] NILM HPV- - fibroid uterus, as per above PMH: - anemia - "fatty liver" - PE ([MASKED]) on Eliquis Surgical History: - ([MASKED]) prim LTCS - ([MASKED]) open MMY - ([MASKED]) rpt LTCS - ([MASKED]) laparoscopic hiatal hernia repair, Roux-En-Y, LOA Social History: [MASKED] Family History: No history of ovarian, uterine, breast, or colon cancer. Physical Exam: On day of discharge: Pertinent Results: [MASKED] 10:25AM BLOOD WBC-7.1 RBC-5.03 Hgb-11.0* Hct-36.1 MCV-72* MCH-21.9* MCHC-30.5* RDW-16.6* RDWSD-42.7 Plt [MASKED] Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after undergoing the procedures listed below. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and a TAP block. She was transitioned to lovenox 12 hours post-operatively given her history of provoked PE. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to PO oxycodone, tylenol. By post-operative day 2 she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Apixaban 2.5mg BID Leuprolide Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hrs RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*2 2. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth Two times per day Disp #*56 Tablet Refills:*2 3. Docusate Sodium 100 mg PO BID Hold for loose stools RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice per day Disp #*60 Capsule Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate [MASKED] cause sedation. Do not drink or drive. RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Fibroid uterus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED] [MASKED] were admitted to the gynecology service after your procedure. [MASKED] have recovered well and the team believes [MASKED] are ready to be discharged home. Please call Dr. [MASKED] office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking opioids (e.g. oxycodone, hydromorphone) * Take a stool softener such as colace while taking opioids to prevent constipation. * Do not combine opioid and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * [MASKED] may eat a regular diet. * [MASKED] may walk up and down stairs. Incision care: * [MASKED] may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Leave the steri-strips in place. They will fall off on their own. If they have not fallen off by 7 days post-op, [MASKED] may remove them. * If [MASKED] have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where [MASKED] are unable to keep down fluids/food or your medication 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 [MASKED] are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]
[]
[ "Z86718", "Z7902" ]
[ "D259: Leiomyoma of uterus, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,039,272
23,744,596
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / amiodarone Attending: ___. Chief Complaint: neutropenic fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ CAD, Afib (Coumadin), GERD, and dx of pleural mesothelioma (___) s/p cycle two of pemetrexed at ___ ___ (primary oncologist Dr. ___ who presents with several day history of fatigue, malaise, dry cough, myalgias over the past week, with Tmax of 100.0. He received his most recent dose of pemetrexed on ___. After receiving treatment, he experienced several days of myalgias and malaise. He experienced similar symptoms during his initial chemotherapy regimen, however was able to recover after ___ days. However after this dose of pemetrexed, the symptoms the symptoms have lasted longer. He has experienced night sweats and chills the night prior to presentation. Also has experienced dry cough over the last two days. Also experienced rhinorrhea. Has had a persistent left sided pleuritic chest pain that has worsened over the past week. Denies sores throat, nausea, vomiting, diarrhea, dysuria, rash, or joint pains. Denies headache or neck stiffness. Does note that a family member he interacted with last week has since ___ down with a sore throat. Mr. ___ was diagnosed with pleural mesothelioma ___ after being admitted from ___ to ___ for progressive dyspnea on exertion over a 10 month period. At that time, patient underwent pleuroscopy/thorascopy and talc pleurodesis. Pleural biopsy was performed at that time which showed malignant mesothelioma, epitheliod type with cytology of pleural effusion positive for mesothelioma. He was referred to ___ for mesothelioma treatment. He initially was seen by Dr. ___ surgical consideration, however, he was deemed not a surgical candidate and subsequently was transferred to Dr. ___. They had discussed palliative treatment with pemetrexed to assess whether mesothelioma would be improved. If mesothelioma did not improve, plan was to stop chemotherapy and transition to comfort measures. In the ED, initial VS were: 99.5 109 131/89 20 99% RA. Labs were notable for: Neutropenia to 1.3 (ANC 440), lactate 2.3, INR 1.8 Imaging included: CXR (results below) Treatments received: 1L NS, Ciprofloxacin 400 mg IV ONCE, clindamycin 600 mg IV ONCE On arrival to the floor, patient is in no discomfort, resting comfortably. He is interested in eating food. REVIEW OF SYSTEMS: As per HPI, otherwise negative. Past Medical History: PAST ONCOLOGIC HISTORY: Mr. ___ was diagnosed with pleural mesothelioma ___ after being admitted from ___ to ___ for progressive dyspnea on exertion over a 10 month period. At that time, patient underwent pleuroscopy/thorascopy and talc pleurodesis. Pleural biopsy was performed at that time which showed malignant mesothelioma, epitheliod type with cytology of pleural effusion positive for mesothelioma. He was referred to ___ for mesothelioma treatment. He initially was seen by Dr. ___ surgical consideration, however, he was deemed not a surgical candidate and subsequently was transferred to Dr. ___. They had discussed palliative treatment with pemetrexed to assess whether mesothelioma would be improved. If mesothelioma did not improve, plan was to stop chemotherapy and transition to comfort measures. PAST MEDICAL HISTORY: ANXIETY ATRIAL FIBRILLATION s/p PVI ABLATION ___ on Coumadin. BENIGN PROSTATIC HYPERTROPHY CONSTIPATION CORONARY ARTERY DISEASE GASTROESOPHAGEAL REFLUX HYPERTENSION HYPOTHYROIDISM LOWER EXTREMITY EDEMA HIP FRACTURE SENSORINEURAL HEARING LOSS SEBORRHEIC KERATOSIS BASAL CELL CARCINOMA ACTINIC KERATOSIS GALLBLADDER POLYP PLEURAL EFFUSION s/p MULTIPLE THORACENTESES PLEURAL MEOTHELIOMA Social History: ___ Family History: - Mother ___ ___ HEART PROBLEMS / PACEMAKER PLACEMENT - Father ___ ___ LUNG CANCER non-smoker - Sister Living ___ ALZHEIMER'S DISEASE - MGM Deceased CANCER died early Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.0, 151/86, 18, 97% on RA. GENERAL: Pleasant appearing, does not appear in any acute distress, sitting in bed comfortably. HEENT: EOMI, posterior pharynx is non-erythematous, no lymphadenopathy. No oral ulcers or mucositis. CARDIAC: Irregularly irregular rhythm, normal S1 & S2, minimal murmur at right upper sternal border. LUNG: Crackles at left lower lobe about ___ up the lung fields, minimal crackles at right lower lobe, no wheezes. ABD: soft, non-tender, non-distended, no rebound or guarding, normoactive bowel sounds. EXT: Right lower extremity swelling with chronic venous changes on anterior shins. Surgical scar of right knee. NEURO: A&O x 3, CN II-XII intact SKIN: Numerous seborrheic keratosis. DISCHARGE PHYSICAL EXAM: VS: 98 130/81 78 16 99RA GENERAL: Sitting in chair, appears comfortable. HEENT: NCAT, MMM, EOMI CARDIAC: Irregularly irregular rhythm, normal S1 & S2, ?murmur at RUSB LUNG: Mildly diminished BS over L lung fields in comparison to R. Otherwise clear to auscultation. ABD: soft, non-tender, non-distended, no rebound or guarding. EXT: +1 RLE edema with chronic venous changes on anterior shin. Surgical scar of right knee. NEURO: A&O x 3, CN II-XII intact SKIN: Numerous seborrheic keratosis. Pertinent Results: ADMISSION LABS ============== ___ 11:03AM BLOOD WBC-1.3*# RBC-3.29* Hgb-8.6* Hct-27.6* MCV-84 MCH-26.1 MCHC-31.2* RDW-15.9* RDWSD-47.9* Plt ___ ___ 11:03AM BLOOD Neuts-34 Bands-0 ___ Monos-23* Eos-7 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-0.44* AbsLymp-0.47* AbsMono-0.30 AbsEos-0.09 AbsBaso-0.00* ___ 11:03AM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-1+ Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+ Ellipto-OCCASIONAL ___ 11:03AM BLOOD ___ PTT-33.3 ___ ___ 11:03AM BLOOD Glucose-122* UreaN-20 Creat-0.9 Na-139 K-3.7 Cl-104 HCO3-24 AnGap-15 ___ 11:03AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.9 ___ 11:16AM BLOOD Lactate-2.3* ___ 01:37PM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:37PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 01:37PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 01:37PM URINE Mucous-RARE DISCHARGE LABS ============== ___ 07:00AM BLOOD WBC-2.6* RBC-3.24* Hgb-8.2* Hct-27.1* MCV-84 MCH-25.3* MCHC-30.3* RDW-15.9* RDWSD-48.1* Plt ___ ___ 07:00AM BLOOD Neuts-43.6 ___ Monos-16.6* Eos-6.2 Baso-0.0 Im ___ AbsNeut-1.13*# AbsLymp-0.82* AbsMono-0.43 AbsEos-0.16 AbsBaso-0.00* ___ 07:00AM BLOOD ___ PTT-43.7* ___ ___ 07:00AM BLOOD Glucose-90 UreaN-17 Creat-0.8 Na-142 K-3.8 Cl-110* HCO3-24 AnGap-12 ___ 07:00AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0 MICRO ===== ___ Blood Cx: NGTD x2 ___ Urine Cx: Negative IMAGING ======= ___ CXR: Vague opacity projecting over the left mid lung which is new since prior but may be due to known underlying mesothelioma as opposed to new underlying parenchymal process although this would be difficult to exclude entirely. ___ UNILAT LOWER EXT VEINS: No evidence of deep venous thrombosis in the right lower extremity veins. Note is made of slow flow in the calf veins requiring power Doppler analysis to demonstrate flow. Brief Hospital Course: Mr. ___ is an ___ year old man w/ CAD, Afib (Coumadin), GERD, and dx of pleural mesothelioma (___) s/p cycle two of pemetrexed at ___ (primary oncologist Dr. ___ who p/w several day history of fatigue, malaise, dry cough, myalgias over the past week, with Tmax of 100.0. #Pneumonia, febrile neutropenia: On admission, patient found to have WBC 1.3, ANC 440 corresponding to nadir after chemotherapy with a Tmax of 100.0. On evaluation, CXR showed possible left lower lobe opacity; along with the cough and rhinorrhea and recent sick contact, this made pneumonia a possibility and so patient was started on vanc/cefepime (___). Patient denied other localizing symptoms including that of GU and GI systems. UCx was negative. Patient remained afebrile for remainder of hospital stay and was discharged on PO levofloxacin to complete a total 8-day course for pneumonia (End date ___. Notably, patient was monitored until ___ appeared to be increasing for two consecutive days. # Pleuritic Chest Pain: Likely related to underlying pneumonia versus mesothelioma. Low likelihood of pulmonary embolus as patient currently on anticoagulation and not tachycardic/tachypneic. Ultrasound of RLE negative for DVT. Pleuritic CP resolved after starting abx. # Atrial fibrillation: Continued warfarin and sotalol. Pt's INR rose quickly while on home dose of warfarin. On discharge, dose decreased from 2mg daily to 1.5 mg daily. INR on discharge was 3.2. Next INR to be drawn on ___. # Lower extremity swelling: Patient has history of R TKR c/b hemarthrosis and subsequent chronic RLE edema. R ___ was negative for DVT. # Mesothelioma: Currently on palliative pemetrexed, followed by Dr. ___. # Anxiety: Continued home sertraline 25 mg daily and alprazolam QHS:PRN. # BPH: Continued finasteride 5 mg daily. # Levothyroxine: Continued home 100 mcg 6 days/week. TRANSITIONAL ISSUES: ========================================== 1. Pt is to complete 8 day course of Levofloxacin for pneumonia. End date ___. 2. Pt's INR rose quickly while on home dose of warfarin. Dose decreased from 2mg daily to 1.5 mg daily. Next INR to be drawn on ___. 3. Pt noted that his quality of life in the hospital is poor and would not want to undergo further chemotherapy if it caused repeated admissions. Accordingly, he plans to discuss utility of future chemotherapy with oncologist after discharge. 4. Pt is to have repeat CBC drawn on ___ at next oncology f/u appt. CODE Status: DNR/DNI EMERGENCY CONTACT: ___ (daughter): ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Acetaminophen 1000 mg PO Q8H:PRN fever or pain 3. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 4. Sotalol 120 mg PO BID 5. Warfarin 2 mg PO DAILY16 6. bifidobacterium infantis 4 mg oral DAILY 7. Atorvastatin 5 mg PO QPM 8. Omeprazole 40 mg PO DAILY 9. Loratadine 10 mg PO DAILY 10. Sertraline 25 mg PO DAILY 11. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___) 12. FoLIC Acid 1 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN fever or pain 2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 3. Atorvastatin 5 mg PO QPM 4. Finasteride 5 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___) 7. Loratadine 10 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Sertraline 25 mg PO DAILY 10. Sotalol 120 mg PO BID 11. Vitamin D 1000 UNIT PO DAILY 12. Warfarin 1.5 mg PO DAILY16 13. bifidobacterium infantis 4 mg oral DAILY 14. Levofloxacin 500 mg PO Q24H RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Neutropenic fever Healthcare associated pneumonia SECONDARY: Discharge Condition: Discharge Condition: Stable Mental Status: AOx3 Ambulatory Status at Discharge: Independent Discharge Instructions: Dear Mr. ___, You were admitted to the ___ for fever. Unfortunately, we did not identify a clear source. However, your chest x-ray was convincing for pneumonia, and for that you were treated with antibiotics. You will need to complete the antibiotic course (total 8 days, end date listed below). Your INR was also elevated due to the antibiotics, so your Coumadin dose was decreased to 1.5mg daily, and you will need to have your INR re-drawn on ___. It was a pleasure taking part in your care. Your ___ team Followup Instructions: ___
[ "J189", "I482", "D709", "C457", "H905", "R5081", "I2510", "Z7901", "K219", "J3489", "R0781", "F419", "N401", "K5900", "I10", "E039", "R600", "Z8781", "L821", "Z85828", "Z87891" ]
Allergies: Penicillins / amiodarone Chief Complaint: neutropenic fever Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/ CAD, Afib (Coumadin), GERD, and dx of pleural mesothelioma ([MASKED]) s/p cycle two of pemetrexed at [MASKED] [MASKED] (primary oncologist Dr. [MASKED] who presents with several day history of fatigue, malaise, dry cough, myalgias over the past week, with Tmax of 100.0. He received his most recent dose of pemetrexed on [MASKED]. After receiving treatment, he experienced several days of myalgias and malaise. He experienced similar symptoms during his initial chemotherapy regimen, however was able to recover after [MASKED] days. However after this dose of pemetrexed, the symptoms the symptoms have lasted longer. He has experienced night sweats and chills the night prior to presentation. Also has experienced dry cough over the last two days. Also experienced rhinorrhea. Has had a persistent left sided pleuritic chest pain that has worsened over the past week. Denies sores throat, nausea, vomiting, diarrhea, dysuria, rash, or joint pains. Denies headache or neck stiffness. Does note that a family member he interacted with last week has since [MASKED] down with a sore throat. Mr. [MASKED] was diagnosed with pleural mesothelioma [MASKED] after being admitted from [MASKED] to [MASKED] for progressive dyspnea on exertion over a 10 month period. At that time, patient underwent pleuroscopy/thorascopy and talc pleurodesis. Pleural biopsy was performed at that time which showed malignant mesothelioma, epitheliod type with cytology of pleural effusion positive for mesothelioma. He was referred to [MASKED] for mesothelioma treatment. He initially was seen by Dr. [MASKED] surgical consideration, however, he was deemed not a surgical candidate and subsequently was transferred to Dr. [MASKED]. They had discussed palliative treatment with pemetrexed to assess whether mesothelioma would be improved. If mesothelioma did not improve, plan was to stop chemotherapy and transition to comfort measures. In the ED, initial VS were: 99.5 109 131/89 20 99% RA. Labs were notable for: Neutropenia to 1.3 (ANC 440), lactate 2.3, INR 1.8 Imaging included: CXR (results below) Treatments received: 1L NS, Ciprofloxacin 400 mg IV ONCE, clindamycin 600 mg IV ONCE On arrival to the floor, patient is in no discomfort, resting comfortably. He is interested in eating food. REVIEW OF SYSTEMS: As per HPI, otherwise negative. Past Medical History: PAST ONCOLOGIC HISTORY: Mr. [MASKED] was diagnosed with pleural mesothelioma [MASKED] after being admitted from [MASKED] to [MASKED] for progressive dyspnea on exertion over a 10 month period. At that time, patient underwent pleuroscopy/thorascopy and talc pleurodesis. Pleural biopsy was performed at that time which showed malignant mesothelioma, epitheliod type with cytology of pleural effusion positive for mesothelioma. He was referred to [MASKED] for mesothelioma treatment. He initially was seen by Dr. [MASKED] surgical consideration, however, he was deemed not a surgical candidate and subsequently was transferred to Dr. [MASKED]. They had discussed palliative treatment with pemetrexed to assess whether mesothelioma would be improved. If mesothelioma did not improve, plan was to stop chemotherapy and transition to comfort measures. PAST MEDICAL HISTORY: ANXIETY ATRIAL FIBRILLATION s/p PVI ABLATION [MASKED] on Coumadin. BENIGN PROSTATIC HYPERTROPHY CONSTIPATION CORONARY ARTERY DISEASE GASTROESOPHAGEAL REFLUX HYPERTENSION HYPOTHYROIDISM LOWER EXTREMITY EDEMA HIP FRACTURE SENSORINEURAL HEARING LOSS SEBORRHEIC KERATOSIS BASAL CELL CARCINOMA ACTINIC KERATOSIS GALLBLADDER POLYP PLEURAL EFFUSION s/p MULTIPLE THORACENTESES PLEURAL MEOTHELIOMA Social History: [MASKED] Family History: - Mother [MASKED] [MASKED] HEART PROBLEMS / PACEMAKER PLACEMENT - Father [MASKED] [MASKED] LUNG CANCER non-smoker - Sister Living [MASKED] ALZHEIMER'S DISEASE - MGM Deceased CANCER died early Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.0, 151/86, 18, 97% on RA. GENERAL: Pleasant appearing, does not appear in any acute distress, sitting in bed comfortably. HEENT: EOMI, posterior pharynx is non-erythematous, no lymphadenopathy. No oral ulcers or mucositis. CARDIAC: Irregularly irregular rhythm, normal S1 & S2, minimal murmur at right upper sternal border. LUNG: Crackles at left lower lobe about [MASKED] up the lung fields, minimal crackles at right lower lobe, no wheezes. ABD: soft, non-tender, non-distended, no rebound or guarding, normoactive bowel sounds. EXT: Right lower extremity swelling with chronic venous changes on anterior shins. Surgical scar of right knee. NEURO: A&O x 3, CN II-XII intact SKIN: Numerous seborrheic keratosis. DISCHARGE PHYSICAL EXAM: VS: 98 130/81 78 16 99RA GENERAL: Sitting in chair, appears comfortable. HEENT: NCAT, MMM, EOMI CARDIAC: Irregularly irregular rhythm, normal S1 & S2, ?murmur at RUSB LUNG: Mildly diminished BS over L lung fields in comparison to R. Otherwise clear to auscultation. ABD: soft, non-tender, non-distended, no rebound or guarding. EXT: +1 RLE edema with chronic venous changes on anterior shin. Surgical scar of right knee. NEURO: A&O x 3, CN II-XII intact SKIN: Numerous seborrheic keratosis. Pertinent Results: ADMISSION LABS ============== [MASKED] 11:03AM BLOOD WBC-1.3*# RBC-3.29* Hgb-8.6* Hct-27.6* MCV-84 MCH-26.1 MCHC-31.2* RDW-15.9* RDWSD-47.9* Plt [MASKED] [MASKED] 11:03AM BLOOD Neuts-34 Bands-0 [MASKED] Monos-23* Eos-7 Baso-0 [MASKED] Myelos-0 NRBC-1* AbsNeut-0.44* AbsLymp-0.47* AbsMono-0.30 AbsEos-0.09 AbsBaso-0.00* [MASKED] 11:03AM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-1+ Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+ Ellipto-OCCASIONAL [MASKED] 11:03AM BLOOD [MASKED] PTT-33.3 [MASKED] [MASKED] 11:03AM BLOOD Glucose-122* UreaN-20 Creat-0.9 Na-139 K-3.7 Cl-104 HCO3-24 AnGap-15 [MASKED] 11:03AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.9 [MASKED] 11:16AM BLOOD Lactate-2.3* [MASKED] 01:37PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 01:37PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [MASKED] 01:37PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 [MASKED] 01:37PM URINE Mucous-RARE DISCHARGE LABS ============== [MASKED] 07:00AM BLOOD WBC-2.6* RBC-3.24* Hgb-8.2* Hct-27.1* MCV-84 MCH-25.3* MCHC-30.3* RDW-15.9* RDWSD-48.1* Plt [MASKED] [MASKED] 07:00AM BLOOD Neuts-43.6 [MASKED] Monos-16.6* Eos-6.2 Baso-0.0 Im [MASKED] AbsNeut-1.13*# AbsLymp-0.82* AbsMono-0.43 AbsEos-0.16 AbsBaso-0.00* [MASKED] 07:00AM BLOOD [MASKED] PTT-43.7* [MASKED] [MASKED] 07:00AM BLOOD Glucose-90 UreaN-17 Creat-0.8 Na-142 K-3.8 Cl-110* HCO3-24 AnGap-12 [MASKED] 07:00AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0 MICRO ===== [MASKED] Blood Cx: NGTD x2 [MASKED] Urine Cx: Negative IMAGING ======= [MASKED] CXR: Vague opacity projecting over the left mid lung which is new since prior but may be due to known underlying mesothelioma as opposed to new underlying parenchymal process although this would be difficult to exclude entirely. [MASKED] UNILAT LOWER EXT VEINS: No evidence of deep venous thrombosis in the right lower extremity veins. Note is made of slow flow in the calf veins requiring power Doppler analysis to demonstrate flow. Brief Hospital Course: Mr. [MASKED] is an [MASKED] year old man w/ CAD, Afib (Coumadin), GERD, and dx of pleural mesothelioma ([MASKED]) s/p cycle two of pemetrexed at [MASKED] (primary oncologist Dr. [MASKED] who p/w several day history of fatigue, malaise, dry cough, myalgias over the past week, with Tmax of 100.0. #Pneumonia, febrile neutropenia: On admission, patient found to have WBC 1.3, ANC 440 corresponding to nadir after chemotherapy with a Tmax of 100.0. On evaluation, CXR showed possible left lower lobe opacity; along with the cough and rhinorrhea and recent sick contact, this made pneumonia a possibility and so patient was started on vanc/cefepime ([MASKED]). Patient denied other localizing symptoms including that of GU and GI systems. UCx was negative. Patient remained afebrile for remainder of hospital stay and was discharged on PO levofloxacin to complete a total 8-day course for pneumonia (End date [MASKED]. Notably, patient was monitored until [MASKED] appeared to be increasing for two consecutive days. # Pleuritic Chest Pain: Likely related to underlying pneumonia versus mesothelioma. Low likelihood of pulmonary embolus as patient currently on anticoagulation and not tachycardic/tachypneic. Ultrasound of RLE negative for DVT. Pleuritic CP resolved after starting abx. # Atrial fibrillation: Continued warfarin and sotalol. Pt's INR rose quickly while on home dose of warfarin. On discharge, dose decreased from 2mg daily to 1.5 mg daily. INR on discharge was 3.2. Next INR to be drawn on [MASKED]. # Lower extremity swelling: Patient has history of R TKR c/b hemarthrosis and subsequent chronic RLE edema. R [MASKED] was negative for DVT. # Mesothelioma: Currently on palliative pemetrexed, followed by Dr. [MASKED]. # Anxiety: Continued home sertraline 25 mg daily and alprazolam QHS:PRN. # BPH: Continued finasteride 5 mg daily. # Levothyroxine: Continued home 100 mcg 6 days/week. TRANSITIONAL ISSUES: ========================================== 1. Pt is to complete 8 day course of Levofloxacin for pneumonia. End date [MASKED]. 2. Pt's INR rose quickly while on home dose of warfarin. Dose decreased from 2mg daily to 1.5 mg daily. Next INR to be drawn on [MASKED]. 3. Pt noted that his quality of life in the hospital is poor and would not want to undergo further chemotherapy if it caused repeated admissions. Accordingly, he plans to discuss utility of future chemotherapy with oncologist after discharge. 4. Pt is to have repeat CBC drawn on [MASKED] at next oncology f/u appt. CODE Status: DNR/DNI EMERGENCY CONTACT: [MASKED] (daughter): [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Acetaminophen 1000 mg PO Q8H:PRN fever or pain 3. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 4. Sotalol 120 mg PO BID 5. Warfarin 2 mg PO DAILY16 6. bifidobacterium infantis 4 mg oral DAILY 7. Atorvastatin 5 mg PO QPM 8. Omeprazole 40 mg PO DAILY 9. Loratadine 10 mg PO DAILY 10. Sertraline 25 mg PO DAILY 11. Levothyroxine Sodium 100 mcg PO 6X/WEEK ([MASKED]) 12. FoLIC Acid 1 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN fever or pain 2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia 3. Atorvastatin 5 mg PO QPM 4. Finasteride 5 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Levothyroxine Sodium 100 mcg PO 6X/WEEK ([MASKED]) 7. Loratadine 10 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Sertraline 25 mg PO DAILY 10. Sotalol 120 mg PO BID 11. Vitamin D 1000 UNIT PO DAILY 12. Warfarin 1.5 mg PO DAILY16 13. bifidobacterium infantis 4 mg oral DAILY 14. Levofloxacin 500 mg PO Q24H RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Neutropenic fever Healthcare associated pneumonia SECONDARY: Discharge Condition: Discharge Condition: Stable Mental Status: AOx3 Ambulatory Status at Discharge: Independent Discharge Instructions: Dear Mr. [MASKED], You were admitted to the [MASKED] for fever. Unfortunately, we did not identify a clear source. However, your chest x-ray was convincing for pneumonia, and for that you were treated with antibiotics. You will need to complete the antibiotic course (total 8 days, end date listed below). Your INR was also elevated due to the antibiotics, so your Coumadin dose was decreased to 1.5mg daily, and you will need to have your INR re-drawn on [MASKED]. It was a pleasure taking part in your care. Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "I2510", "Z7901", "K219", "F419", "K5900", "I10", "E039", "Z87891" ]
[ "J189: Pneumonia, unspecified organism", "I482: Chronic atrial fibrillation", "D709: Neutropenia, unspecified", "C457: Mesothelioma of other sites", "H905: Unspecified sensorineural hearing loss", "R5081: Fever presenting with conditions classified elsewhere", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z7901: Long term (current) use of anticoagulants", "K219: Gastro-esophageal reflux disease without esophagitis", "J3489: Other specified disorders of nose and nasal sinuses", "R0781: Pleurodynia", "F419: Anxiety disorder, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "K5900: Constipation, unspecified", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "R600: Localized edema", "Z8781: Personal history of (healed) traumatic fracture", "L821: Other seborrheic keratosis", "Z85828: Personal history of other malignant neoplasm of skin", "Z87891: Personal history of nicotine dependence" ]
10,039,302
20,263,091
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel / Sulfur / Nsaids / Ace Inhibitors / Statins-Hmg-Coa Reductase Inhibitors / Niacin Attending: ___. Chief Complaint: Left heel ulcer secondary to peripheral vascular disease Major Surgical or Invasive Procedure: Left Lower Extremity Angiogram. History of Present Illness: Ms. ___ is a ___ woman with a history of peripheral arterial disease now s/p R BKA in ___. This was done for nonhealing foot ulceration after all revascularization options had been exhausted. She was recently noted to have ulceration on her left heel at her rehab and today she presents to undergo an angiogram. She denies rest pain and although she keeps her left leg hanging off the bed, she states she has done this since childhood because it "feels better". Past Medical History: PMH: CAD/MI s/p CABG, PVD< T2DM, HTN, hypothyroidism, breast CA PSH: - Debridement of osteomyelitis with ___ ray resection ___ - Right above-knee popliteal to dorsalis pedis bypass with vein graft anatomically tunneled behind the knee using left cephalic vein graft - ___ - Right lower extremity angiogram - ___ - Angioplasty of the right peroneal artery - ___ - RLE Angiogram w/ iliac stent angioplasty - ___ - Renal Artery Stent - ___ - Right BK pop-DP bypass - ___ - Bilateral Iliac Stents - ___ - CABG ___ - Left mastectomy - Tonsillectomy Social History: ___ Family History: No family history of vascular disease Physical Exam: Gen: Well appearing, in NAD CV: RRR Pulm: CTAB GI: Soft, NTND Extremity: On left heel, clean appearing 2cm ulcer with no fluctuance or surrounding erythema; no purulent drainage noted. Pulses: R: P/D/ L: P/D/P/D E Pertinent Results: ___ 08:50PM GLUCOSE-129* UREA N-17 CREAT-0.9 SODIUM-136 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14 ___ 08:50PM estGFR-Using this ___ 08:50PM CALCIUM-9.6 PHOSPHATE-3.9 MAGNESIUM-1.9 ___ 08:50PM WBC-11.4* RBC-3.66*# HGB-10.5*# HCT-33.5*# MCV-92 MCH-28.7 MCHC-31.3* RDW-16.9* RDWSD-57.1* ___ 08:50PM PLT COUNT-306 ___ 08:50PM ___ PTT-31.3 ___ ___ ANGIOGRAPHIC FINDINGS: 1. Patent abdominal aorta and bilateral renal arteries. 2. Patent bilateral iliac arterial systems. 3. Minor restenosis of right common iliac artery stent and patent left common iliac artery stent. 4. Patent left common femoral and profunda femoris. 5. Diffusely diseased left superficial femoral artery and popliteal. 6. Occluded left posterior tibial artery. 7. Occluded left peroneal artery. 8. Occluded left anterior tibial artery which was reconstituted as the primary runoff to the foot. 9. Patent left dorsalis pedis. Brief Hospital Course: Ms. ___ underwent a diagnostic angiogram on ___ after she developed a left nonhealing ulcer while she was in rehab. She tolerated the procedure well with no complications and was transferred to the PACU in stable condition. The angiogram showed diffusely diseased left SFA and popliteal arteries, occluded L ___, occluded peroneal, occluded L AT with reconstitution as primary runoff to the foot. After the procedure, her pain was controlled; she was ambulating, her foley was removed and she was voiding. She was deemed stable for discharge back to rehab She will return to the hospital on ___ when she is scheduled to undergo a left femoral to AT bypass with PTFE graft. Medications on Admission: 1. Clopidogrel 75 mg PO DAILY 2. Diltiazem Extended-Release 240 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. NovoLOG (insulin aspart) 100 unit/mL subcutaneous per sliding scale 6. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Diltiazem Extended-Release 240 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. NovoLOG (insulin aspart) 100 unit/mL subcutaneous per sliding scale If BG <60, call MD ___ BG ___, give 0 units If BG 151-200, give 2 units If BG 201-250, give 4 units If BG 251-300, give 6 units If BG 301-350. give 8 units If BG 351-400, give 10 units If BG >400, give 12 units Should be given before meals and at bedtime 6. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left heel ulcer secondary to peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ were admitted to ___ and underwent a Left Lower Extremity Angiogram. ___ have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: MEDICATION: • Take Aspirin 325mg (enteric coated) once daily • If instructed, take Plavix (Clopidogrel) 75mg once daily • Continue all other medications ___ were taking before surgery, unless otherwise directed • ___ 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 ___ go home, ___ may walk and use stairs • ___ may shower (let the soapy water run over groin incision, rinse and pat dry) • Your incision may be left uncovered, unless ___ 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, ___ may resume sexual activity • After 1 week, gradually increase your activities and distance walked as ___ can tolerate • No driving until ___ 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: ___
[ "I70244", "E1151", "L97429", "Z89511", "I2510", "I252", "Z951", "Z794", "I10", "E039", "Z853", "Z006" ]
Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel / Sulfur / Nsaids / Ace Inhibitors / Statins-Hmg-Coa Reductase Inhibitors / Niacin Chief Complaint: Left heel ulcer secondary to peripheral vascular disease Major Surgical or Invasive Procedure: Left Lower Extremity Angiogram. History of Present Illness: Ms. [MASKED] is a [MASKED] woman with a history of peripheral arterial disease now s/p R BKA in [MASKED]. This was done for nonhealing foot ulceration after all revascularization options had been exhausted. She was recently noted to have ulceration on her left heel at her rehab and today she presents to undergo an angiogram. She denies rest pain and although she keeps her left leg hanging off the bed, she states she has done this since childhood because it "feels better". Past Medical History: PMH: CAD/MI s/p CABG, PVD< T2DM, HTN, hypothyroidism, breast CA PSH: - Debridement of osteomyelitis with [MASKED] ray resection [MASKED] - Right above-knee popliteal to dorsalis pedis bypass with vein graft anatomically tunneled behind the knee using left cephalic vein graft - [MASKED] - Right lower extremity angiogram - [MASKED] - Angioplasty of the right peroneal artery - [MASKED] - RLE Angiogram w/ iliac stent angioplasty - [MASKED] - Renal Artery Stent - [MASKED] - Right BK pop-DP bypass - [MASKED] - Bilateral Iliac Stents - [MASKED] - CABG [MASKED] - Left mastectomy - Tonsillectomy Social History: [MASKED] Family History: No family history of vascular disease Physical Exam: Gen: Well appearing, in NAD CV: RRR Pulm: CTAB GI: Soft, NTND Extremity: On left heel, clean appearing 2cm ulcer with no fluctuance or surrounding erythema; no purulent drainage noted. Pulses: R: P/D/ L: P/D/P/D E Pertinent Results: [MASKED] 08:50PM GLUCOSE-129* UREA N-17 CREAT-0.9 SODIUM-136 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14 [MASKED] 08:50PM estGFR-Using this [MASKED] 08:50PM CALCIUM-9.6 PHOSPHATE-3.9 MAGNESIUM-1.9 [MASKED] 08:50PM WBC-11.4* RBC-3.66*# HGB-10.5*# HCT-33.5*# MCV-92 MCH-28.7 MCHC-31.3* RDW-16.9* RDWSD-57.1* [MASKED] 08:50PM PLT COUNT-306 [MASKED] 08:50PM [MASKED] PTT-31.3 [MASKED] [MASKED] ANGIOGRAPHIC FINDINGS: 1. Patent abdominal aorta and bilateral renal arteries. 2. Patent bilateral iliac arterial systems. 3. Minor restenosis of right common iliac artery stent and patent left common iliac artery stent. 4. Patent left common femoral and profunda femoris. 5. Diffusely diseased left superficial femoral artery and popliteal. 6. Occluded left posterior tibial artery. 7. Occluded left peroneal artery. 8. Occluded left anterior tibial artery which was reconstituted as the primary runoff to the foot. 9. Patent left dorsalis pedis. Brief Hospital Course: Ms. [MASKED] underwent a diagnostic angiogram on [MASKED] after she developed a left nonhealing ulcer while she was in rehab. She tolerated the procedure well with no complications and was transferred to the PACU in stable condition. The angiogram showed diffusely diseased left SFA and popliteal arteries, occluded L [MASKED], occluded peroneal, occluded L AT with reconstitution as primary runoff to the foot. After the procedure, her pain was controlled; she was ambulating, her foley was removed and she was voiding. She was deemed stable for discharge back to rehab She will return to the hospital on [MASKED] when she is scheduled to undergo a left femoral to AT bypass with PTFE graft. Medications on Admission: 1. Clopidogrel 75 mg PO DAILY 2. Diltiazem Extended-Release 240 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. NovoLOG (insulin aspart) 100 unit/mL subcutaneous per sliding scale 6. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Diltiazem Extended-Release 240 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. NovoLOG (insulin aspart) 100 unit/mL subcutaneous per sliding scale If BG <60, call MD [MASKED] BG [MASKED], give 0 units If BG 151-200, give 2 units If BG 201-250, give 4 units If BG 251-300, give 6 units If BG 301-350. give 8 units If BG 351-400, give 10 units If BG >400, give 12 units Should be given before meals and at bedtime 6. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Left heel ulcer secondary to peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED] were admitted to [MASKED] and underwent a Left Lower Extremity Angiogram. [MASKED] have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: MEDICATION: • Take Aspirin 325mg (enteric coated) once daily • If instructed, take Plavix (Clopidogrel) 75mg once daily • Continue all other medications [MASKED] were taking before surgery, unless otherwise directed • [MASKED] 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 [MASKED] go home, [MASKED] may walk and use stairs • [MASKED] may shower (let the soapy water run over groin incision, rinse and pat dry) • Your incision may be left uncovered, unless [MASKED] 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, [MASKED] may resume sexual activity • After 1 week, gradually increase your activities and distance walked as [MASKED] can tolerate • No driving until [MASKED] 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]
[]
[ "I2510", "I252", "Z951", "Z794", "I10", "E039" ]
[ "I70244: Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity", "Z89511: Acquired absence of right leg below knee", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "Z951: Presence of aortocoronary bypass graft", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "Z853: Personal history of malignant neoplasm of breast", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]
10,039,302
21,345,637
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel / Sulfur / Nsaids / Ace Inhibitors / Statins-Hmg-Coa Reductase Inhibitors / Niacin Attending: ___. Chief Complaint: Non healing left heel wound. Major Surgical or Invasive Procedure: ___: Left femoral-anterior tibial bypass using polytetrafluoroethylene graft. History of Present Illness: ___ year old woman with a vascular history of a right below-the-knee amputation on ___ returns to clinic with concerns of breakdown on the left heel. Additionally, she reports waking up in the middle of the night with pain in her left leg relieved by dangling her leg over the side of the bed. Angio showed occluded SFA and pop disease and left posterior tibial and peroneal arteries . THe left anterior tibial artery is occluded but reconstituted as the primary runoff to the foot. The left dorsalis pedis is patent. She presents for elective bypass with PTFE as no vein is available. Past Medical History: PMH: CAD/MI s/p CABG (last coronary DES ___ for UA), PVD, T2DM, HTN, hypothyroidism, breast CA PSH: - Diagnostic angiogram ___ ( study showed diffusely diseased left SFA and popliteal arteries, occluded L ___, occluded peroneal, occluded L AT with reconstitution as primary runoff to the foot) - Debridement of osteomyelitis with ___ ray resection ___ - Right above-knee popliteal to dorsalis pedis bypass with vein graft anatomically tunneled behind the knee using left cephalic vein graft - ___ - Right lower extremity angiogram - ___ - Angioplasty of the right peroneal artery - ___ - RLE Angiogram w/ iliac stent angioplasty - ___ - Renal Artery Stent - ___ - Right BK pop-DP bypass - ___ - Bilateral Iliac Stents - ___ - CABG ___ - Left mastectomy - Tonsillectomy Social History: ___ Family History: No family history of vascular disease Physical Exam: Vitals: T 98.5 HR 76 BP 139/54 RR 14 Sat 100% RA Physical Exam: Gen: Awake and alert CV: Regular rate and rhythm Resp: CTAB Abd: Soft, nontender, nondistended Ext: RLE - femoral palpable, popliteal dopplerable, s/p BKA LLE - femoral palpable, popliteal dopplerable, DP palpable ___ dopplerable. Right stump is well healed. There is no edema. Incision edges are well approximated. Left lower extremity, well healing heel ulcer, significantly improved from previous. No eschar noted. No surrounding erythema and tenderness. No discharge or odor noted. Left Leg does not appear swollen. Pertinent Results: ___ 07:15PM GLUCOSE-240* UREA N-15 CREAT-0.9 SODIUM-140 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18 ___ 07:15PM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-1.7 ___ 07:15PM WBC-11.2* RBC-3.79* HGB-10.7* HCT-34.8 MCV-92 MCH-28.2 MCHC-30.7* RDW-16.6* RDWSD-55.2* ___ 07:15PM PLT COUNT-402* ___ 07:15PM ___ PTT-27.7 ___ Echocardiogram Date/Time: ___ at 15:43 ___ MD: ___, MD ___ Type: Portable TTE (Complete) Sonographer: ___, ___ Doppler: Full Doppler and color Doppler ___ Location: ___ Contrast: None Tech Quality: Adequate Tape #: Machine: Q-2 Vivid Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm Left Atrium - Volume: *68 ml < 40 ml Left Atrium - ___ Volume/BSA: *47 ml/m2 <= 28 ml/m2 Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.4 cm Left Ventricle - Fractional Shortening: *0.17 >= 0.29 Left Ventricle - Ejection Fraction: 30% >= 55% Left Ventricle - Stroke Volume: 43 ml/beat Left Ventricle - Cardiac Output: 3.32 L/min Left Ventricle - Cardiac Index: 2.30 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.03 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *32 < 13 Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 15 Aortic Valve - LVOT diam: 1.9 cm Mitral Valve - E Wave: 1.6 m/sec Mitral Valve - E Wave deceleration time: 168 ms 140-250 ms TR Gradient (+ RA = PASP): *59 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Mild ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Moderate-severe global left ventricular hypokinesis. TDI E/e' >13, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Borderline normal RV systolic function. [Intrinsic RV systolic function likely more depressed given the severity of TR]. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. ___ (2+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. Severe [4+] TR. Severe PA systolic hypertension. Given severity of TR, PASP may be underestimated due to elevated RA pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. Brief Hospital Course: ___ year old woman with a vascular history of a right below-the-knee amputation on ___ returns to clinic with concerns of breakdown on the left heel. Additionally, she reports waking up in the middle of the night with pain in her left leg relieved by dangling her leg over the side of the bed. Angio showed diffuse SFA and pop disease and occlusions of left posterior tibial and peroneal arteries . THe left anterior tibial artery is occluded but reconstituted as the primary runoff to the foot. She presents for elective bypass with PTFE as no vein is available. The OR course was uncomplicated. On POD #2, she was noted to have ST depressions on her bedside monitor, confirmed by 12 lead. She was asymptomatic, trops were negative. Given her history of recent DES in SVG, cardiology was consulted. ECHO showed 30% EF. Low dose metrop was added and this was titrated as tolerated to 25mg TID. Per cardiology recommendations, diltiazem was discontinued. The patient tolerated this appropriately with SBPs remaining 120-30s and HR no lower than 60. Postoperatively, the patient was found to have urinary pain/urgency thus UA/UCx were sent which showed UTI. On ___ the patient was started on CTX and this was changed to po Macrobid on ___. On ___ the Allergy service was consulted regarding the patient's ASA allergy and indicated that the patient's clinical history was not compatible with a true aspirin allergy. Allergy service also recommended a trial of 81mg ASA which was completed without issue. The patient experienced no reactive symptoms and was thus discharged on aspirin 81mg qd along Plavix, Pradaxa, Macrobid (x3 days for UTI) and other home medications. Medications on Admission: (See admission record) Discharge Medications: 1. Dabigatran Etexilate 150 mg PO BID RX *dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN prn pain, fever RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth four times a day Disp #*60 Tablet Refills:*0 3. Aspirin 81 mg PO ONCE Duration: 1 Dose RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 4. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 5. Gabapentin 300 mg PO TID 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 3 Days RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth twice a day Disp #*6 Capsule Refills:*0 8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN pain Duration: 7 Days RX *oxycodone [Roxicodone] 5 mg ___ tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills:*0 9. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 10. Metoprolol Tartrate 25 mg PO TID Hold for SBP<110 Hold for HR<60 RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 11. Calcium Carbonate 500 mg PO QID:PRN indigestion Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PMH: Coronary artery disease Peripheral vascular disease s/p CABG (last coronary Drug eluting stent ___, Diabetes Type 2 Hypertension Hypothyroidism Breast Cancer PSH: - Diagnostic angiogram ___ ( study showed diffusely diseased left SFA and popliteal arteries, occluded L Posterior tibial, occluded peroneal, occluded L AT with reconstitution as primary runoff to the foot) - Debridement of osteomyelitis with ___ ray resection ___ - Right above-knee popliteal to dorsalis pedis bypass with vein graft anatomically tunneled behind the knee using left cephalic vein graft - ___ - Right lower extremity angiogram - ___ - Angioplasty of the right peroneal artery - ___ - RLE Angiogram w/ iliac stent angioplasty - ___ - Renal Artery Stent - ___ - Right below knee popliteal-dorsalis pedis bypass - ___ - Bilateral Iliac Stents - ___ - Coronary artery bypass graft ___ - Left mastectomy - Tonsillectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. ___, It was a pleasure taking care of you here at ___ ___. You were admitted to our hospital for bypass surgery on your leg to improve the circulation to the wound on your left heel and allow healing. You were treated with IV antibiotics. We then did an angiogram and placed a stent in your left leg artery to improve circulation and promote healing. Please follow the recommendations below to ensure a speedy and uneventful recovery. Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions WHAT TO EXPECT: 1. It is normal to feel tired, this will last for ___ weeks •You should get up out of bed every day and gradually increase your activity each day •Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs •Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: •Elevate your leg above the level of your heart (use ___ pillows or a recliner) every ___ hours throughout the day and at night •Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time •You will probably lose your taste for food and lose some weight •Eat small frequent meals •It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing •To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication MEDICATION: •Take Plavix/pradaxa as instructed ACTIVITIES: •You should get up every day, get dressed and walk •You should gradually increase your activity •You may up and down stairs, go outside and/or ride in a car •Increase your activities as you can tolerate- do not do too much right away! •No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit •You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry •Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed Followup Instructions: ___
[ "I70244", "I7092", "E1140", "N390", "L97429", "I10", "Z89511", "I2510", "I252", "Z951", "Z955", "E039", "R9431", "Z853", "Z8673" ]
Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel / Sulfur / Nsaids / Ace Inhibitors / Statins-Hmg-Coa Reductase Inhibitors / Niacin Chief Complaint: Non healing left heel wound. Major Surgical or Invasive Procedure: [MASKED]: Left femoral-anterior tibial bypass using polytetrafluoroethylene graft. History of Present Illness: [MASKED] year old woman with a vascular history of a right below-the-knee amputation on [MASKED] returns to clinic with concerns of breakdown on the left heel. Additionally, she reports waking up in the middle of the night with pain in her left leg relieved by dangling her leg over the side of the bed. Angio showed occluded SFA and pop disease and left posterior tibial and peroneal arteries . THe left anterior tibial artery is occluded but reconstituted as the primary runoff to the foot. The left dorsalis pedis is patent. She presents for elective bypass with PTFE as no vein is available. Past Medical History: PMH: CAD/MI s/p CABG (last coronary DES [MASKED] for UA), PVD, T2DM, HTN, hypothyroidism, breast CA PSH: - Diagnostic angiogram [MASKED] ( study showed diffusely diseased left SFA and popliteal arteries, occluded L [MASKED], occluded peroneal, occluded L AT with reconstitution as primary runoff to the foot) - Debridement of osteomyelitis with [MASKED] ray resection [MASKED] - Right above-knee popliteal to dorsalis pedis bypass with vein graft anatomically tunneled behind the knee using left cephalic vein graft - [MASKED] - Right lower extremity angiogram - [MASKED] - Angioplasty of the right peroneal artery - [MASKED] - RLE Angiogram w/ iliac stent angioplasty - [MASKED] - Renal Artery Stent - [MASKED] - Right BK pop-DP bypass - [MASKED] - Bilateral Iliac Stents - [MASKED] - CABG [MASKED] - Left mastectomy - Tonsillectomy Social History: [MASKED] Family History: No family history of vascular disease Physical Exam: Vitals: T 98.5 HR 76 BP 139/54 RR 14 Sat 100% RA Physical Exam: Gen: Awake and alert CV: Regular rate and rhythm Resp: CTAB Abd: Soft, nontender, nondistended Ext: RLE - femoral palpable, popliteal dopplerable, s/p BKA LLE - femoral palpable, popliteal dopplerable, DP palpable [MASKED] dopplerable. Right stump is well healed. There is no edema. Incision edges are well approximated. Left lower extremity, well healing heel ulcer, significantly improved from previous. No eschar noted. No surrounding erythema and tenderness. No discharge or odor noted. Left Leg does not appear swollen. Pertinent Results: [MASKED] 07:15PM GLUCOSE-240* UREA N-15 CREAT-0.9 SODIUM-140 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18 [MASKED] 07:15PM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-1.7 [MASKED] 07:15PM WBC-11.2* RBC-3.79* HGB-10.7* HCT-34.8 MCV-92 MCH-28.2 MCHC-30.7* RDW-16.6* RDWSD-55.2* [MASKED] 07:15PM PLT COUNT-402* [MASKED] 07:15PM [MASKED] PTT-27.7 [MASKED] Echocardiogram Date/Time: [MASKED] at 15:43 [MASKED] MD: [MASKED], MD [MASKED] Type: Portable TTE (Complete) Sonographer: [MASKED], [MASKED] Doppler: Full Doppler and color Doppler [MASKED] Location: [MASKED] Contrast: None Tech Quality: Adequate Tape #: Machine: Q-2 Vivid Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm Left Atrium - Volume: *68 ml < 40 ml Left Atrium - [MASKED] Volume/BSA: *47 ml/m2 <= 28 ml/m2 Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.4 cm Left Ventricle - Fractional Shortening: *0.17 >= 0.29 Left Ventricle - Ejection Fraction: 30% >= 55% Left Ventricle - Stroke Volume: 43 ml/beat Left Ventricle - Cardiac Output: 3.32 L/min Left Ventricle - Cardiac Index: 2.30 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.03 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *32 < 13 Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 15 Aortic Valve - LVOT diam: 1.9 cm Mitral Valve - E Wave: 1.6 m/sec Mitral Valve - E Wave deceleration time: 168 ms 140-250 ms TR Gradient (+ RA = PASP): *59 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Mild [MASKED]. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Moderate-severe global left ventricular hypokinesis. TDI E/e' >13, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Borderline normal RV systolic function. [Intrinsic RV systolic function likely more depressed given the severity of TR]. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. [MASKED] (2+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. Severe [4+] TR. Severe PA systolic hypertension. Given severity of TR, PASP may be underestimated due to elevated RA pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. Brief Hospital Course: [MASKED] year old woman with a vascular history of a right below-the-knee amputation on [MASKED] returns to clinic with concerns of breakdown on the left heel. Additionally, she reports waking up in the middle of the night with pain in her left leg relieved by dangling her leg over the side of the bed. Angio showed diffuse SFA and pop disease and occlusions of left posterior tibial and peroneal arteries . THe left anterior tibial artery is occluded but reconstituted as the primary runoff to the foot. She presents for elective bypass with PTFE as no vein is available. The OR course was uncomplicated. On POD #2, she was noted to have ST depressions on her bedside monitor, confirmed by 12 lead. She was asymptomatic, trops were negative. Given her history of recent DES in SVG, cardiology was consulted. ECHO showed 30% EF. Low dose metrop was added and this was titrated as tolerated to 25mg TID. Per cardiology recommendations, diltiazem was discontinued. The patient tolerated this appropriately with SBPs remaining 120-30s and HR no lower than 60. Postoperatively, the patient was found to have urinary pain/urgency thus UA/UCx were sent which showed UTI. On [MASKED] the patient was started on CTX and this was changed to po Macrobid on [MASKED]. On [MASKED] the Allergy service was consulted regarding the patient's ASA allergy and indicated that the patient's clinical history was not compatible with a true aspirin allergy. Allergy service also recommended a trial of 81mg ASA which was completed without issue. The patient experienced no reactive symptoms and was thus discharged on aspirin 81mg qd along Plavix, Pradaxa, Macrobid (x3 days for UTI) and other home medications. Medications on Admission: (See admission record) Discharge Medications: 1. Dabigatran Etexilate 150 mg PO BID RX *dabigatran etexilate [Pradaxa] 150 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN prn pain, fever RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth four times a day Disp #*60 Tablet Refills:*0 3. Aspirin 81 mg PO ONCE Duration: 1 Dose RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 4. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 5. Gabapentin 300 mg PO TID 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 3 Days RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth twice a day Disp #*6 Capsule Refills:*0 8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN pain Duration: 7 Days RX *oxycodone [Roxicodone] 5 mg [MASKED] tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills:*0 9. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 10. Metoprolol Tartrate 25 mg PO TID Hold for SBP<110 Hold for HR<60 RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 11. Calcium Carbonate 500 mg PO QID:PRN indigestion Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PMH: Coronary artery disease Peripheral vascular disease s/p CABG (last coronary Drug eluting stent [MASKED], Diabetes Type 2 Hypertension Hypothyroidism Breast Cancer PSH: - Diagnostic angiogram [MASKED] ( study showed diffusely diseased left SFA and popliteal arteries, occluded L Posterior tibial, occluded peroneal, occluded L AT with reconstitution as primary runoff to the foot) - Debridement of osteomyelitis with [MASKED] ray resection [MASKED] - Right above-knee popliteal to dorsalis pedis bypass with vein graft anatomically tunneled behind the knee using left cephalic vein graft - [MASKED] - Right lower extremity angiogram - [MASKED] - Angioplasty of the right peroneal artery - [MASKED] - RLE Angiogram w/ iliac stent angioplasty - [MASKED] - Renal Artery Stent - [MASKED] - Right below knee popliteal-dorsalis pedis bypass - [MASKED] - Bilateral Iliac Stents - [MASKED] - Coronary artery bypass graft [MASKED] - Left mastectomy - Tonsillectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [MASKED], It was a pleasure taking care of you here at [MASKED] [MASKED]. You were admitted to our hospital for bypass surgery on your leg to improve the circulation to the wound on your left heel and allow healing. You were treated with IV antibiotics. We then did an angiogram and placed a stent in your left leg artery to improve circulation and promote healing. Please follow the recommendations below to ensure a speedy and uneventful recovery. Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions WHAT TO EXPECT: 1. It is normal to feel tired, this will last for [MASKED] weeks •You should get up out of bed every day and gradually increase your activity each day •Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs •Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: •Elevate your leg above the level of your heart (use [MASKED] pillows or a recliner) every [MASKED] hours throughout the day and at night •Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time •You will probably lose your taste for food and lose some weight •Eat small frequent meals •It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing •To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication MEDICATION: •Take Plavix/pradaxa as instructed ACTIVITIES: •You should get up every day, get dressed and walk •You should gradually increase your activity •You may up and down stairs, go outside and/or ride in a car •Increase your activities as you can tolerate- do not do too much right away! •No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit •You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry •Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed Followup Instructions: [MASKED]
[]
[ "N390", "I10", "I2510", "I252", "Z951", "Z955", "E039", "Z8673" ]
[ "I70244: Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot", "I7092: Chronic total occlusion of artery of the extremities", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "N390: Urinary tract infection, site not specified", "L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity", "I10: Essential (primary) hypertension", "Z89511: Acquired absence of right leg below knee", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "E039: Hypothyroidism, unspecified", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "Z853: Personal history of malignant neoplasm of breast", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,039,302
28,794,550
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel / Sulfur / Nsaids / Ace Inhibitors / Statins-Hmg-Coa Reductase Inhibitors / Niacin / minocycline Attending: ___. Chief Complaint: LLE wound dehiscence, right arm edema and pain. Major Surgical or Invasive Procedure: None History of Present Illness: ___ sp left fem to anterior tibial bypass graft with PTFE on ___. for nonhealing left heel ulcer. She presents to clinic with acute right arm pain. The arm is ecchymotic from the elbow to the wrist, extremely tender to touch. She has been unable to straighten the arm. She says that there was a PICC line in that arm and they started IV antibiotics recently for her leg. She has positive sensation and motion in her hand and a palpable ulnar and radial pulse. Additionally, her left lower extremity has woody edema, cool to touch. She has strongly dopplerable ___ and DP signals but the left lateral calf wound is tense, dehisced draining serous fluid. Past Medical History: PMH: CAD/MI s/p CABG (last coronary DES ___ for UA), PVD, T2DM, HTN, hypothyroidism, breast CA PSH: - left fem to anterior tibial bypass graft with PTFE on ___ for nonhealing left heel ulcer - Right BKA ___ - Debridement of osteomyelitis with ___ ray resection ___ - Right above-knee popliteal to dorsalis pedis bypass with vein graft anatomically tunneled behind the knee using left cephalic vein graft - ___ - Right lower extremity angiogram - ___ - Angioplasty of the right peroneal artery - ___ - RLE Angiogram w/ iliac stent angioplasty - ___ - Renal Artery Stent - ___ - Right BK pop-DP bypass - ___ - Bilateral Iliac Stents - ___ - CABG ___ - Left mastectomy - Tonsillectomy Social History: Physical Exam: Vital signs 97.3 75 157/60 20 100% General: A&O x3, in NAD. HEENT: NC/AT. PERRLA. EOMI. No cervical lymphadenopathy, no bruit, no pallor, neck supple. P: Breathing comfortably on RA. CTAB. CV: RRR. Abd: Soft, NT, ND. Torso: Left Mastectomy scar. Extremities: RUE: bruised, tender to touch, unable to straighten the arm entirely although improved from discharge. ROM hand normal. Radial and ulnar pulse palpable. LUE: edematous, redness, scar in medial aspect of arm. RLE: Her stump is well healed, no edema LLE: no edema, soft, dehiscenced lateral surgical incision now superficial and dry, no erythema, drainage or signs of infection. Left heel dry eschar. Dopplerable DP and ___ pulses. Foot warm, well perfused. Pertinent Results: ___ 05:32AM BLOOD WBC-12.1* RBC-2.84* Hgb-8.3* Hct-27.4* MCV-97 MCH-29.2 MCHC-30.3* RDW-17.3* RDWSD-60.6* Plt ___ ___ 06:28AM BLOOD Glucose-101* UreaN-32* Creat-0.9 Na-134 K-4.5 Cl-102 HCO3-21* AnGap-16 ___ 06:10AM BLOOD ALT-18 AST-30 AlkPhos-129* TotBili-0.7 Right arm Xray. The bony structures and joint spaces are essentially within normal limits without evidence of posterior fat pad to indicate joint effusion. Right arm venous duplex: No evidence of deep vein thrombosis in the right upper extremity. Left Lower Extremity Duplex: The left PTFE fem anterior tibial bypass graft is widely patent. Brief Hospital Course: Mrs. ___ presented to the ___ clinic on ___ with dehiscence of LLE wound above her PTFE graft site and RUE swelling, pain and redness, as well as confusion. She was directly admitted to the floor, where she was started on broad spectrum antibiotics (Vancomycin, Ciprofloxacin, Flagyl) and IVF. A LLE Duplex US showed a widely patent graft. A RUE US showed no DVT or thrombophlebitis. RUE X- rays showed no signs of bony injury. Orthopedic hand surgery recommended an OT consult. Range of motion improved as edema and pain subsided. We feel these symptoms are related to a PICC that was placed prior to admission. Wound culture of her LLE grew MRSA sensitive to Vancomycin. A UA and UCx was negative. Blood culture were also negative. A temporary IJ line was placed for IV antibiotics and IV access. Her IV antibiotics were switched to minocycline. Due to itching, Minocycline was converted to PO Bactrim on ___. Unfortunately, she was started on Benadryl which altered her mental status making her extremely somnolent. PO Bactrim was given on discharge for a 1 week course to end ___. LLE Erythema continued to decrease. At the time of discharge, she was doing well, afebrile with stable vital signs. She is now at her baseline mental status, pain free without signs of infection. She was deemed ready for discharge to her nursing home. We will follow her in clinic in 2 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO ONCE 2. Clopidogrel 75 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN pain 6. Metoprolol Tartrate 25 mg PO TID 7. Dabigatran Etexilate 150 mg PO BID 8. Docusate Sodium 100 mg PO BID 9. CefePIME 2 g IV Q8H 10. Vancomycin 1000 mg IV Q 12H 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 81 mg PO ONCE Duration: 1 Dose 2. Clopidogrel 75 mg PO DAILY 3. Dabigatran Etexilate 150 mg PO BID 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 300 mg PO TID 6. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Metoprolol Tartrate 25 mg PO TID 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth Q4 Disp #*30 Tablet Refills:*0 10. Sarna Lotion 1 Appl TP QID:PRN pruritis 11. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Superficial wound infection left leg Idiopathic LUE swelling and pain s/p PICC line Altered mental status Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms ___ You were admitted to the hospital from our clinic secondary to an extremely painful, bruised and swollen right arm and a swollen, infected left calf surgical incision that had opened slightly. We started intravenous antibiotics and ACE wrapped and elevated your leg which quickly improved the appearance of the wound. We also did a venous ultrasound of your right arm that showed no blood clot. We also hand the orthopedic team which specializes in hands see you for the pain and swelling. Xrays were negative and they felt the pain was from a malfunction of the PICC you had in that arm. The swelling and pain improved. Unfortunately, the pain and itch medication you required altered your mental status. We needed to watch you closely for several days. With time your mental status improved and you are now pain free and back to baseline. Followup Instructions: ___
[ "T8131XA", "L97429", "E118", "L03116", "I2510", "Z951", "I252", "I10", "E039", "Z853", "Z89511", "Z87891", "B9562", "R4182", "T450X5A", "L298", "M7989", "Y839", "Y929" ]
Allergies: Lipitor / Prempro / Fosamax / Aspirin / Tamoxifen / Zetia / Naproxen / Rofecoxib / Celebrex / Atenolol / Metoprolol / Glucophage / Lotrel / Sulfur / Nsaids / Ace Inhibitors / Statins-Hmg-Coa Reductase Inhibitors / Niacin / minocycline Chief Complaint: LLE wound dehiscence, right arm edema and pain. Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] sp left fem to anterior tibial bypass graft with PTFE on [MASKED]. for nonhealing left heel ulcer. She presents to clinic with acute right arm pain. The arm is ecchymotic from the elbow to the wrist, extremely tender to touch. She has been unable to straighten the arm. She says that there was a PICC line in that arm and they started IV antibiotics recently for her leg. She has positive sensation and motion in her hand and a palpable ulnar and radial pulse. Additionally, her left lower extremity has woody edema, cool to touch. She has strongly dopplerable [MASKED] and DP signals but the left lateral calf wound is tense, dehisced draining serous fluid. Past Medical History: PMH: CAD/MI s/p CABG (last coronary DES [MASKED] for UA), PVD, T2DM, HTN, hypothyroidism, breast CA PSH: - left fem to anterior tibial bypass graft with PTFE on [MASKED] for nonhealing left heel ulcer - Right BKA [MASKED] - Debridement of osteomyelitis with [MASKED] ray resection [MASKED] - Right above-knee popliteal to dorsalis pedis bypass with vein graft anatomically tunneled behind the knee using left cephalic vein graft - [MASKED] - Right lower extremity angiogram - [MASKED] - Angioplasty of the right peroneal artery - [MASKED] - RLE Angiogram w/ iliac stent angioplasty - [MASKED] - Renal Artery Stent - [MASKED] - Right BK pop-DP bypass - [MASKED] - Bilateral Iliac Stents - [MASKED] - CABG [MASKED] - Left mastectomy - Tonsillectomy Social History: Physical Exam: Vital signs 97.3 75 157/60 20 100% General: A&O x3, in NAD. HEENT: NC/AT. PERRLA. EOMI. No cervical lymphadenopathy, no bruit, no pallor, neck supple. P: Breathing comfortably on RA. CTAB. CV: RRR. Abd: Soft, NT, ND. Torso: Left Mastectomy scar. Extremities: RUE: bruised, tender to touch, unable to straighten the arm entirely although improved from discharge. ROM hand normal. Radial and ulnar pulse palpable. LUE: edematous, redness, scar in medial aspect of arm. RLE: Her stump is well healed, no edema LLE: no edema, soft, dehiscenced lateral surgical incision now superficial and dry, no erythema, drainage or signs of infection. Left heel dry eschar. Dopplerable DP and [MASKED] pulses. Foot warm, well perfused. Pertinent Results: [MASKED] 05:32AM BLOOD WBC-12.1* RBC-2.84* Hgb-8.3* Hct-27.4* MCV-97 MCH-29.2 MCHC-30.3* RDW-17.3* RDWSD-60.6* Plt [MASKED] [MASKED] 06:28AM BLOOD Glucose-101* UreaN-32* Creat-0.9 Na-134 K-4.5 Cl-102 HCO3-21* AnGap-16 [MASKED] 06:10AM BLOOD ALT-18 AST-30 AlkPhos-129* TotBili-0.7 Right arm Xray. The bony structures and joint spaces are essentially within normal limits without evidence of posterior fat pad to indicate joint effusion. Right arm venous duplex: No evidence of deep vein thrombosis in the right upper extremity. Left Lower Extremity Duplex: The left PTFE fem anterior tibial bypass graft is widely patent. Brief Hospital Course: Mrs. [MASKED] presented to the [MASKED] clinic on [MASKED] with dehiscence of LLE wound above her PTFE graft site and RUE swelling, pain and redness, as well as confusion. She was directly admitted to the floor, where she was started on broad spectrum antibiotics (Vancomycin, Ciprofloxacin, Flagyl) and IVF. A LLE Duplex US showed a widely patent graft. A RUE US showed no DVT or thrombophlebitis. RUE X- rays showed no signs of bony injury. Orthopedic hand surgery recommended an OT consult. Range of motion improved as edema and pain subsided. We feel these symptoms are related to a PICC that was placed prior to admission. Wound culture of her LLE grew MRSA sensitive to Vancomycin. A UA and UCx was negative. Blood culture were also negative. A temporary IJ line was placed for IV antibiotics and IV access. Her IV antibiotics were switched to minocycline. Due to itching, Minocycline was converted to PO Bactrim on [MASKED]. Unfortunately, she was started on Benadryl which altered her mental status making her extremely somnolent. PO Bactrim was given on discharge for a 1 week course to end [MASKED]. LLE Erythema continued to decrease. At the time of discharge, she was doing well, afebrile with stable vital signs. She is now at her baseline mental status, pain free without signs of infection. She was deemed ready for discharge to her nursing home. We will follow her in clinic in 2 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO ONCE 2. Clopidogrel 75 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Levothyroxine Sodium 75 mcg PO DAILY 5. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN pain 6. Metoprolol Tartrate 25 mg PO TID 7. Dabigatran Etexilate 150 mg PO BID 8. Docusate Sodium 100 mg PO BID 9. CefePIME 2 g IV Q8H 10. Vancomycin 1000 mg IV Q 12H 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 81 mg PO ONCE Duration: 1 Dose 2. Clopidogrel 75 mg PO DAILY 3. Dabigatran Etexilate 150 mg PO BID 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 300 mg PO TID 6. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Metoprolol Tartrate 25 mg PO TID 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth Q4 Disp #*30 Tablet Refills:*0 10. Sarna Lotion 1 Appl TP QID:PRN pruritis 11. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Superficial wound infection left leg Idiopathic LUE swelling and pain s/p PICC line Altered mental status Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms [MASKED] You were admitted to the hospital from our clinic secondary to an extremely painful, bruised and swollen right arm and a swollen, infected left calf surgical incision that had opened slightly. We started intravenous antibiotics and ACE wrapped and elevated your leg which quickly improved the appearance of the wound. We also did a venous ultrasound of your right arm that showed no blood clot. We also hand the orthopedic team which specializes in hands see you for the pain and swelling. Xrays were negative and they felt the pain was from a malfunction of the PICC you had in that arm. The swelling and pain improved. Unfortunately, the pain and itch medication you required altered your mental status. We needed to watch you closely for several days. With time your mental status improved and you are now pain free and back to baseline. Followup Instructions: [MASKED]
[]
[ "I2510", "Z951", "I252", "I10", "E039", "Z87891", "Y929" ]
[ "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter", "L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity", "E118: Type 2 diabetes mellitus with unspecified complications", "L03116: Cellulitis of left lower limb", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "I252: Old myocardial infarction", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "Z853: Personal history of malignant neoplasm of breast", "Z89511: Acquired absence of right leg below knee", "Z87891: Personal history of nicotine dependence", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "R4182: Altered mental status, unspecified", "T450X5A: Adverse effect of antiallergic and antiemetic drugs, initial encounter", "L298: Other pruritus", "M7989: Other specified soft tissue disorders", "Y839: Surgical procedure, unspecified as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]
10,039,393
20,123,798
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Percocet / Motrin / crab and lobster / shellfish derived Attending: ___. Chief Complaint: back pain Major Surgical or Invasive Procedure: ___ L5-S1 ALIF ___ L4-S1 PLF History of Present Illness: Patient returns to the office for follow-up. Since his last visit, he states his back pain has gotten worse. He has a known L5-S1 spondylolysis from a previous back injury. He was doing well with SI joint injections and lumbar ESI. He has pain with increase activity. The is experiencing more leg pain and discomfort. He had an MRI showing lumbar spodylosis stable if not worse spondylolysis at L5/S1. His pain shoots down lateral aspects of his legs. He denies any weakness or paresthesias. He has tried all forms of therapy without relief. Past Medical History: high blood pressure, asthma, depression and arthritis. Social History: ___ Family History: noncontributory Physical Exam: GENERAL APPEARANCE: in no acute distress, well developed, well nourished. NECK/THYROID: neck supple, full range of motion, no cervical lymphadenopathy. SKIN: warm and dry. HEART: no murmurs, regular rate and rhythm, S1, S2 normal. LUNGS: clear to auscultation bilaterally. ABDOMEN: normal, bowel sounds present, soft, nontender, nondistended. MUSCULOSKELETAL: cervical spine normal, full range of motion, lumbosacral spine normal, no swelling or deformity. EXTREMITIES: Gross motor strength is intact in terms of deltoid, biceps, triceps, wrist extension/flexion, finger extension/flexion and intrinsics, no clubbing, cyanosis, or edema. Postop General: NAD. AAO x3. Lying awake in bed. Skin: warm, dry, no rash CV: RRR, s1 and S2 nl Pulm: normal effort, lungs are clear Abd: soft, NT/ND, + BS Wound: C/D/I. No swelling, redness, or warmth Extremities: calves are soft, no edema Neurologic: PERRL. Face symmetrical. Speech clear and fluent. Tongue ML. EOMs intact. Negative pronator drift. Normal tone and bulk universally. Motor Strength: Delt Bi Tri BR WF/WE HI Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 IP Quad Ham TA Gas ___ Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: intact to light touch Brief Hospital Course: Patient was admitted to Orthopedic Spine Service on ___ and underwent the above stated procedure(s) on consecutive days. Patient tolerated the procedures well without complication. Please review dictated operative report for details. Patient was extubated without incident and was transferred to PAC/U then floor in stable condition. During the patient's course ___ 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 in routine fashion and patient voided without incident. Lumbar epidural catheter was removed on POD#1. Hemovac was removed in routine fashion once the output per 8 hours became minimal. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's. Hospital course was otherwise unremarkable. Now, Day of Discharge, patient is afebrile, VSS, and neuro intact with improvement in sciatica. Patient tolerated a good oral diet and pain was controlled on oral pain medications. Patient ambulated without issues. Patient's wound is clean, dry and intact. Patient noted improvement in radicular pain. Patient is set for discharge to home in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Gabapentin 300 mg PO TID 3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 4. melatonin 3 mg oral QHS:PRN insomnia 5. Pantoprazole 40 mg PO Q24H 6. PARoxetine 10 mg PO DAILY Discharge Medications: 1. Cyclobenzaprine 5 mg PO Q8H RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID constipation 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX *hydromorphone 2 mg 1 tablet(s) by mouth Q4-6h Disp #*90 Tablet Refills:*0 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 6. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 7. Gabapentin 300 mg PO TID 8. melatonin 3 mg oral QHS:PRN insomnia 9. Pantoprazole 40 mg PO Q24H 10. PARoxetine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: lumbar spondylolisthesis lumbar spondylolysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Lumbar Decompression With Fusion: You have undergone the following operation: Lumbar Decompression With Fusion Follow-up Appointments •After you are discharged from the hospital and settled at home or rehab, please make sure you have two appointments: 1.2 week post-operative wound check visit after surgery 2.a post-operative visit with your surgeon for ___ weeks after surgery. •You can reach the office at ___ and ask to speak with your surgeon’s surgical coordinator/staff to schedule or confirm your appointments Wound Care •If not already done in the hospital, remove the incision dressing on day 2 after surgery. •You may shower day 3 after surgery. Starting on this ___ day, you should gently cleanse the incision and surrounding area daily with mild soap and water, patting it dry when you are finished. •Some swelling and bruising around the incision is normal. Your muscles have been cut, separated and sewn back together as part of your surgical procedure. You will leave the hospital with back discomfort from the surgical incision. As you become more active and the incision and muscles continue to heal, the swelling and pain will decrease. •Have someone look at the incision daily for 2 weeks. Call the surgeon’s office if you notice any of the following: Increased redness along the length of the incision Increased swelling of the area around your incision Drainage from the incision Weakness of your extremities greater than before surgery Loss of bowel or bladder control Development of severe headache Leg swelling or calf tenderness Fever above 101.5 •Do not soak or immerse your incision in water for 1 month. For example, no tub baths, swimming pools or jacuzzi. Activity Guidelines •You MAY be given a RIGID BRACE that you will wear whenever sitting up, standing, or walking. You will wear it for ___ weeks after surgery. See the last page of these instructions for details on wearing the brace. •Avoid strenuous activity, bending, pushing or holding your breath. For example, do not vacuum, wash the car, do large loads of laundry, or walk the dog until your follow-up visit with your surgeon. •Avoid heavy lifting. Do not lift anything over ___ pounds for the first few weeks that you are home from the hospital. •Increase your activities a little each day. Walking is good exercise. Plan rest periods and try to avoid hills if possible. Remember, exercise should not increase your back pain or cause leg pain. •Reaching: When you have to reach things on or near the floor, always squat (bending the knees), rather than bending over at the waist. •Lying down: when lying on your back, you may find that a pillow under the knees is more comfortable. When on your side, a pillow between the knees will help keep your back straight. •Sitting: should be limited to 40-60 minutes at a time for the first week. Slowly increase the amount of sitting time, remembering that it should not increase your back pain. •Stairs: use stairs only once or twice a day for the first week, or as directed by the surgeon. Climb steps one at a time, placing both feet on the step before moving to the next one. •Driving: you should not drive for ___ weeks after surgery. You should discuss driving with your surgeon /nurse practitioner /physician ___. You may ride in a car for short distances. When in the car, avoid sitting in one position for too long. If you must take long car rides, do not ride for more than 60 minutes without taking a break to stretch (walk for several minutes and change position.). •Sexual activity: you may resume sexual activity ___ weeks after surgery (avoiding pain or stress on the back). •Reduction in symptoms: patients who have experienced back and radiating leg pain for a short window of time before surgery should anticipate a significant decrease in pre-operative symptoms. If the pain has been present for a longer period (months to years), the pre-operative symptoms will recover on a more gradual basis week by week. It is not practical to expect immediate relief of symptoms. Routinely, pain will gradually improve on a weekly basis, weakness on a monthly basis, and numbness in a range of 6 months to ___ year. Physical Therapy •Outpatient Physical Therapy (if appropriate) will not begin until after your post-operative visit with your surgeon. A prescription is needed for formal outpatient therapy. •You may be given simple stretching exercises or a prescription for formal outpatient physical therapy, based on what your needs are after surgery. Medications •You will be given prescriptions for pain medications and stool softeners upon discharge from the hospital. •Pain medications should be taken as prescribed by your surgeon or nurse practitioner/ physician ___. You are allowed to gradually reduce the number of pills you take when the pain begins to subside. •If you are taking more than the recommended dose, please contact the office to discuss this with a practitioner ___ medication may need to be increased or changed). •Constipation: Pain medications (narcotics) may cause constipation. It is important to be aware of your bowel habits so you ___ develop severe constipation that cannot be treated with simple, over the counter laxatives. Most prescription pain medications cannot be called into the pharmacy for renewal. The following are 2 options you may explore to obtain a renewal of your narcotic medications: 1.Call the office ___ days before your prescription runs out and speak with office staff about mailing a prescription to your home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS) 2.Call the office 24 hours in advance and speak with our office staff about coming into the office to pick up a prescription. •If you continue to require medications, you may be referred to a pain management specialist or your medical doctor for ongoing management of your pain medications •Avoid NSAIDS for ___ weeks post-operative. These medications include, but are not limited to the following: 1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam, Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin, Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen, Tolectin, Toradol, Trilisate, Voltarin Blood Clots in the Leg 1.It is not uncommon for patients who recently had surgery to develop blood clots in leg veins. •Symptoms include low-grade fever, and/or redness, swelling, tenderness, and/or an •aching/cramping pain in your calf. •You should call your doctor immediately if you have these symptoms. •To prevent blood clots in legs, try walking and/ or pumping ankles several times during the day. •If the blood clot breaks free from the leg vein, it can travel to the lungs and cause severe breathing difficulty and/or chest pain. If you experience this, call ___ immediately. Questions •Any questions may be directed to your surgeon or physician ___. 1.During normal business hours (8:30am- 5:00pm), you can call the office directly at ___. Turn around time for a phone call is 24 hours. After normal business hours, you can call the on-call service and we will get back to you the next business day. •If you are calling with an urgent medical issue, please tell the coordinator that it is an “urgent issue” and needs to be discussed in less than 24 hours (i.e. pain unrelieved with medications, wound breakdown/infection, or new neurological symptoms). Lumbar Corset or (TLSO) Brace Guidelines •You MAY have been given a rigid brace that you will wear for ___ weeks after surgery. •You should put on your brace as you have been instructed by the orthotist (brace maker). Instructions will be reviewed in the hospital by the nursing staff and Physical Therapist. •It is a good idea to start practicing with your brace before surgery (putting it on/taking it off, sitting, standing, walking, and climbing steps with the brace) so you can assist with your post-operative care in the hospital. •Keep the name and phone number of the person who fitted and dispensed your brace close by in case you need to have the brace checked and/or adjusted. •You should always have a barrier between your surgical incision and the brace. For example, you may want to put on a light t-shirt and then the brace before getting dressed for the day. •During periods of rest, take off the brace and expose the incision to the air by lying on your side for a few hours. This will reduce the chance of your wound breaking down. 1.The brace must be worn at all times with the following 3 exceptions: 1.Lying flat in bed during a rest period or at night to sleep. 2.Getting out of bed at night to go to the bathroom, returning to bed immediately when you are finished. 3.Showering. You may wish to use a shower chair to help prevent bending/twisting while bathing. You should have someone help wash your back and legs. Followup Instructions: ___
[ "M4807", "M5117", "M4317", "I10", "J45909", "F329", "Z96651", "Z8711", "Z961" ]
Allergies: Percocet / Motrin / crab and lobster / shellfish derived Chief Complaint: back pain Major Surgical or Invasive Procedure: [MASKED] L5-S1 ALIF [MASKED] L4-S1 PLF History of Present Illness: Patient returns to the office for follow-up. Since his last visit, he states his back pain has gotten worse. He has a known L5-S1 spondylolysis from a previous back injury. He was doing well with SI joint injections and lumbar ESI. He has pain with increase activity. The is experiencing more leg pain and discomfort. He had an MRI showing lumbar spodylosis stable if not worse spondylolysis at L5/S1. His pain shoots down lateral aspects of his legs. He denies any weakness or paresthesias. He has tried all forms of therapy without relief. Past Medical History: high blood pressure, asthma, depression and arthritis. Social History: [MASKED] Family History: noncontributory Physical Exam: GENERAL APPEARANCE: in no acute distress, well developed, well nourished. NECK/THYROID: neck supple, full range of motion, no cervical lymphadenopathy. SKIN: warm and dry. HEART: no murmurs, regular rate and rhythm, S1, S2 normal. LUNGS: clear to auscultation bilaterally. ABDOMEN: normal, bowel sounds present, soft, nontender, nondistended. MUSCULOSKELETAL: cervical spine normal, full range of motion, lumbosacral spine normal, no swelling or deformity. EXTREMITIES: Gross motor strength is intact in terms of deltoid, biceps, triceps, wrist extension/flexion, finger extension/flexion and intrinsics, no clubbing, cyanosis, or edema. Postop General: NAD. AAO x3. Lying awake in bed. Skin: warm, dry, no rash CV: RRR, s1 and S2 nl Pulm: normal effort, lungs are clear Abd: soft, NT/ND, + BS Wound: C/D/I. No swelling, redness, or warmth Extremities: calves are soft, no edema Neurologic: PERRL. Face symmetrical. Speech clear and fluent. Tongue ML. EOMs intact. Negative pronator drift. Normal tone and bulk universally. Motor Strength: Delt Bi Tri BR WF/WE HI Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 IP Quad Ham TA Gas [MASKED] Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: intact to light touch Brief Hospital Course: Patient was admitted to Orthopedic Spine Service on [MASKED] and underwent the above stated procedure(s) on consecutive days. Patient tolerated the procedures well without complication. Please review dictated operative report for details. Patient was extubated without incident and was transferred to PAC/U then floor in stable condition. During the patient's course [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 in routine fashion and patient voided without incident. Lumbar epidural catheter was removed on POD#1. Hemovac was removed in routine fashion once the output per 8 hours became minimal. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's. Hospital course was otherwise unremarkable. Now, Day of Discharge, patient is afebrile, VSS, and neuro intact with improvement in sciatica. Patient tolerated a good oral diet and pain was controlled on oral pain medications. Patient ambulated without issues. Patient's wound is clean, dry and intact. Patient noted improvement in radicular pain. Patient is set for discharge to home in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Gabapentin 300 mg PO TID 3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 4. melatonin 3 mg oral QHS:PRN insomnia 5. Pantoprazole 40 mg PO Q24H 6. PARoxetine 10 mg PO DAILY Discharge Medications: 1. Cyclobenzaprine 5 mg PO Q8H RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID constipation 3. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *hydromorphone 2 mg 1 tablet(s) by mouth Q4-6h Disp #*90 Tablet Refills:*0 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 6. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 7. Gabapentin 300 mg PO TID 8. melatonin 3 mg oral QHS:PRN insomnia 9. Pantoprazole 40 mg PO Q24H 10. PARoxetine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: lumbar spondylolisthesis lumbar spondylolysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Lumbar Decompression With Fusion: You have undergone the following operation: Lumbar Decompression With Fusion Follow-up Appointments •After you are discharged from the hospital and settled at home or rehab, please make sure you have two appointments: 1.2 week post-operative wound check visit after surgery 2.a post-operative visit with your surgeon for [MASKED] weeks after surgery. •You can reach the office at [MASKED] and ask to speak with your surgeon’s surgical coordinator/staff to schedule or confirm your appointments Wound Care •If not already done in the hospital, remove the incision dressing on day 2 after surgery. •You may shower day 3 after surgery. Starting on this [MASKED] day, you should gently cleanse the incision and surrounding area daily with mild soap and water, patting it dry when you are finished. •Some swelling and bruising around the incision is normal. Your muscles have been cut, separated and sewn back together as part of your surgical procedure. You will leave the hospital with back discomfort from the surgical incision. As you become more active and the incision and muscles continue to heal, the swelling and pain will decrease. •Have someone look at the incision daily for 2 weeks. Call the surgeon’s office if you notice any of the following: Increased redness along the length of the incision Increased swelling of the area around your incision Drainage from the incision Weakness of your extremities greater than before surgery Loss of bowel or bladder control Development of severe headache Leg swelling or calf tenderness Fever above 101.5 •Do not soak or immerse your incision in water for 1 month. For example, no tub baths, swimming pools or jacuzzi. Activity Guidelines •You MAY be given a RIGID BRACE that you will wear whenever sitting up, standing, or walking. You will wear it for [MASKED] weeks after surgery. See the last page of these instructions for details on wearing the brace. •Avoid strenuous activity, bending, pushing or holding your breath. For example, do not vacuum, wash the car, do large loads of laundry, or walk the dog until your follow-up visit with your surgeon. •Avoid heavy lifting. Do not lift anything over [MASKED] pounds for the first few weeks that you are home from the hospital. •Increase your activities a little each day. Walking is good exercise. Plan rest periods and try to avoid hills if possible. Remember, exercise should not increase your back pain or cause leg pain. •Reaching: When you have to reach things on or near the floor, always squat (bending the knees), rather than bending over at the waist. •Lying down: when lying on your back, you may find that a pillow under the knees is more comfortable. When on your side, a pillow between the knees will help keep your back straight. •Sitting: should be limited to 40-60 minutes at a time for the first week. Slowly increase the amount of sitting time, remembering that it should not increase your back pain. •Stairs: use stairs only once or twice a day for the first week, or as directed by the surgeon. Climb steps one at a time, placing both feet on the step before moving to the next one. •Driving: you should not drive for [MASKED] weeks after surgery. You should discuss driving with your surgeon /nurse practitioner /physician [MASKED]. You may ride in a car for short distances. When in the car, avoid sitting in one position for too long. If you must take long car rides, do not ride for more than 60 minutes without taking a break to stretch (walk for several minutes and change position.). •Sexual activity: you may resume sexual activity [MASKED] weeks after surgery (avoiding pain or stress on the back). •Reduction in symptoms: patients who have experienced back and radiating leg pain for a short window of time before surgery should anticipate a significant decrease in pre-operative symptoms. If the pain has been present for a longer period (months to years), the pre-operative symptoms will recover on a more gradual basis week by week. It is not practical to expect immediate relief of symptoms. Routinely, pain will gradually improve on a weekly basis, weakness on a monthly basis, and numbness in a range of 6 months to [MASKED] year. Physical Therapy •Outpatient Physical Therapy (if appropriate) will not begin until after your post-operative visit with your surgeon. A prescription is needed for formal outpatient therapy. •You may be given simple stretching exercises or a prescription for formal outpatient physical therapy, based on what your needs are after surgery. Medications •You will be given prescriptions for pain medications and stool softeners upon discharge from the hospital. •Pain medications should be taken as prescribed by your surgeon or nurse practitioner/ physician [MASKED]. You are allowed to gradually reduce the number of pills you take when the pain begins to subside. •If you are taking more than the recommended dose, please contact the office to discuss this with a practitioner [MASKED] medication may need to be increased or changed). •Constipation: Pain medications (narcotics) may cause constipation. It is important to be aware of your bowel habits so you [MASKED] develop severe constipation that cannot be treated with simple, over the counter laxatives. Most prescription pain medications cannot be called into the pharmacy for renewal. The following are 2 options you may explore to obtain a renewal of your narcotic medications: 1.Call the office [MASKED] days before your prescription runs out and speak with office staff about mailing a prescription to your home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS) 2.Call the office 24 hours in advance and speak with our office staff about coming into the office to pick up a prescription. •If you continue to require medications, you may be referred to a pain management specialist or your medical doctor for ongoing management of your pain medications •Avoid NSAIDS for [MASKED] weeks post-operative. These medications include, but are not limited to the following: 1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam, Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin, Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen, Tolectin, Toradol, Trilisate, Voltarin Blood Clots in the Leg 1.It is not uncommon for patients who recently had surgery to develop blood clots in leg veins. •Symptoms include low-grade fever, and/or redness, swelling, tenderness, and/or an •aching/cramping pain in your calf. •You should call your doctor immediately if you have these symptoms. •To prevent blood clots in legs, try walking and/ or pumping ankles several times during the day. •If the blood clot breaks free from the leg vein, it can travel to the lungs and cause severe breathing difficulty and/or chest pain. If you experience this, call [MASKED] immediately. Questions •Any questions may be directed to your surgeon or physician [MASKED]. 1.During normal business hours (8:30am- 5:00pm), you can call the office directly at [MASKED]. Turn around time for a phone call is 24 hours. After normal business hours, you can call the on-call service and we will get back to you the next business day. •If you are calling with an urgent medical issue, please tell the coordinator that it is an “urgent issue” and needs to be discussed in less than 24 hours (i.e. pain unrelieved with medications, wound breakdown/infection, or new neurological symptoms). Lumbar Corset or (TLSO) Brace Guidelines •You MAY have been given a rigid brace that you will wear for [MASKED] weeks after surgery. •You should put on your brace as you have been instructed by the orthotist (brace maker). Instructions will be reviewed in the hospital by the nursing staff and Physical Therapist. •It is a good idea to start practicing with your brace before surgery (putting it on/taking it off, sitting, standing, walking, and climbing steps with the brace) so you can assist with your post-operative care in the hospital. •Keep the name and phone number of the person who fitted and dispensed your brace close by in case you need to have the brace checked and/or adjusted. •You should always have a barrier between your surgical incision and the brace. For example, you may want to put on a light t-shirt and then the brace before getting dressed for the day. •During periods of rest, take off the brace and expose the incision to the air by lying on your side for a few hours. This will reduce the chance of your wound breaking down. 1.The brace must be worn at all times with the following 3 exceptions: 1.Lying flat in bed during a rest period or at night to sleep. 2.Getting out of bed at night to go to the bathroom, returning to bed immediately when you are finished. 3.Showering. You may wish to use a shower chair to help prevent bending/twisting while bathing. You should have someone help wash your back and legs. Followup Instructions: [MASKED]
[]
[ "I10", "J45909", "F329" ]
[ "M4807: Spinal stenosis, lumbosacral region", "M5117: Intervertebral disc disorders with radiculopathy, lumbosacral region", "M4317: Spondylolisthesis, lumbosacral region", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "Z96651: Presence of right artificial knee joint", "Z8711: Personal history of peptic ulcer disease", "Z961: Presence of intraocular lens" ]
10,039,396
27,932,215
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Aphasia, weakness Major Surgical or Invasive Procedure: Aborted thrombectomy ___ History of Present Illness: NEUROLOGY STROKE ADMISSION/CONSULT NOTE Neurology at bedside after Code Stroke activation within: 3 mins Time/Date the patient was last known well: 14:25 on ___ I was present during the CT scanning and reviewed the images within 20 minutes of their completion. ___ Stroke Scale Score: 17 t-PA administered: [] Yes - Time given: __ [x] No - Reason t-PA was not given or considered: __ Thrombectomy performed: [x] Yes - unsuccessful due to tortuous vasculature. Unable to get into distal ICA [] No - Reason not performed or considered: __ ___ Performed within 6 hours of presentation at: 18:25 on ___ NIHSS Total: 17 1a. Level of Consciousness: 0 1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 0 3. Visual fields: 1 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 1 6a. Motor leg, left: 0 6b. Motor leg, right: 3 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 3 10. Dysarthria: 2 11. Extinction and Neglect: 2 REASON FOR CONSULTATION: HPI: Mr. ___ is a ___ year old man with history of L MCA infarct, hypertension, hyperlipidemia presents with aphasia and R-sided weakness as transfer from ___ for mechanical thrombectomy. Patient history. History obtained from ___ records and chart review. He has a history of a stroke on ___ when he presented to ___ with acute dysarthria/aphasia and difficulty comprehending speech. The brain MRI showed evidence of small acute emboli in the cortical/subcortical distribution of the left MCA. Two days later, he was able to speak and said he was "90% better". Per family, he improved quickly after this stroke and was able to care for himself and cook for himself. Per neurology note from ___, prior to ___, he had had another previous episode of inability to speak which resolved without residual deficits. Patient is on aspirin and plavix at home. Current presentation: LKW 14:25 on ___ Around 14:25, patient was seen to have significant right facial droop, right-sided weakness, and became mute. He was slumped over. He was brought by EMS to ___. Initial NIHSS 22. Outside telestroke with ___ recommended tPA. Family initially declined tPA because he did not want tPA during his last stroke. CTA showed L M1 occlusion. Patient was transferred to ___ for thrombectomy. After discussion with ___ stroke fellow, Dr. ___ amenable to possible tPA and consented for thrombectomy. In ___ ___, code stroke was called. NIHSS was 17. tPA was not given due to past 3 hour window and patient is ___ years old. CT head showed loss of grey white differentiation from L MCA infarct. CTP perfusion showed significant mismatch. Patient went directly to thrombectomy suite after CT and CTP. Thrombectomy was unsuccessful as the team was unable to get into the distal ICA due to tortuous vasculature. Patient had a groin puncture and a R radial puncture. ROS: Patient is globally aphasic so unable to obtain ROS. Past Medical History: Hypertension Hyperlipidemia coronary artery disease Chronic stroke - L MCA Chronic R cerebellar infarct seen on imaging Social History: SOCIAL HISTORY: ___ Family History: FAMILY HISTORY: Father: died at ___ CHF Mother: died at ___ intestinal infection Physical Exam: PHYSICAL EXAMINATION: Vitals: T:98.1 HR:55 BP:147/75 RR:16 SaO2:97% on RA General: Awake, alert, mute. HEENT: NC/AT, no scleral icterus noted, MMM. Neck: Supple. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, awake. Globally aphasic. Cannot repeat. Cannot follow simple verbal commands. -Cranial Nerves: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Visual fields unclear due to asphasia, inconsistent BTT. R facial droop Hearing appears intact to voice. -Motor: RUE: drifts down LUE: antigravity and spontaneous movement RLE: falls down with very little antigravity effort LLE: antigravity with nonverbal prompting -Sensory: Appears to grimace to noxious. -Reflexes: deferred due to urgent thrombectomy -Coordination: unable to assess -Gait: unable to assess DISCHARGE EXAM ================== General: Awake, alert, mumbles. Skin: erythematous petechial rash diffusely over the buttocks, thighs and back. Sparing the abdomen and chest, neck. Appears to have gotten worse overnight. Neurologic: -Mental Status: Alert, awake. Regards. Tracks. Globally aphasic. Cannot follow simple midline or appendicular verbal commands (close your eyes, show thumb, stick out your tongue). Speech is more fluent this morning with nonsensical words. -Cranial Nerves: PERRL 3 to 2mm and brisk. EOMI without nystagmus. L gaze preference - able to cross midline. Visual fields unclear due to aphasia, inconsistent BTT. Slight R facial droop. Hearing appears intact to voice. -Motor: RUE: Brisk antigravity movement. At least ___ at the delt, ___, tri, wrE, fE LUE: antigravity with nonverbal prompting RLE: Moderate antigravity effort. Spontaneous and purposeful movement present LLE: antigravity with nonverbal prompting -Sensory: Sensation UTA. -Reflexes: Plantar response is extensor on the right, flexor on the left -Coordination: Unable to assess -Gait: Able to stand on his own, unsteady Pertinent Results: Admission Labs =================\ ___ 08:48PM BLOOD WBC-10.3* RBC-4.00* Hgb-7.9* Hct-25.7* MCV-64* MCH-19.8* MCHC-30.7* RDW-18.1* RDWSD-40.5 Plt ___ ___ 08:48PM BLOOD ___ PTT-44.9* ___ ___ 08:48PM BLOOD Plt ___ ___ 08:48PM BLOOD Glucose-121* UreaN-36* Creat-1.4* Na-138 K-4.8 Cl-104 HCO3-22 AnGap-12 ___ 05:52AM BLOOD ALT-6 AST-19 LD(LDH)-161 CK(CPK)-40* AlkPhos-75 TotBili-0.7 ___ 08:48PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 08:48PM BLOOD Calcium-8.3* Phos-4.1 Mg-2.1 ___ 05:52AM BLOOD Triglyc-78 HDL-33* CHOL/HD-3.2 LDLcalc-55 ___ 05:52AM BLOOD %HbA1c-5.4 eAG-108 ___ 05:52AM BLOOD TSH-1.5 Pertinent Labs =-============= ___ 05:52AM BLOOD TSH-1.5 ___ 05:52AM BLOOD Triglyc-78 HDL-33* CHOL/HD-3.2 LDLcalc-55 ___ 05:52AM BLOOD %HbA1c-5.4 eAG-108 Imaging =-======= ___ ___ ___ ___ Radiology Report CT HEAD W/O CONTRAST Study Date of ___ 5:23 ___ IMPRESSION: 1. Developing acute infarction in the left insula. Left MCA occlusion distal to the M1 segment is better demonstrated on the CTA from approximately 1 hour prior. 2. CT perfusion within increased T-max/MTT involving 110 mL and reduction of CBF in the left MCA territory involving 13 mL, with mismatch volume of 97 mL indicating ischemic penumbra. 3. Chronic infarctions in the right cerebellar hemisphere and in the subcortical white matter of the right insula. 4. Scattered supratentorial white hypodensities are nonspecific but most likely sequela of chronic small vessel ischemic disease in this age group. Radiology ___ ___ PLACE CATH CAROTID ART Study Date of ___ 5:39 ___ IMPRESSION: -Extremely tortuous vascular anatomy. -Large vessel occlusion of the left M1 -Mechanical thrombectomy was attempted but was aborted without passes due to challenges in accessing the intracranial left internal carotid artery. Radiology Report MR HEAD W/O CONTRAST Study Date of ___ 10:03 ___ IMPRESSION: Large left MCA territory acute infarction with moderate adjacent cytotoxic edema. No evidence of hemorrhage, mass effect, or midline shift. Transthoracic Echocardiogram Report Name: ___ MRN: ___ Date: ___ 10:00 IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Echocardiographic evidence for diastolic dysfunction with elevated PCWP. Mild calcific aortic stenosis. Moderate pulmonary hypertension. Discharge Labs ================== ___ 06:36AM BLOOD WBC-11.5* RBC-3.95* Hgb-7.7* Hct-25.6* MCV-65* MCH-19.5* MCHC-30.1* RDW-17.9* RDWSD-40.3 Plt ___ ___ 06:36AM BLOOD Neuts-75.1* Lymphs-7.0* Monos-6.2 Eos-11.0* Baso-0.3 Im ___ AbsNeut-8.63* AbsLymp-0.81* AbsMono-0.71 AbsEos-1.27* AbsBaso-0.___ year old man with history of L MCA infarct, HTN, HLD presents with aphasia and R-sided weakness found to have L M1 occlusion on CTA. He was on DAPT. LKW 14:25 on ___. Was not a tPA candidate given time to presentation. Went for thrombectomy, but this was aborted due to tortuosity of his carotids. MRI scan showed Large L-MCA acute infarction with significant involvement of broca's and Wernicke's area. Exam w/ dense global aphasia, L-gaze preference, RUE>RLE weakness. Unable to pass speech and swallow evaluation. Etiology most likely thromboembolic due to carotid disease, given history of previous L-MCA, versus cardioembolic. Additional possibility includes retrograde extension of prior M2 clot. Risk factor eval with TSH 1.2. HbA1C 5.4%. LDL 55. Normal TTE. He has had a stroke despite DAPT and will need to be considered for AC in the future, this was not started in the inpatient setting due to large stroke size. He was ultimately felt to require PEG tube. By the end of his hospitalization, he was able to safely swallow and was transitioned back to a ground diet. Discharge Exam summarized: Alert, tracks, regards, follows no commands. Some nonsensical verbal output. Forcefully antigravity bilaterally. Transitional Issues =================== [] blood pressure goals: normal blood pressure, we had to hold metoprolol succinate and Imdur as cannot be crushed via PEG tube. patient transitioned to metop tartrate, plan to uptitrate for goal normal blood pressure. [] ___ [] Consider AC in the outpatient setting at stroke follow up appointment pending results of ___ and given that had stroke through aspirin/clopidogrel [] TTE demonstrated LVH and elevated pulmonary pressures, consider routine right heart function evaluation [] Schedule for PEG tube removal if patient is able to maintain caloric intake by oral means [] Patient noted to have a rash on his trunk, evaluated by dermatology felt to be a drug rash secondary to fluoxetine. This medication was discontinued, please montitor for improvement AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = 50) - () No 5. Intensive statin therapy administered? (x) Yes - atorvastatin 80mg [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? (x) No 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - atorvastatin 80mg 10. Discharged on antithrombotic therapy? (x) Yes Clopidogrel 75mg, Aspirin 81 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? No - to be discussed pending ___ with outpatient neurologist Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Metoprolol Tartrate 12.5 mg PO BID Goal SBP normal blood pressure, please uptitrate accordingly 2. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID rash Stop with completion of rash 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Clopidogrel 75 mg PO DAILY 6. HELD- Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY This medication was held. Do not restart Isosorbide Mononitrate (Extended Release) until patient can tolerate swallowing hold pills. Goal blood pressure is normal blood pressure (SBP<160) 7. HELD- Metoprolol Succinate XL 25 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until patient can tolerate PO. Goal BP <160 if resuming Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis Acute Ischemic Stroke Secondary Diagnosis Hypertension Hyperlipidemia 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 ___, You were hospitalized due to symptoms of weakness and difficulty speaking resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Hypertension Hyperlipidemia History of a prior stroke We are changing your medications as follows: You are continuing on aspirin You are continuing on plavix You are continuing atorvastatin 80 Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. Additionally, you were evaluated by our speech and swallow service as you were unable to safely swallow. You had a feeding tube placed, which allowed us to feed you while it was unsafe for you to swallow. By the end of the hospitalization, you were able to safely swallow! We will have to set up for you to have the feeding tube removed when it is safe to do so. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
[ "I63412", "G8191", "R1310", "R4701", "R4189", "I10", "E785", "R29717", "I2510", "G510", "Z66", "R21" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Aphasia, weakness Major Surgical or Invasive Procedure: Aborted thrombectomy [MASKED] History of Present Illness: NEUROLOGY STROKE ADMISSION/CONSULT NOTE Neurology at bedside after Code Stroke activation within: 3 mins Time/Date the patient was last known well: 14:25 on [MASKED] I was present during the CT scanning and reviewed the images within 20 minutes of their completion. [MASKED] Stroke Scale Score: 17 t-PA administered: [] Yes - Time given: [x] No - Reason t-PA was not given or considered: Thrombectomy performed: [x] Yes - unsuccessful due to tortuous vasculature. Unable to get into distal ICA [] No - Reason not performed or considered: [MASKED] Performed within 6 hours of presentation at: 18:25 on [MASKED] NIHSS Total: 17 1a. Level of Consciousness: 0 1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 0 3. Visual fields: 1 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 1 6a. Motor leg, left: 0 6b. Motor leg, right: 3 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 3 10. Dysarthria: 2 11. Extinction and Neglect: 2 REASON FOR CONSULTATION: HPI: Mr. [MASKED] is a [MASKED] year old man with history of L MCA infarct, hypertension, hyperlipidemia presents with aphasia and R-sided weakness as transfer from [MASKED] for mechanical thrombectomy. Patient history. History obtained from [MASKED] records and chart review. He has a history of a stroke on [MASKED] when he presented to [MASKED] with acute dysarthria/aphasia and difficulty comprehending speech. The brain MRI showed evidence of small acute emboli in the cortical/subcortical distribution of the left MCA. Two days later, he was able to speak and said he was "90% better". Per family, he improved quickly after this stroke and was able to care for himself and cook for himself. Per neurology note from [MASKED], prior to [MASKED], he had had another previous episode of inability to speak which resolved without residual deficits. Patient is on aspirin and plavix at home. Current presentation: LKW 14:25 on [MASKED] Around 14:25, patient was seen to have significant right facial droop, right-sided weakness, and became mute. He was slumped over. He was brought by EMS to [MASKED]. Initial NIHSS 22. Outside telestroke with [MASKED] recommended tPA. Family initially declined tPA because he did not want tPA during his last stroke. CTA showed L M1 occlusion. Patient was transferred to [MASKED] for thrombectomy. After discussion with [MASKED] stroke fellow, Dr. [MASKED] amenable to possible tPA and consented for thrombectomy. In [MASKED] [MASKED], code stroke was called. NIHSS was 17. tPA was not given due to past 3 hour window and patient is [MASKED] years old. CT head showed loss of grey white differentiation from L MCA infarct. CTP perfusion showed significant mismatch. Patient went directly to thrombectomy suite after CT and CTP. Thrombectomy was unsuccessful as the team was unable to get into the distal ICA due to tortuous vasculature. Patient had a groin puncture and a R radial puncture. ROS: Patient is globally aphasic so unable to obtain ROS. Past Medical History: Hypertension Hyperlipidemia coronary artery disease Chronic stroke - L MCA Chronic R cerebellar infarct seen on imaging Social History: SOCIAL HISTORY: [MASKED] Family History: FAMILY HISTORY: Father: died at [MASKED] CHF Mother: died at [MASKED] intestinal infection Physical Exam: PHYSICAL EXAMINATION: Vitals: T:98.1 HR:55 BP:147/75 RR:16 SaO2:97% on RA General: Awake, alert, mute. HEENT: NC/AT, no scleral icterus noted, MMM. Neck: Supple. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No [MASKED] edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, awake. Globally aphasic. Cannot repeat. Cannot follow simple verbal commands. -Cranial Nerves: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Visual fields unclear due to asphasia, inconsistent BTT. R facial droop Hearing appears intact to voice. -Motor: RUE: drifts down LUE: antigravity and spontaneous movement RLE: falls down with very little antigravity effort LLE: antigravity with nonverbal prompting -Sensory: Appears to grimace to noxious. -Reflexes: deferred due to urgent thrombectomy -Coordination: unable to assess -Gait: unable to assess DISCHARGE EXAM ================== General: Awake, alert, mumbles. Skin: erythematous petechial rash diffusely over the buttocks, thighs and back. Sparing the abdomen and chest, neck. Appears to have gotten worse overnight. Neurologic: -Mental Status: Alert, awake. Regards. Tracks. Globally aphasic. Cannot follow simple midline or appendicular verbal commands (close your eyes, show thumb, stick out your tongue). Speech is more fluent this morning with nonsensical words. -Cranial Nerves: PERRL 3 to 2mm and brisk. EOMI without nystagmus. L gaze preference - able to cross midline. Visual fields unclear due to aphasia, inconsistent BTT. Slight R facial droop. Hearing appears intact to voice. -Motor: RUE: Brisk antigravity movement. At least [MASKED] at the delt, [MASKED], tri, wrE, fE LUE: antigravity with nonverbal prompting RLE: Moderate antigravity effort. Spontaneous and purposeful movement present LLE: antigravity with nonverbal prompting -Sensory: Sensation UTA. -Reflexes: Plantar response is extensor on the right, flexor on the left -Coordination: Unable to assess -Gait: Able to stand on his own, unsteady Pertinent Results: Admission Labs =================\ [MASKED] 08:48PM BLOOD WBC-10.3* RBC-4.00* Hgb-7.9* Hct-25.7* MCV-64* MCH-19.8* MCHC-30.7* RDW-18.1* RDWSD-40.5 Plt [MASKED] [MASKED] 08:48PM BLOOD [MASKED] PTT-44.9* [MASKED] [MASKED] 08:48PM BLOOD Plt [MASKED] [MASKED] 08:48PM BLOOD Glucose-121* UreaN-36* Creat-1.4* Na-138 K-4.8 Cl-104 HCO3-22 AnGap-12 [MASKED] 05:52AM BLOOD ALT-6 AST-19 LD(LDH)-161 CK(CPK)-40* AlkPhos-75 TotBili-0.7 [MASKED] 08:48PM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 08:48PM BLOOD Calcium-8.3* Phos-4.1 Mg-2.1 [MASKED] 05:52AM BLOOD Triglyc-78 HDL-33* CHOL/HD-3.2 LDLcalc-55 [MASKED] 05:52AM BLOOD %HbA1c-5.4 eAG-108 [MASKED] 05:52AM BLOOD TSH-1.5 Pertinent Labs =-============= [MASKED] 05:52AM BLOOD TSH-1.5 [MASKED] 05:52AM BLOOD Triglyc-78 HDL-33* CHOL/HD-3.2 LDLcalc-55 [MASKED] 05:52AM BLOOD %HbA1c-5.4 eAG-108 Imaging =-======= [MASKED] [MASKED] [MASKED] [MASKED] Radiology Report CT HEAD W/O CONTRAST Study Date of [MASKED] 5:23 [MASKED] IMPRESSION: 1. Developing acute infarction in the left insula. Left MCA occlusion distal to the M1 segment is better demonstrated on the CTA from approximately 1 hour prior. 2. CT perfusion within increased T-max/MTT involving 110 mL and reduction of CBF in the left MCA territory involving 13 mL, with mismatch volume of 97 mL indicating ischemic penumbra. 3. Chronic infarctions in the right cerebellar hemisphere and in the subcortical white matter of the right insula. 4. Scattered supratentorial white hypodensities are nonspecific but most likely sequela of chronic small vessel ischemic disease in this age group. Radiology [MASKED] [MASKED] PLACE CATH CAROTID ART Study Date of [MASKED] 5:39 [MASKED] IMPRESSION: -Extremely tortuous vascular anatomy. -Large vessel occlusion of the left M1 -Mechanical thrombectomy was attempted but was aborted without passes due to challenges in accessing the intracranial left internal carotid artery. Radiology Report MR HEAD W/O CONTRAST Study Date of [MASKED] 10:03 [MASKED] IMPRESSION: Large left MCA territory acute infarction with moderate adjacent cytotoxic edema. No evidence of hemorrhage, mass effect, or midline shift. Transthoracic Echocardiogram Report IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Echocardiographic evidence for diastolic dysfunction with elevated PCWP. Mild calcific aortic stenosis. Moderate pulmonary hypertension. Discharge Labs ================== [MASKED] 06:36AM BLOOD WBC-11.5* RBC-3.95* Hgb-7.7* Hct-25.6* MCV-65* MCH-19.5* MCHC-30.1* RDW-17.9* RDWSD-40.3 Plt [MASKED] [MASKED] 06:36AM BLOOD Neuts-75.1* Lymphs-7.0* Monos-6.2 Eos-11.0* Baso-0.3 Im [MASKED] AbsNeut-8.63* AbsLymp-0.81* AbsMono-0.71 AbsEos-1.27* AbsBaso-0.[MASKED] year old man with history of L MCA infarct, HTN, HLD presents with aphasia and R-sided weakness found to have L M1 occlusion on CTA. He was on DAPT. LKW 14:25 on [MASKED]. Was not a tPA candidate given time to presentation. Went for thrombectomy, but this was aborted due to tortuosity of his carotids. MRI scan showed Large L-MCA acute infarction with significant involvement of broca's and Wernicke's area. Exam w/ dense global aphasia, L-gaze preference, RUE>RLE weakness. Unable to pass speech and swallow evaluation. Etiology most likely thromboembolic due to carotid disease, given history of previous L-MCA, versus cardioembolic. Additional possibility includes retrograde extension of prior M2 clot. Risk factor eval with TSH 1.2. HbA1C 5.4%. LDL 55. Normal TTE. He has had a stroke despite DAPT and will need to be considered for AC in the future, this was not started in the inpatient setting due to large stroke size. He was ultimately felt to require PEG tube. By the end of his hospitalization, he was able to safely swallow and was transitioned back to a ground diet. Discharge Exam summarized: Alert, tracks, regards, follows no commands. Some nonsensical verbal output. Forcefully antigravity bilaterally. Transitional Issues =================== [] blood pressure goals: normal blood pressure, we had to hold metoprolol succinate and Imdur as cannot be crushed via PEG tube. patient transitioned to metop tartrate, plan to uptitrate for goal normal blood pressure. [] [MASKED] [] Consider AC in the outpatient setting at stroke follow up appointment pending results of [MASKED] and given that had stroke through aspirin/clopidogrel [] TTE demonstrated LVH and elevated pulmonary pressures, consider routine right heart function evaluation [] Schedule for PEG tube removal if patient is able to maintain caloric intake by oral means [] Patient noted to have a rash on his trunk, evaluated by dermatology felt to be a drug rash secondary to fluoxetine. This medication was discontinued, please montitor for improvement AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = 50) - () No 5. Intensive statin therapy administered? (x) Yes - atorvastatin 80mg [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? (x) No 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - atorvastatin 80mg 10. Discharged on antithrombotic therapy? (x) Yes Clopidogrel 75mg, Aspirin 81 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? No - to be discussed pending [MASKED] with outpatient neurologist Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Metoprolol Tartrate 12.5 mg PO BID Goal SBP normal blood pressure, please uptitrate accordingly 2. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID rash Stop with completion of rash 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Clopidogrel 75 mg PO DAILY 6. HELD- Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY This medication was held. Do not restart Isosorbide Mononitrate (Extended Release) until patient can tolerate swallowing hold pills. Goal blood pressure is normal blood pressure (SBP<160) 7. HELD- Metoprolol Succinate XL 25 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until patient can tolerate PO. Goal BP <160 if resuming Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis Acute Ischemic Stroke Secondary Diagnosis Hypertension Hyperlipidemia 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 [MASKED], You were hospitalized due to symptoms of weakness and difficulty speaking resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Hypertension Hyperlipidemia History of a prior stroke We are changing your medications as follows: You are continuing on aspirin You are continuing on plavix You are continuing atorvastatin 80 Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. Additionally, you were evaluated by our speech and swallow service as you were unable to safely swallow. You had a feeding tube placed, which allowed us to feed you while it was unsafe for you to swallow. By the end of the hospitalization, you were able to safely swallow! We will have to set up for you to have the feeding tube removed when it is safe to do so. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
[]
[ "I10", "E785", "I2510", "Z66" ]
[ "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "G8191: Hemiplegia, unspecified affecting right dominant side", "R1310: Dysphagia, unspecified", "R4701: Aphasia", "R4189: Other symptoms and signs involving cognitive functions and awareness", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "R29717: NIHSS score 17", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "G510: Bell's palsy", "Z66: Do not resuscitate", "R21: Rash and other nonspecific skin eruption" ]
10,039,708
20,093,566
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cats, dogs, dust, pollen Attending: ___. Chief Complaint: Lethargy Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo F with hx of EtOH cirrhosis c/b esophageal varices s/p recent banding (___), stomach ulcer, ESRD (HD TTS, last session ___, HTN, asthma who presented to the ED from ___ ___ concerns of increased lethargy. Past Medical History: EtOh Cirrhosis Stage IV CKD Anemia Wernicke's Encephalopathy Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT ___ dt L patella fx s/p IVC filter (removed), w/ catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture S/P BARIATRIC SURGERY ___ - ___ w/ Dr. ___ ___ Seasonal allergies ascites esophageal varices malnutrition HEMORRHOIDS HEPATIC HYDROTHORAX COLONIC ADENOMA Social History: ___ Family History: Mother ASTHMA DIABETES ___ HYPERTENSION THYROID DISORDER OBESITY Father SUBSTANCE ABUSE CARDIAC HYPERTENSION Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: 112/64, HR 55, RR 16, 100% on RA GENERAL: Sleepy and only opens eyes to voice when asked. She is responsive to voice though and able to answer all questions. On reassessment, wide awake, attentive, interactive. HEENT: Sclera anicteric and without injection. Dry mucous membranes. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. Tenderness to palpation over right breast, no overlying bruise. LUNGS: Bilateral basilar crackles during inspiration in lower lung fields. Clear to auscultation otherwise. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. Multiple ecchymoses including over right flank and right shoulder. ABDOMEN: Normal bowels sounds, non distended, diffusely tender to palpation in all quadrants, greatest in RUQ. EXTREMITIES: Pitting edema bilaterally to mid-shin 2+. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. Large ecchymosis with mild erythema with no fluctuance on right AC. NEUROLOGIC: AOx3 -- able to state ___, ___, did not know it was ___. + Asterixis bilaterally. Bilateral arms and legs passive motion intact without spasticity. DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated ___ @ 1123) Temp: 98.4 (Tm 98.6), BP: 112/73 (93-133/56-77), HR: 76 (74-87), RR: 15 (___), O2 sat: 97% (97-99), O2 delivery: ra, Wt: 175.5 lb/79.61 kg GENERAL: AAOx3, no acute distress, appears well compared to prior examinations HEAD: large ecchymosis on left later head HEENT: PERRL, EOMI NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Systolic murmur. LUNGS: CTAB, no increased work of breathing ABDOMEN: Normal bowels sounds, non distended, non-tender to palpation in all quadrants but also appeared somnolent, difficult to assess EXTREMITIES: Pitting edema bilaterally to mid-shin 2+ R>L. Pulses DP/Radial 2+ bilaterally. Large ecchymosis on left shoulder. SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. NEUROLOGIC: AOx3, + Asterixis bilaterally but improved compared to yesterday. Bilateral arms and legs passive motion intact without spasticity. Pertinent Results: ADMISSION LABS: ============== ___ 11:30AM ___ PTT-31.4 ___ ___ 11:30AM PLT COUNT-84* ___ 11:30AM NEUTS-69.8 LYMPHS-14.9* MONOS-12.2 EOS-2.3 BASOS-0.4 IM ___ AbsNeut-5.41 AbsLymp-1.16* AbsMono-0.95* AbsEos-0.18 AbsBaso-0.03 ___ 11:30AM WBC-7.8 RBC-1.84* HGB-5.8* HCT-19.3* MCV-105* MCH-31.5 MCHC-30.1* RDW-22.5* RDWSD-84.2* ___ 11:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG ___ 11:30AM HCG-6 ___ 11:30AM ALBUMIN-3.2* ___ 11:30AM CK-MB-14* ___ 11:30AM cTropnT-0.05* ___ 11:30AM LIPASE-90* ___ 11:30AM ALT(SGPT)-27 AST(SGOT)-51* ALK PHOS-253* TOT BILI-0.9 ___ 11:30AM GLUCOSE-104* UREA N-49* CREAT-9.2*# SODIUM-136 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-22 ANION GAP-15 ___ 11:34AM LACTATE-1.8 ___ 11:34AM ___ COMMENTS-GREEN TOP ___ 03:45PM URINE WBCCLUMP-FEW* ___ 03:45PM URINE RBC-7* WBC-32* BACTERIA-FEW* YEAST-NONE EPI-27 ___ 03:45PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG* ___ 03:45PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 03:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 03:45PM URINE UCG-NEGATIVE ___ 03:45PM URINE HOURS-RANDOM ___ 06:15PM cTropnT-0.04* ___ 06:15PM CK(CPK)-432* ___ 07:00PM PLT COUNT-78* ___ 07:00PM WBC-6.6 RBC-2.21* HGB-6.8* HCT-22.7* MCV-103* MCH-30.8 MCHC-30.0* RDW-21.2* RDWSD-77.5* ___ 11:21PM PLT COUNT-80* ___ 11:21PM WBC-6.7 RBC-2.45* HGB-7.6* HCT-24.5* MCV-100* MCH-31.0 MCHC-31.0* RDW-21.1* RDWSD-74.4* ___ 11:36PM LACTATE-2.5* NA+-135 K+-3.7 ___ 11:36PM ___ PO2-153* PCO2-41 PH-7.29* TOTAL CO2-21 BASE XS--6 COMMENTS-GREEN TOP MICRO: ====== ___ UCx: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ BCx: NGTD REPORTS: ======== ___ GLENOHEMORAL XR No fracture or dislocation ___ DX ELBOW & FOREARM No visualized fracture. Of note, patient was unable to properly position for 90 degree flexion lateral view of the right elbow to assess for the presence/absence of an elbow joint effusion. ___ CT C-SPINE W/O CONTRAST No cervical spine fracture or malalignment. ___ CT CHEST/ABD/PELVIS W/O 1. No evidence of acute intrathoracic or intraabdominal injury within the limitation of an unenhanced scan. 2. No fractures the imaged portions of the body. The left clavicle is not included in the study. 3. New subcutaneous hematomas measure up to 1.9 cm anterior to the right iliac crest and in the left gluteal region. 4. Redemonstrated 1.7 cm intermediate density lesion in the interpolar region of the right kidney. Consider renal ultrasound in non urgent basis for further characterization. DISCHARGE LABS: ============== ___ 07:17AM BLOOD WBC-8.3 RBC-2.37* Hgb-7.3* Hct-24.2* MCV-102* MCH-30.8 MCHC-30.2* RDW-20.4* RDWSD-74.1* Plt Ct-87* ___ 07:17AM BLOOD Plt Ct-87* ___ 07:17AM BLOOD ___ PTT-33.7 ___ ___ 07:17AM BLOOD Glucose-75 UreaN-26* Creat-5.3*# Na-139 K-4.3 Cl-101 HCO3-24 AnGap-14 ___ 07:17AM BLOOD ALT-28 AST-54* LD(LDH)-281* AlkPhos-272* TotBili-1.5 ___ 07:17AM BLOOD Albumin-3.0* Calcium-8.2* Phos-4.0 Mg-2.___RIEF SUMMARY: ============== Ms. ___ is a ___ yo F with hx of EtOH cirrhosis c/b esophageal varices s/p recent banding (___), stomach ulcer, ESRD (HD TTS), HTN, asthma who presents to the ED from ___ concerns of increased lethargy following a fall down stairs at home. The patient required 2u pRBCs for low Hgb in the ED and was noted to be lethargic, her lactulose was increased and she received HD and her mentation improved. She was discharged AAOx3 in stable condition. ACUTE ISSUES: ============= #Hepatic encephalopathy #Uremic encephalopathy #AMS The patient presented from her hemodialysis center to the ED w/ lethargy and a known recent fall down a flight of stairs. At the time of presentation, she was noted to be lethargic but able to converse without difficulty. Upon arrival to the floor, she remained lethargic but arousable to voice and able to follow commands. She described not taking her lactulose recently, missing a session of HD as a result of her lethargy, and recent alcohol use. HE, uremic encephalopathy, and alcohol use were all considered as etiologies for her AMS. She was given lactulose at an increased rate and had runs of HD on back-to-back days. Her mentation improved to baseline, AAOx3, and she was returned to her usual lactulose dose and TTS HD schedule at time of discharge. #Alcoholic hallucinosis On day two of her hospitalization the patient described a hallucination in which a man was standing over her and repeating her name, ___ She was frightened and unwilling to open her eyes. This was concerning for alcoholic hallucinosis given the time frame and her recent alcohol use, so she was placed on CIWA protocol w/ lorazepam for management. By day three, her hallucinations had ceased and at time of discharge she was out of the alcohol withdrawal window. #Acute on chronic blood loss anemia At admission to the ED, the patient was noted to have a Hgb <7, so she was given 2u pRBCs, to which she bumped appropriately. She has a history of esophageal varices so she was monitored with daily CBCs and her Hgb remained > 7 for the rest of her stay. She had no evidence of blood loss (no melena, hematemesis, BRBPR) throughout her hospitalization. Given her recent fall, a CT was ordered to assess for an RP bleed but was negative. #Fall ___ alcohol use The patient states that she had been drinking and was exiting her closet at which point she fell down a flight of stairs. On admission, she had ecchymoses on her arms, legs, and scalp. CT head negative for intracranial hemorrhage, CT c-spine negative, and shoulder XR normal. She saw ___ while inpatient who recommended further ___ while outpatient, for which patient already has ___ services. CHRONIC ISSUES: =============== #Alcoholic cirrhosis Patient was monitored for signs of GI bleeds, but no evidence. She was started on rifaximin. Otherwise monitored daily MELD labs. #ESRD on HD Due to concern for uremic encephalopathy, was given HD on two consecutive days, then transitioned to home TTS schedule prior to discharge. #Alcohol use disorder Patient met with social work but stated she does not wish to stop drinking at this time. Was given resources for relapse prevention. TRANSITIONAL ISSUES: ==================== [ ] Discharge Cr 5.3 [ ] Discharge AST/ALT ___ [ ] Discharge T bili [ ] Discharge Hgb 7.3 [ ] Patient continues to drink alcohol and would benefit from therapy, was given resources from Psychology Today for clinicians in ___ area that take her insurance and have experience in addiction counseling [ ] Would benefit from further ___ given recent fall [ ] Weekly CBC and may benefit as an outpatient from scheduled transfusions, likely has chronic low volume blood loss from GI source leading to anemia [ ] Would benefit from follow-up on whether she is taking lactulose, has history of non-compliance leading to hospitalization [ ] Has missed HD sessions in the past leading to hospitalization, could benefit from further counseling [ ] Had visual hallucinations during alcohol withdrawal and is actively drinking, on repeat hospitalizations will be important to monitor for signs of withdrawal, she describes this as her first episode [ ] New prescription of rifaximin for patient, but at time of discharge unclear if insurance will cover/if she needs prior auth, would recommend following up to see if patient is able to get medication [ ] Is taking baclofen for muscle spasms/aches, may be contributing to her frequent hospitalizations for AMS, would consider re-assessing if necessary in patient CODE: FCp CONTACT: ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 30 mL PO TID 2. Pantoprazole 40 mg PO Q12H 3. Sucralfate 1 gm PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Allopurinol ___ mg PO EVERY OTHER DAY 6. Baclofen 5 mg PO TID 7. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 8. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 9. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 10. Levothyroxine Sodium 62.5 mcg PO DAILY 11. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 12. Midodrine 20 mg PO TID 13. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Lactulose 30 mL PO TID RX *lactulose 10 gram/15 mL 30 ml by mouth three times a day Refills:*0 2. rifAXIMin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*1 3. Baclofen 2.5 mg PO BID 4. Allopurinol ___ mg PO EVERY OTHER DAY 5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 7. FoLIC Acid 1 mg PO DAILY 8. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 9. Lactulose 30 mL PO TID 10. Levothyroxine Sodium 62.5 mcg PO DAILY 11. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 12. Midodrine 20 mg PO TID 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q12H 15. Sucralfate 1 gm PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Hepatic encephalopathy Alcoholic hallucinosis Acute on chronic blood loss anemia Fall ___ alcohol use SECONDARY DIAGNOSIS Alcoholic cirrhosis ESRD on HD 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 were confused and you fell down stairs. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were given lactulose until you were no longer confused. - You were given blood because your blood count was low. - You were monitored for alcohol withdrawal and given medications to prevent the symptoms of withdrawal. - You went to dialysis. - You saw physical therapy to help with your strength after your fall. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - You must never drink alcohol again or you will die - Please enroll in AA and work with your primary care doctor to determine the best strategy to help you stay sober - Take all of your medications as prescribed (listed below) - Please continue to go to your hemodialysis appointments on ___, and ___ - Please do not miss your lactulose medication, if you miss this medication you ___ become confused and likely end up in the hospital - Please call your primary care doctor and schedule an appointment within one week of your discharge - Keep your follow up appointments with your doctors - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight changes by more than 3 pounds - Please stick to a low salt diet and monitor your fluid intake - If you experience any of the danger signs listed below please call your primary care doctor or come to the emergency department immediately. It was a pleasure participating in your care. We wish you the best! - Your ___ Care Team Followup Instructions: ___
[ "K7040", "N186", "F10251", "F10239", "I8510", "I120", "D62", "K921", "E872", "K7030", "Z8711", "Z992", "D638", "F17210", "J45909", "E039", "Z86718", "Z9884", "M109", "S40022A", "S40021A", "S8012XA", "S8011XA", "S0003XA", "S20222A", "S20221A", "W108XXA", "Y92018", "R740", "R748", "R600", "D696" ]
Allergies: cats, dogs, dust, pollen Chief Complaint: Lethargy Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] yo F with hx of EtOH cirrhosis c/b esophageal varices s/p recent banding ([MASKED]), stomach ulcer, ESRD (HD TTS, last session [MASKED], HTN, asthma who presented to the ED from [MASKED] [MASKED] concerns of increased lethargy. Past Medical History: EtOh Cirrhosis Stage IV CKD Anemia Wernicke's Encephalopathy Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT [MASKED] dt L patella fx s/p IVC filter (removed), w/ catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture S/P BARIATRIC SURGERY [MASKED] - [MASKED] w/ Dr. [MASKED] [MASKED] Seasonal allergies ascites esophageal varices malnutrition HEMORRHOIDS HEPATIC HYDROTHORAX COLONIC ADENOMA Social History: [MASKED] Family History: Mother ASTHMA DIABETES [MASKED] HYPERTENSION THYROID DISORDER OBESITY Father SUBSTANCE ABUSE CARDIAC HYPERTENSION Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: 112/64, HR 55, RR 16, 100% on RA GENERAL: Sleepy and only opens eyes to voice when asked. She is responsive to voice though and able to answer all questions. On reassessment, wide awake, attentive, interactive. HEENT: Sclera anicteric and without injection. Dry mucous membranes. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. Tenderness to palpation over right breast, no overlying bruise. LUNGS: Bilateral basilar crackles during inspiration in lower lung fields. Clear to auscultation otherwise. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. Multiple ecchymoses including over right flank and right shoulder. ABDOMEN: Normal bowels sounds, non distended, diffusely tender to palpation in all quadrants, greatest in RUQ. EXTREMITIES: Pitting edema bilaterally to mid-shin 2+. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. Large ecchymosis with mild erythema with no fluctuance on right AC. NEUROLOGIC: AOx3 -- able to state [MASKED], [MASKED], did not know it was [MASKED]. + Asterixis bilaterally. Bilateral arms and legs passive motion intact without spasticity. DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated [MASKED] @ 1123) Temp: 98.4 (Tm 98.6), BP: 112/73 (93-133/56-77), HR: 76 (74-87), RR: 15 ([MASKED]), O2 sat: 97% (97-99), O2 delivery: ra, Wt: 175.5 lb/79.61 kg GENERAL: AAOx3, no acute distress, appears well compared to prior examinations HEAD: large ecchymosis on left later head HEENT: PERRL, EOMI NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Systolic murmur. LUNGS: CTAB, no increased work of breathing ABDOMEN: Normal bowels sounds, non distended, non-tender to palpation in all quadrants but also appeared somnolent, difficult to assess EXTREMITIES: Pitting edema bilaterally to mid-shin 2+ R>L. Pulses DP/Radial 2+ bilaterally. Large ecchymosis on left shoulder. SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. NEUROLOGIC: AOx3, + Asterixis bilaterally but improved compared to yesterday. Bilateral arms and legs passive motion intact without spasticity. Pertinent Results: ADMISSION LABS: ============== [MASKED] 11:30AM [MASKED] PTT-31.4 [MASKED] [MASKED] 11:30AM PLT COUNT-84* [MASKED] 11:30AM NEUTS-69.8 LYMPHS-14.9* MONOS-12.2 EOS-2.3 BASOS-0.4 IM [MASKED] AbsNeut-5.41 AbsLymp-1.16* AbsMono-0.95* AbsEos-0.18 AbsBaso-0.03 [MASKED] 11:30AM WBC-7.8 RBC-1.84* HGB-5.8* HCT-19.3* MCV-105* MCH-31.5 MCHC-30.1* RDW-22.5* RDWSD-84.2* [MASKED] 11:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG [MASKED] 11:30AM HCG-6 [MASKED] 11:30AM ALBUMIN-3.2* [MASKED] 11:30AM CK-MB-14* [MASKED] 11:30AM cTropnT-0.05* [MASKED] 11:30AM LIPASE-90* [MASKED] 11:30AM ALT(SGPT)-27 AST(SGOT)-51* ALK PHOS-253* TOT BILI-0.9 [MASKED] 11:30AM GLUCOSE-104* UREA N-49* CREAT-9.2*# SODIUM-136 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-22 ANION GAP-15 [MASKED] 11:34AM LACTATE-1.8 [MASKED] 11:34AM [MASKED] COMMENTS-GREEN TOP [MASKED] 03:45PM URINE WBCCLUMP-FEW* [MASKED] 03:45PM URINE RBC-7* WBC-32* BACTERIA-FEW* YEAST-NONE EPI-27 [MASKED] 03:45PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG* [MASKED] 03:45PM URINE COLOR-Yellow APPEAR-Hazy* SP [MASKED] [MASKED] 03:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 03:45PM URINE UCG-NEGATIVE [MASKED] 03:45PM URINE HOURS-RANDOM [MASKED] 06:15PM cTropnT-0.04* [MASKED] 06:15PM CK(CPK)-432* [MASKED] 07:00PM PLT COUNT-78* [MASKED] 07:00PM WBC-6.6 RBC-2.21* HGB-6.8* HCT-22.7* MCV-103* MCH-30.8 MCHC-30.0* RDW-21.2* RDWSD-77.5* [MASKED] 11:21PM PLT COUNT-80* [MASKED] 11:21PM WBC-6.7 RBC-2.45* HGB-7.6* HCT-24.5* MCV-100* MCH-31.0 MCHC-31.0* RDW-21.1* RDWSD-74.4* [MASKED] 11:36PM LACTATE-2.5* NA+-135 K+-3.7 [MASKED] 11:36PM [MASKED] PO2-153* PCO2-41 PH-7.29* TOTAL CO2-21 BASE XS--6 COMMENTS-GREEN TOP MICRO: ====== [MASKED] UCx: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] BCx: NGTD REPORTS: ======== [MASKED] GLENOHEMORAL XR No fracture or dislocation [MASKED] DX ELBOW & FOREARM No visualized fracture. Of note, patient was unable to properly position for 90 degree flexion lateral view of the right elbow to assess for the presence/absence of an elbow joint effusion. [MASKED] CT C-SPINE W/O CONTRAST No cervical spine fracture or malalignment. [MASKED] CT CHEST/ABD/PELVIS W/O 1. No evidence of acute intrathoracic or intraabdominal injury within the limitation of an unenhanced scan. 2. No fractures the imaged portions of the body. The left clavicle is not included in the study. 3. New subcutaneous hematomas measure up to 1.9 cm anterior to the right iliac crest and in the left gluteal region. 4. Redemonstrated 1.7 cm intermediate density lesion in the interpolar region of the right kidney. Consider renal ultrasound in non urgent basis for further characterization. DISCHARGE LABS: ============== [MASKED] 07:17AM BLOOD WBC-8.3 RBC-2.37* Hgb-7.3* Hct-24.2* MCV-102* MCH-30.8 MCHC-30.2* RDW-20.4* RDWSD-74.1* Plt Ct-87* [MASKED] 07:17AM BLOOD Plt Ct-87* [MASKED] 07:17AM BLOOD [MASKED] PTT-33.7 [MASKED] [MASKED] 07:17AM BLOOD Glucose-75 UreaN-26* Creat-5.3*# Na-139 K-4.3 Cl-101 HCO3-24 AnGap-14 [MASKED] 07:17AM BLOOD ALT-28 AST-54* LD(LDH)-281* AlkPhos-272* TotBili-1.5 [MASKED] 07:17AM BLOOD Albumin-3.0* Calcium-8.2* Phos-4.0 Mg-2. RIEF SUMMARY: ============== Ms. [MASKED] is a [MASKED] yo F with hx of EtOH cirrhosis c/b esophageal varices s/p recent banding ([MASKED]), stomach ulcer, ESRD (HD TTS), HTN, asthma who presents to the ED from [MASKED] concerns of increased lethargy following a fall down stairs at home. The patient required 2u pRBCs for low Hgb in the ED and was noted to be lethargic, her lactulose was increased and she received HD and her mentation improved. She was discharged AAOx3 in stable condition. ACUTE ISSUES: ============= #Hepatic encephalopathy #Uremic encephalopathy #AMS The patient presented from her hemodialysis center to the ED w/ lethargy and a known recent fall down a flight of stairs. At the time of presentation, she was noted to be lethargic but able to converse without difficulty. Upon arrival to the floor, she remained lethargic but arousable to voice and able to follow commands. She described not taking her lactulose recently, missing a session of HD as a result of her lethargy, and recent alcohol use. HE, uremic encephalopathy, and alcohol use were all considered as etiologies for her AMS. She was given lactulose at an increased rate and had runs of HD on back-to-back days. Her mentation improved to baseline, AAOx3, and she was returned to her usual lactulose dose and TTS HD schedule at time of discharge. #Alcoholic hallucinosis On day two of her hospitalization the patient described a hallucination in which a man was standing over her and repeating her name, [MASKED] She was frightened and unwilling to open her eyes. This was concerning for alcoholic hallucinosis given the time frame and her recent alcohol use, so she was placed on CIWA protocol w/ lorazepam for management. By day three, her hallucinations had ceased and at time of discharge she was out of the alcohol withdrawal window. #Acute on chronic blood loss anemia At admission to the ED, the patient was noted to have a Hgb <7, so she was given 2u pRBCs, to which she bumped appropriately. She has a history of esophageal varices so she was monitored with daily CBCs and her Hgb remained > 7 for the rest of her stay. She had no evidence of blood loss (no melena, hematemesis, BRBPR) throughout her hospitalization. Given her recent fall, a CT was ordered to assess for an RP bleed but was negative. #Fall [MASKED] alcohol use The patient states that she had been drinking and was exiting her closet at which point she fell down a flight of stairs. On admission, she had ecchymoses on her arms, legs, and scalp. CT head negative for intracranial hemorrhage, CT c-spine negative, and shoulder XR normal. She saw [MASKED] while inpatient who recommended further [MASKED] while outpatient, for which patient already has [MASKED] services. CHRONIC ISSUES: =============== #Alcoholic cirrhosis Patient was monitored for signs of GI bleeds, but no evidence. She was started on rifaximin. Otherwise monitored daily MELD labs. #ESRD on HD Due to concern for uremic encephalopathy, was given HD on two consecutive days, then transitioned to home TTS schedule prior to discharge. #Alcohol use disorder Patient met with social work but stated she does not wish to stop drinking at this time. Was given resources for relapse prevention. TRANSITIONAL ISSUES: ==================== [ ] Discharge Cr 5.3 [ ] Discharge AST/ALT [MASKED] [ ] Discharge T bili [ ] Discharge Hgb 7.3 [ ] Patient continues to drink alcohol and would benefit from therapy, was given resources from Psychology Today for clinicians in [MASKED] area that take her insurance and have experience in addiction counseling [ ] Would benefit from further [MASKED] given recent fall [ ] Weekly CBC and may benefit as an outpatient from scheduled transfusions, likely has chronic low volume blood loss from GI source leading to anemia [ ] Would benefit from follow-up on whether she is taking lactulose, has history of non-compliance leading to hospitalization [ ] Has missed HD sessions in the past leading to hospitalization, could benefit from further counseling [ ] Had visual hallucinations during alcohol withdrawal and is actively drinking, on repeat hospitalizations will be important to monitor for signs of withdrawal, she describes this as her first episode [ ] New prescription of rifaximin for patient, but at time of discharge unclear if insurance will cover/if she needs prior auth, would recommend following up to see if patient is able to get medication [ ] Is taking baclofen for muscle spasms/aches, may be contributing to her frequent hospitalizations for AMS, would consider re-assessing if necessary in patient CODE: FCp CONTACT: [MASKED] (son) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 30 mL PO TID 2. Pantoprazole 40 mg PO Q12H 3. Sucralfate 1 gm PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Allopurinol [MASKED] mg PO EVERY OTHER DAY 6. Baclofen 5 mg PO TID 7. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 8. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 9. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 10. Levothyroxine Sodium 62.5 mcg PO DAILY 11. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 12. Midodrine 20 mg PO TID 13. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Lactulose 30 mL PO TID RX *lactulose 10 gram/15 mL 30 ml by mouth three times a day Refills:*0 2. rifAXIMin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*1 3. Baclofen 2.5 mg PO BID 4. Allopurinol [MASKED] mg PO EVERY OTHER DAY 5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 7. FoLIC Acid 1 mg PO DAILY 8. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 9. Lactulose 30 mL PO TID 10. Levothyroxine Sodium 62.5 mcg PO DAILY 11. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 12. Midodrine 20 mg PO TID 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q12H 15. Sucralfate 1 gm PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS Hepatic encephalopathy Alcoholic hallucinosis Acute on chronic blood loss anemia Fall [MASKED] alcohol use SECONDARY DIAGNOSIS Alcoholic cirrhosis ESRD on HD 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 were confused and you fell down stairs. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were given lactulose until you were no longer confused. - You were given blood because your blood count was low. - You were monitored for alcohol withdrawal and given medications to prevent the symptoms of withdrawal. - You went to dialysis. - You saw physical therapy to help with your strength after your fall. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - You must never drink alcohol again or you will die - Please enroll in AA and work with your primary care doctor to determine the best strategy to help you stay sober - Take all of your medications as prescribed (listed below) - Please continue to go to your hemodialysis appointments on [MASKED], and [MASKED] - Please do not miss your lactulose medication, if you miss this medication you [MASKED] become confused and likely end up in the hospital - Please call your primary care doctor and schedule an appointment within one week of your discharge - Keep your follow up appointments with your doctors - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight changes by more than 3 pounds - Please stick to a low salt diet and monitor your fluid intake - If you experience any of the danger signs listed below please call your primary care doctor or come to the emergency department immediately. It was a pleasure participating in your care. We wish you the best! - Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "D62", "E872", "F17210", "J45909", "E039", "Z86718", "M109", "D696" ]
[ "K7040: Alcoholic hepatic failure without coma", "N186: End stage renal disease", "F10251: Alcohol dependence with alcohol-induced psychotic disorder with hallucinations", "F10239: Alcohol dependence with withdrawal, unspecified", "I8510: Secondary esophageal varices without bleeding", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "D62: Acute posthemorrhagic anemia", "K921: Melena", "E872: Acidosis", "K7030: Alcoholic cirrhosis of liver without ascites", "Z8711: Personal history of peptic ulcer disease", "Z992: Dependence on renal dialysis", "D638: Anemia in other chronic diseases classified elsewhere", "F17210: Nicotine dependence, cigarettes, uncomplicated", "J45909: Unspecified asthma, uncomplicated", "E039: Hypothyroidism, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z9884: Bariatric surgery status", "M109: Gout, unspecified", "S40022A: Contusion of left upper arm, initial encounter", "S40021A: Contusion of right upper arm, initial encounter", "S8012XA: Contusion of left lower leg, initial encounter", "S8011XA: Contusion of right lower leg, initial encounter", "S0003XA: Contusion of scalp, initial encounter", "S20222A: Contusion of left back wall of thorax, initial encounter", "S20221A: Contusion of right back wall of thorax, initial encounter", "W108XXA: Fall (on) (from) other stairs and steps, initial encounter", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "R748: Abnormal levels of other serum enzymes", "R600: Localized edema", "D696: Thrombocytopenia, unspecified" ]
10,039,708
23,819,016
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypotension, Abdominal Pain Major Surgical or Invasive Procedure: Right internal jugular line placement History of Present Illness: Ms. ___ is a ___ w/ PMH of EtOH abuse (currently still drinking) c/b EtOH hepatitis, Wernicke's encephalopathy, hypotension likely due to autonomic neuropathy; hypothyroidism, hypertension, Hx of bariatric surgery, and other issues who was sent to the ED with hypotension. She was at a ___ appointment at her oncologist's office today where her SBP was noted to be in the ___. On review of systems, she endorsed nausea, vomiting, and diffuse abdominal pain. She also endorsed night sweats. She denied dysuria, cough, chest pain. Denied diarrhea, BPR, or melena. In the ED, initial vitals: 98.1 89 98/68 16 98% RA. Exam notable for suprapubic, periumbilical, epigastric, and RUQ TTP. Labs were notable for WBC 4.7 w/ 71% PMNs and 9% bands, Hgb 12.5, plts 232, BUN/Cr 94/3.3 (most recent Cr 2.9), HCO3 18, anion gap 27, ALT/AST 247/286, alk phos 590, T bili 3.2, Lactate 4.4. UA unremarkable. serum bHCG was 7 (equivocal). Stool was guiac negative. RUQ US notable for "Small amount of gallbladder sludge, without gallbladder distention or pericholecystic fluid., and Normal CBD caliber, without intrahepatic biliary dilatation." CT abdomen/pelvis was ordered, and BCx were collected. Patient received 2L NS, Zofran, and piperacillin/tazobactam and was admitted. On transfer, vitals were: 99.1 77 110/56 15 100% RA. On arrival to the MICU, the patient reported ongoing diffuse abdominal pain. Past Medical History: ___'S ENCEPHELOPATHY ASTHMA TOBACCO DEPENDENCE ALCOHOL DEPENDENCE HYPOTHYROIDISM HYPERTENSION S/P BARIATRIC SURGERY H/O ALCOHOLIC HEPATITIS GOUT Social History: ___ Family History: Family history significant for T2DM, HTN, hypothyroidism and asthma. Physical Exam: ================================== PHYSICAL EXAMINATION ON ADMISSION: ================================== Vitals: 99.1 77 110/56 15 100% RA. GENERAL: Alert, oriented, cachectic, ___ woman in mild distress HEENT: Sclera anicteric, MM dry, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs ABD: soft, diffuse TTP worse in the RUQ, bowel sounds present EXT: Warm, well perfused, 2+ pulses, no edema SKIN: Dressing covering surgical site on R thigh NEURO: Moving all extremities ================================== PHYSICAL EXAMINATION ON DISCHARGE: ================================== Vitals: T 97.9 BP ___ HR ___ 96 RA GENERAL: Alert, oriented, cachectic, ___ woman in no acute distress. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: clean dressing over site of previous R IJ CVL LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs ABD: soft, mild diffuse TTP, no rebound, slight guarding EXT: Warm, well perfused. trace RLE edema SKIN: no rashes, lesions appreciated NEURO: Moving all extremities Pertinent Results: ====================== LABS ON ADMISSION ====================== ___ 10:03PM BLOOD ___ ___ Plt ___ ___ 10:03PM BLOOD ___ ___ ___ ___ 10:03PM BLOOD ___ ___ Tear ___ ___ 10:03PM BLOOD ___ ___ ___ 10:03PM BLOOD Plt ___ ___ 10:03PM BLOOD ___ ___ ___ 10:03PM BLOOD ___ ___ ___ 10:03PM BLOOD ___ ___ 10:03PM BLOOD ___ ___ 10:03PM BLOOD ___ ___ 10:08PM BLOOD ___ ___ 02:33AM BLOOD ___ ___ Base XS--1 ___ TOP ___ 12:19AM URINE ___ Sp ___ ___ 12:19AM URINE ___ ___ ___ 12:19AM URINE ___ Epi-<1 ___ 10:27AM URINE ___ ====================== PERTINENT INTERVAL LABS ====================== LFT TREND: ___ 10:03PM BLOOD ___ ___ ___ 02:17AM BLOOD ___ LD(LDH)-189 ___ ___ 09:35AM BLOOD ___ LD(LDH)-139 ___ ___ 12:06PM BLOOD ___ LD(LDH)-140 ___ ___ 05:37AM BLOOD ___ ___ ___ 09:53AM BLOOD ___ Lipase: ___ 10:03PM BLOOD ___ ___ 02:17AM BLOOD ___ Lactate: ___ 10:08PM BLOOD ___ ___ 02:33AM BLOOD ___ ___ 06:11AM BLOOD Ret ___ Abs ___ ====================== MICROBIOLGY ====================== ___ 9:15 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ ___ 11:10 ___. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ 11:10 ___. GRAM NEGATIVE ROD(S). ___ 10:18 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: KLEBSIELLA PNEUMONIAE. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ___ 4:55 am URINE Site: CATHETER Source: Catheter. **FINAL REPORT ___ Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final ___: Negative for Chlamydia trachomatis by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final ___: Negative for Neisseria gonorrhoeae by ___ System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the ___ Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. ___ - Blood Culture x 2 - Pending ___ - Blood Culture x 2 - Pending ___ - Blood Culture x 2 - Pending ====================== LABS ON DISCHARGE ====================== ___ 09:53AM BLOOD ___ ___ Plt ___ ___ 09:53AM BLOOD ___ ___ ___ 09:53AM BLOOD ___ ___ 09:53AM BLOOD ___ ====================== IMAGING/STUDIES ====================== Cardiovascular Report ECG Study Date of ___ 6:08:45 ___ Sinus rhythm. Compared to the previous tracing of ___ voltage has normalized. Cardiovascular Report ECG Study Date of ___ 9:26:38 ___ Baseline artifact. Probable sinus rhythm. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ 1. Small amount of gallbladder sludge, without gallbladder distention or pericholecystic fluid. 2. Normal CBD caliber, without intrahepatic biliary dilatation. PELVIS LIMITED Study Date of ___ 5:51 ___ The uterus and ovaries are not visualized. The patient declined the transvaginal portion of the exam for further although evaluation CT ABD & PELVIS W/O CONTRAST Study Date of ___ 2:09 ___ 1. No etiology for the patient's pain identified. No evidence for infection in the abdomen and pelvis. No ovarian masses. 2. 0.9 cm opacity in the right lower lobe is new from ___ and may represent an infectious focus. Further evaluation with full chest CT is recommended 3. Significant improvement in hepatic steatosis. CT CHEST W/O CONTRAST Study Date of ___ Normal Chest CT. No evidence of active intrathoracic infection or malignancy. Right lower lobe opacity described on recent CT has almost completely resolved consistent with resolving atelectasis Brief Hospital Course: Ms. ___ is a ___ w/ PMH of EtOH abuse (currently still drinking) c/b EtOH hepatitis, Wernicke's encephalopathy, hypotension likely due to autonomic neuropathy; hypothyroidism, hypertension, Hx of bariatric surgery, and other issues who was sent to the ED with hypotension and bandemia concerning for pancreatitis. #Septic shock: Patient presented with abdominal pain and fever, was found to have hypotension requiring IVF resuscitation and levophed for which she had a R IJ CVL placed. She was subsequently found to have GNR bacteremia which speciated to pan sensitive klebsiella in ___ bottles. She was initialy treated with broad spectrum antibiotics with IV Vancomycin/Zosyn which was narrowed to PO Ciprolfoxacin on discharge. Her blood pressure gradually increased and patient was off levophed with overall improvement of her symptoms. The etiology of the bacteremia as thought likely to be intrabdominal given pain and further findings described below in # abdominal pain. The differential also included pelvic process given adnexal tenderness on physical exam. Urinary etiologies were on the differential, though no urine culture prior to antibiosis obtained. The patient had previous hematoma evacuation of right thigh though wound appeared intact without evidence of infection. Of note the patient had a history of high risk HPV with ASCUS and there was concern that cervical etiologies could be the source of infection, particularly concerning for malignancy in the setting of her anemia and recent thrombosis as well. The patient understood the need for outpatient follow up with pap smear and IUD removal, and this was relayed to the patient's PCP as well. There were no other appreciate sources of infection on non contrast (in setting ___ on CKD) scans of the chest, abdomen and pelvis. The patient remained afebrile and hemodynamically stable after transfer to the medicine floor from the MICU. # Abdominal pain: Patient presented with abdominal pain and fever, was found to have GNR bacteremia speciated to pan sensitive klebsiella as above. In terms of source of infection, RUQ ultrasound was without evidence of cholecystitis or CBD dilatation and CT chest/abdomen was not notable for any abnormalities that could explain the symptoms. Elevated lipase with elevated LFTs was suggestive of pancreatitis; however, her pain was not entirely typical (not prominent in epigastrium) and CT abdomen did not show signs of pancrteatitis. Choledocholithiasis with a passed stone was thought to be a possibility as well given the downtrending LFTS. The differential also included pelvic etiology, though patient denied any urinary or vaginal symptoms. The patient's pain improved thoughout the admission and the patient was tolerating PO well on discharge. # Pancreatitis: Patient with lipase >3X ULN and abdominal pain (though somewhat atypical), however no evidence of pancreatitis on CT (though non contrast given ___ on CKD). Differential included EtOH given history of heavy drinking, biliary sources given elevated LFTs on admission as well. However lipase may also have been elevated for alternate etiologies in the setting of possible GI infection and may not have been representative of true pancreatitis. As above the patient's pain improved throughout the admission and was tolerating PO well on discharge. # Transaminitis: The differential included biliary infection, however RUQ US without cholecystitis or biliary dilatation, vs. choledochlithiasis with passed stone. Could consider contribution from heavy EtOH as well, though ration of ALT/AST less suggestive of this etiology. The patient's LFTs improved throughout the hospital course, and T bili normalized. # ___: Patient was recently discontinued from hemodialysis in the past month, as her renal function has recovered from a prior ATN. Cr was elevated on admission to 3.3. She received fluid and her creatinine gradually decreased. Creatinine on discharge was 1.8. # Anemia: Patient with chronic anemia extensively worked up in the past. No evidence of current hemolysis given normalized T bili. Likely component of hemoconcentration on admission in the setting of septic shock. Differential included infection and medication (Zosyn) causing bone marrow suppression, as well as heavy EtOh use. The patient did not require any blood transfusions during the admission. # EtOH abuse: Patient reported drinking ___ to 1 pint of hard liquor per day, with her last drink being the day before admission. She was placed on CIWA scale, and treated with multivitamins and thiamine. The patient attempted to leave AMA the day prior to discharge and was evaluated by psychiatry overnight who were concerned that the patient lacked capacity to at that time. The patient as re evaluated in the morning by psychiatry and after further discussion was deemed to have capacity regarding her plan of care. The patient was instructed regarding risks of alcohol withdrawal and referred to substance abuse treatment by psychiatry which she declined. # ___ metabolic acidosis: Resolved. Most likely due to lactic acidosis on presentation # Equivocal Serum HCG: Patient denied possibility of pregnancy. Urine hCG was negative. Patient with IUD in place with plans for outpatient removal. ==================== CHRONIC ISSUES ==================== # Hypothyroidism: Patient continued Levothyroxine Sodium 62.5 mcg PO DAILY. # Hx of wet beri beri: Furosemide was held in the setting of septic shock and held on discharge given no evidence of volume overload and soft pressures. # HTN: Home Hydrochlorothiazide held as well given infection and soft pressures as well. # Gout: Patient restarted on home allopurinol. ==================== TRANSITIONAL ISSUES ==================== - Please continue PO Ciprofloxacin through ___ (___) - Patient will need pap smear as outpatient for further evaluation of high risk HPV in setting of bacteremia, anemia, and thrombosis - Please discuss with PCP the need for restarting furosemide as an outpatient. - Patient will need removal of IUD - Patient will need removal of IVC filter in future - please discuss with PCP - ___ obtain CBC and Chem 10 at next PCP appointment for evaluation of anemia and Creatinine given ___ on CKD Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 50 mcg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins W/minerals 1 TAB PO BID 4. Levothyroxine Sodium 62.5 mcg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Hydrochlorothiazide 25 mg PO DAILY 7. Allopurinol ___ mg PO DAILY 8. Thiamine 100 mg PO DAILY 9. Ascorbic Acid ___ mg PO BID 10. Ferrous Sulfate 325 mg PO DAILY 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. Acetaminophen 650 mg PO Q8H:PRN pain 13. Vitamin E 400 UNIT PO QD 14. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Allopurinol ___ mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. FoLIC Acid 1 mg PO DAILY 5. Levothyroxine Sodium 62.5 mcg PO DAILY 6. Multivitamins W/minerals 1 TAB PO BID 7. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp #*9 Tablet Refills:*0 8. Ascorbic Acid ___ mg PO BID 9. Cyanocobalamin 50 mcg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Thiamine 100 mg PO DAILY 12. Vitamin D unknown PO DAILY 13. Vitamin E 400 UNIT PO QD Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses =================== Sepsis Klebsiella pneumoniae bacteremia Pancreatitis Transaminitis Abdominal Pain Acute on chronic kidney disease Anemia Anion gap metabolic acidosis Secondary Diagnoses =================== Hypothyroidism Alcohol use disorder Tobacco use disorder History of wet beri beri History of Wernicke's encephalopathy Gout Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you during your stay at ___. You were admitted to the hospital with low blood pressure. You were treated with fluids and medications to increase your blood pressure. You were also found to have an infection in your blood stream. You will need to continue to take antibiotics for this infection for a total of 2 weeks. It is very important that you follow up with your primary care doctor. You will need to have a pap smear as an outpatient. You will also need to have your IUD removed. You should also discuss the optimal timing with your primary care doctor of removal of the IVC filter that was placed in your leg because of blood clots. Please take ciprofloxacin daily THROUGH ___ It was a pleasure to be a part of your care, Your ___ treatment team Followup Instructions: ___
[ "A4189", "K859", "R6521", "N179", "R64", "E46", "E872", "E5112", "G629", "F1020", "K7010", "E039", "I129", "N189", "Z720", "J45909", "M109", "D649", "R410", "Z86718", "Z9884" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Hypotension, Abdominal Pain Major Surgical or Invasive Procedure: Right internal jugular line placement History of Present Illness: Ms. [MASKED] is a [MASKED] w/ PMH of EtOH abuse (currently still drinking) c/b EtOH hepatitis, Wernicke's encephalopathy, hypotension likely due to autonomic neuropathy; hypothyroidism, hypertension, Hx of bariatric surgery, and other issues who was sent to the ED with hypotension. She was at a [MASKED] appointment at her oncologist's office today where her SBP was noted to be in the [MASKED]. On review of systems, she endorsed nausea, vomiting, and diffuse abdominal pain. She also endorsed night sweats. She denied dysuria, cough, chest pain. Denied diarrhea, BPR, or melena. In the ED, initial vitals: 98.1 89 98/68 16 98% RA. Exam notable for suprapubic, periumbilical, epigastric, and RUQ TTP. Labs were notable for WBC 4.7 w/ 71% PMNs and 9% bands, Hgb 12.5, plts 232, BUN/Cr 94/3.3 (most recent Cr 2.9), HCO3 18, anion gap 27, ALT/AST 247/286, alk phos 590, T bili 3.2, Lactate 4.4. UA unremarkable. serum bHCG was 7 (equivocal). Stool was guiac negative. RUQ US notable for "Small amount of gallbladder sludge, without gallbladder distention or pericholecystic fluid., and Normal CBD caliber, without intrahepatic biliary dilatation." CT abdomen/pelvis was ordered, and BCx were collected. Patient received 2L NS, Zofran, and piperacillin/tazobactam and was admitted. On transfer, vitals were: 99.1 77 110/56 15 100% RA. On arrival to the MICU, the patient reported ongoing diffuse abdominal pain. Past Medical History: [MASKED]'S ENCEPHELOPATHY ASTHMA TOBACCO DEPENDENCE ALCOHOL DEPENDENCE HYPOTHYROIDISM HYPERTENSION S/P BARIATRIC SURGERY H/O ALCOHOLIC HEPATITIS GOUT Social History: [MASKED] Family History: Family history significant for T2DM, HTN, hypothyroidism and asthma. Physical Exam: ================================== PHYSICAL EXAMINATION ON ADMISSION: ================================== Vitals: 99.1 77 110/56 15 100% RA. GENERAL: Alert, oriented, cachectic, [MASKED] woman in mild distress HEENT: Sclera anicteric, MM dry, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs ABD: soft, diffuse TTP worse in the RUQ, bowel sounds present EXT: Warm, well perfused, 2+ pulses, no edema SKIN: Dressing covering surgical site on R thigh NEURO: Moving all extremities ================================== PHYSICAL EXAMINATION ON DISCHARGE: ================================== Vitals: T 97.9 BP [MASKED] HR [MASKED] 96 RA GENERAL: Alert, oriented, cachectic, [MASKED] woman in no acute distress. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: clean dressing over site of previous R IJ CVL LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs ABD: soft, mild diffuse TTP, no rebound, slight guarding EXT: Warm, well perfused. trace RLE edema SKIN: no rashes, lesions appreciated NEURO: Moving all extremities Pertinent Results: ====================== LABS ON ADMISSION ====================== [MASKED] 10:03PM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 10:03PM BLOOD [MASKED] [MASKED] [MASKED] [MASKED] 10:03PM BLOOD [MASKED] [MASKED] Tear [MASKED] [MASKED] 10:03PM BLOOD [MASKED] [MASKED] [MASKED] 10:03PM BLOOD Plt [MASKED] [MASKED] 10:03PM BLOOD [MASKED] [MASKED] [MASKED] 10:03PM BLOOD [MASKED] [MASKED] [MASKED] 10:03PM BLOOD [MASKED] [MASKED] 10:03PM BLOOD [MASKED] [MASKED] 10:03PM BLOOD [MASKED] [MASKED] 10:08PM BLOOD [MASKED] [MASKED] 02:33AM BLOOD [MASKED] [MASKED] Base XS--1 [MASKED] TOP [MASKED] 12:19AM URINE [MASKED] Sp [MASKED] [MASKED] 12:19AM URINE [MASKED] [MASKED] [MASKED] 12:19AM URINE [MASKED] Epi-<1 [MASKED] 10:27AM URINE [MASKED] ====================== PERTINENT INTERVAL LABS ====================== LFT TREND: [MASKED] 10:03PM BLOOD [MASKED] [MASKED] [MASKED] 02:17AM BLOOD [MASKED] LD(LDH)-189 [MASKED] [MASKED] 09:35AM BLOOD [MASKED] LD(LDH)-139 [MASKED] [MASKED] 12:06PM BLOOD [MASKED] LD(LDH)-140 [MASKED] [MASKED] 05:37AM BLOOD [MASKED] [MASKED] [MASKED] 09:53AM BLOOD [MASKED] Lipase: [MASKED] 10:03PM BLOOD [MASKED] [MASKED] 02:17AM BLOOD [MASKED] Lactate: [MASKED] 10:08PM BLOOD [MASKED] [MASKED] 02:33AM BLOOD [MASKED] [MASKED] 06:11AM BLOOD Ret [MASKED] Abs [MASKED] ====================== MICROBIOLGY ====================== [MASKED] 9:15 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED] [MASKED] 11:10 [MASKED]. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED] 11:10 [MASKED]. GRAM NEGATIVE ROD(S). [MASKED] 10:18 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: KLEBSIELLA PNEUMONIAE. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [MASKED] [MASKED]. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM NEGATIVE ROD(S). [MASKED] 4:55 am URINE Site: CATHETER Source: Catheter. **FINAL REPORT [MASKED] Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [MASKED]: Negative for Chlamydia trachomatis by [MASKED] System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the [MASKED] Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [MASKED]: Negative for Neisseria gonorrhoeae by [MASKED] System, APTIMA COMBO 2 Assay. Validated for use on Urine Samples by the [MASKED] Microbiology Laboratory. Performance characteristics on urine samples were found to be equivalent to those of FDA- approved TIGRIS APTIMA COMBO 2 and/or COBAS Amplicor methods. [MASKED] - Blood Culture x 2 - Pending [MASKED] - Blood Culture x 2 - Pending [MASKED] - Blood Culture x 2 - Pending ====================== LABS ON DISCHARGE ====================== [MASKED] 09:53AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 09:53AM BLOOD [MASKED] [MASKED] [MASKED] 09:53AM BLOOD [MASKED] [MASKED] 09:53AM BLOOD [MASKED] ====================== IMAGING/STUDIES ====================== Cardiovascular Report ECG Study Date of [MASKED] 6:08:45 [MASKED] Sinus rhythm. Compared to the previous tracing of [MASKED] voltage has normalized. Cardiovascular Report ECG Study Date of [MASKED] 9:26:38 [MASKED] Baseline artifact. Probable sinus rhythm. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [MASKED] 1. Small amount of gallbladder sludge, without gallbladder distention or pericholecystic fluid. 2. Normal CBD caliber, without intrahepatic biliary dilatation. PELVIS LIMITED Study Date of [MASKED] 5:51 [MASKED] The uterus and ovaries are not visualized. The patient declined the transvaginal portion of the exam for further although evaluation CT ABD & PELVIS W/O CONTRAST Study Date of [MASKED] 2:09 [MASKED] 1. No etiology for the patient's pain identified. No evidence for infection in the abdomen and pelvis. No ovarian masses. 2. 0.9 cm opacity in the right lower lobe is new from [MASKED] and may represent an infectious focus. Further evaluation with full chest CT is recommended 3. Significant improvement in hepatic steatosis. CT CHEST W/O CONTRAST Study Date of [MASKED] Normal Chest CT. No evidence of active intrathoracic infection or malignancy. Right lower lobe opacity described on recent CT has almost completely resolved consistent with resolving atelectasis Brief Hospital Course: Ms. [MASKED] is a [MASKED] w/ PMH of EtOH abuse (currently still drinking) c/b EtOH hepatitis, Wernicke's encephalopathy, hypotension likely due to autonomic neuropathy; hypothyroidism, hypertension, Hx of bariatric surgery, and other issues who was sent to the ED with hypotension and bandemia concerning for pancreatitis. #Septic shock: Patient presented with abdominal pain and fever, was found to have hypotension requiring IVF resuscitation and levophed for which she had a R IJ CVL placed. She was subsequently found to have GNR bacteremia which speciated to pan sensitive klebsiella in [MASKED] bottles. She was initialy treated with broad spectrum antibiotics with IV Vancomycin/Zosyn which was narrowed to PO Ciprolfoxacin on discharge. Her blood pressure gradually increased and patient was off levophed with overall improvement of her symptoms. The etiology of the bacteremia as thought likely to be intrabdominal given pain and further findings described below in # abdominal pain. The differential also included pelvic process given adnexal tenderness on physical exam. Urinary etiologies were on the differential, though no urine culture prior to antibiosis obtained. The patient had previous hematoma evacuation of right thigh though wound appeared intact without evidence of infection. Of note the patient had a history of high risk HPV with ASCUS and there was concern that cervical etiologies could be the source of infection, particularly concerning for malignancy in the setting of her anemia and recent thrombosis as well. The patient understood the need for outpatient follow up with pap smear and IUD removal, and this was relayed to the patient's PCP as well. There were no other appreciate sources of infection on non contrast (in setting [MASKED] on CKD) scans of the chest, abdomen and pelvis. The patient remained afebrile and hemodynamically stable after transfer to the medicine floor from the MICU. # Abdominal pain: Patient presented with abdominal pain and fever, was found to have GNR bacteremia speciated to pan sensitive klebsiella as above. In terms of source of infection, RUQ ultrasound was without evidence of cholecystitis or CBD dilatation and CT chest/abdomen was not notable for any abnormalities that could explain the symptoms. Elevated lipase with elevated LFTs was suggestive of pancreatitis; however, her pain was not entirely typical (not prominent in epigastrium) and CT abdomen did not show signs of pancrteatitis. Choledocholithiasis with a passed stone was thought to be a possibility as well given the downtrending LFTS. The differential also included pelvic etiology, though patient denied any urinary or vaginal symptoms. The patient's pain improved thoughout the admission and the patient was tolerating PO well on discharge. # Pancreatitis: Patient with lipase >3X ULN and abdominal pain (though somewhat atypical), however no evidence of pancreatitis on CT (though non contrast given [MASKED] on CKD). Differential included EtOH given history of heavy drinking, biliary sources given elevated LFTs on admission as well. However lipase may also have been elevated for alternate etiologies in the setting of possible GI infection and may not have been representative of true pancreatitis. As above the patient's pain improved throughout the admission and was tolerating PO well on discharge. # Transaminitis: The differential included biliary infection, however RUQ US without cholecystitis or biliary dilatation, vs. choledochlithiasis with passed stone. Could consider contribution from heavy EtOH as well, though ration of ALT/AST less suggestive of this etiology. The patient's LFTs improved throughout the hospital course, and T bili normalized. # [MASKED]: Patient was recently discontinued from hemodialysis in the past month, as her renal function has recovered from a prior ATN. Cr was elevated on admission to 3.3. She received fluid and her creatinine gradually decreased. Creatinine on discharge was 1.8. # Anemia: Patient with chronic anemia extensively worked up in the past. No evidence of current hemolysis given normalized T bili. Likely component of hemoconcentration on admission in the setting of septic shock. Differential included infection and medication (Zosyn) causing bone marrow suppression, as well as heavy EtOh use. The patient did not require any blood transfusions during the admission. # EtOH abuse: Patient reported drinking [MASKED] to 1 pint of hard liquor per day, with her last drink being the day before admission. She was placed on CIWA scale, and treated with multivitamins and thiamine. The patient attempted to leave AMA the day prior to discharge and was evaluated by psychiatry overnight who were concerned that the patient lacked capacity to at that time. The patient as re evaluated in the morning by psychiatry and after further discussion was deemed to have capacity regarding her plan of care. The patient was instructed regarding risks of alcohol withdrawal and referred to substance abuse treatment by psychiatry which she declined. # [MASKED] metabolic acidosis: Resolved. Most likely due to lactic acidosis on presentation # Equivocal Serum HCG: Patient denied possibility of pregnancy. Urine hCG was negative. Patient with IUD in place with plans for outpatient removal. ==================== CHRONIC ISSUES ==================== # Hypothyroidism: Patient continued Levothyroxine Sodium 62.5 mcg PO DAILY. # Hx of wet beri beri: Furosemide was held in the setting of septic shock and held on discharge given no evidence of volume overload and soft pressures. # HTN: Home Hydrochlorothiazide held as well given infection and soft pressures as well. # Gout: Patient restarted on home allopurinol. ==================== TRANSITIONAL ISSUES ==================== - Please continue PO Ciprofloxacin through [MASKED] ([MASKED]) - Patient will need pap smear as outpatient for further evaluation of high risk HPV in setting of bacteremia, anemia, and thrombosis - Please discuss with PCP the need for restarting furosemide as an outpatient. - Patient will need removal of IUD - Patient will need removal of IVC filter in future - please discuss with PCP - [MASKED] obtain CBC and Chem 10 at next PCP appointment for evaluation of anemia and Creatinine given [MASKED] on CKD Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyanocobalamin 50 mcg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins W/minerals 1 TAB PO BID 4. Levothyroxine Sodium 62.5 mcg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Hydrochlorothiazide 25 mg PO DAILY 7. Allopurinol [MASKED] mg PO DAILY 8. Thiamine 100 mg PO DAILY 9. Ascorbic Acid [MASKED] mg PO BID 10. Ferrous Sulfate 325 mg PO DAILY 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. Acetaminophen 650 mg PO Q8H:PRN pain 13. Vitamin E 400 UNIT PO QD 14. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Allopurinol [MASKED] mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. FoLIC Acid 1 mg PO DAILY 5. Levothyroxine Sodium 62.5 mcg PO DAILY 6. Multivitamins W/minerals 1 TAB PO BID 7. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp #*9 Tablet Refills:*0 8. Ascorbic Acid [MASKED] mg PO BID 9. Cyanocobalamin 50 mcg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Thiamine 100 mg PO DAILY 12. Vitamin D unknown PO DAILY 13. Vitamin E 400 UNIT PO QD Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses =================== Sepsis Klebsiella pneumoniae bacteremia Pancreatitis Transaminitis Abdominal Pain Acute on chronic kidney disease Anemia Anion gap metabolic acidosis Secondary Diagnoses =================== Hypothyroidism Alcohol use disorder Tobacco use disorder History of wet beri beri History of Wernicke's encephalopathy Gout Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you during your stay at [MASKED]. You were admitted to the hospital with low blood pressure. You were treated with fluids and medications to increase your blood pressure. You were also found to have an infection in your blood stream. You will need to continue to take antibiotics for this infection for a total of 2 weeks. It is very important that you follow up with your primary care doctor. You will need to have a pap smear as an outpatient. You will also need to have your IUD removed. You should also discuss the optimal timing with your primary care doctor of removal of the IVC filter that was placed in your leg because of blood clots. Please take ciprofloxacin daily THROUGH [MASKED] It was a pleasure to be a part of your care, Your [MASKED] treatment team Followup Instructions: [MASKED]
[]
[ "N179", "E872", "E039", "I129", "N189", "J45909", "M109", "D649", "Z86718" ]
[ "A4189: Other specified sepsis", "K859: Acute pancreatitis, unspecified", "R6521: Severe sepsis with septic shock", "N179: Acute kidney failure, unspecified", "R64: Cachexia", "E46: Unspecified protein-calorie malnutrition", "E872: Acidosis", "E5112: Wet beriberi", "G629: Polyneuropathy, unspecified", "F1020: Alcohol dependence, uncomplicated", "K7010: Alcoholic hepatitis without ascites", "E039: Hypothyroidism, 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", "Z720: Tobacco use", "J45909: Unspecified asthma, uncomplicated", "M109: Gout, unspecified", "D649: Anemia, unspecified", "R410: Disorientation, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z9884: Bariatric surgery status" ]
10,039,708
24,928,679
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cats, dogs, dust, pollen Attending: ___ Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: ___: EGD w/ banding History of Present Illness: Ms. ___ is a ___ yo F with PMH EtOH cirrhosis c/b renal failure (HD ___, continued EtOH abuse (1 pint/day), and prior RLE DVT ___ ago) who presents from HD c/o SOB. She reports that she began feeling SOB "all of a sudden" while at HD after feeling slow and fatigued this AM upon awakening. She skipped her last HD session (___). She also had nbnb emesis 4X's at HD and in the ED. She c/o RLE cramping and pain, this is chronic ___ duration. She also endorsed dysuria, particularly at the start of her urination. She denied CP. She had chronic cough and belly pain. Had 1 "dark" and "sticky" bowel movement yesterday. Reports diarrhea ___ a day of unknown duration. Had orthopnea, sleeps with ___ pillows and legs propped up on pillow as well. Lightheaded. She denied recent sick contacts or travel. She consumes a pint of hard liquor (brandy/vodka), with last drink around 12AM the day before admission. She has had previous admissions for EtOH but denied seizures or withdrawal. Was discharged from rehab for alcohol a few weeks ago. Also concerned about lump in the left arm that she noticed on day of admission. In the ED, initial Vitals: T 98.0 HR 86 133/82 16 100% RA Exam: - General - drowsy but responsive - Cardiac - ___ systolic ejection murmur, RRR - Pulmonary - CTAB - Abdomen - moderate TTP in LUQ>RUQ without guarding or rebound, soft, +BS - Extremities - RLE larger than LLE (pt reports chronic at baseline), TTP in bilateral calves - Neuro - strength/sensation intact and symmetric in BLEs/BUEs Labs: Trop-T: 0.06 K:5.1 Lactate:1.8 Hgb 5 from previous 9.9 in ___. Guaiac + on exam. AST 108, ALT 42, AP 316 Alb 3.4 T.bili 1 lipase 108 Serum ASA, etoh, acetam, tricyclics negative pBNP 1447 ___: 14.3 PTT: 28.8 INR: 1.3 Imaging: ___ Cta Abd & Pelvis **1. No evidence of active contrast extravasation within the gastrointestinal tract. 2. Diffuse mural edema involving the excluded stomach, small and large bowel in keeping with portal gastropathy and enteropathy. **3. Cirrhotic liver with moderate volume ascites and anterior abdominal portosystemic collaterals. 4. Cholelithiasis. Gallbladder wall is edematous, likely due to chronic liver disease and third-spacing. 5. Multiple renal hypodensities, some of which are simple cysts and others of which are indeterminate. Consider renal ultrasound for further assessment. 6. CT findings suggestive of anemia. 7. Evidence of chronic pancreatitis including mild ductal dilatation and pancreatic calcifications. ___ CXR FINDINGS: The lungs are clear. There is no consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IVC filter noted in the abdomen. IMPRESSION: No acute cardiopulmonary process. Consults: GI consulted: NPO at midnight for EGD in AM. 2u RBCs Nephrology/dialysis: HD tomorrow possibly Interventions: Consented for 2U PRBCs 2 PIV, T+S Octreotide and IV PPI CefTRIAXone 1 g IV Octreotide VS Prior to Transfer: T 98.3 HR 71 RR 16 BP 105/66 95% 2L O2 Past Medical History: EtOh Cirrhosis Stage IV CKD Anemia Wernicke's Encephalopathy Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT ___ dt L patella fx s/p IVC filter (removed), w/ catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture S/P BARIATRIC SURGERY ___ - ___ w/ Dr. ___ ___ Seasonal allergies ascites esophageal varices malnutrition HEMORRHOIDS HEPATIC HYDROTHORAX COLONIC ADENOMA Social History: ___ Family History: Mother ASTHMA DIABETES ___ HYPERTENSION THYROID DISORDER OBESITY Father SUBSTANCE ABUSE CARDIAC HYPERTENSION Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.5 HR 73 105/53 RR 10 96% RA GEN: NAD, resting comfortably in bed HEENT: EOMI, NECK: CV: systolic ejection murmur, regular rate RESP: CTABL GI: Soft, tender to palpation in the RUQ, no rebound or guarding, +BS MSK: Has a lump approximately ___ inches in diameter in the left arm Swelling in the bilateral lower extremities. Right lower extremity is more swollen than left, chronic at baseline. SKIN: No rashes, lesions NEURO: alert and interactive, moving all extremities spontaneously. BP dropped and became more confused when lying-->sitting. DISCHARGE PHYSICAL EXAM: ======================== VS:24 HR Data (last updated ___ @ 836) Temp: 97.9 (Tm 98.2), BP: 96/51 (95-120/51-67), HR: 73 (72-76), RR: 16 (___), O2 sat: 96% (96-100), O2 delivery: Ra, Wt: 170.5 lb/77.34 kg GEN: NAD, resting comfortably in bed, non-jaundiced; up and ambulating wit help of walker during part of examination HEENT: EOMI, no scleral icterus CV: systolic ejection murmur, regular rate RESP: CTABL, no increased work of breathing GI: Soft, non-tender to palpation, no rebound or guarding, +BS MSK: Swelling in the bilateral lower extremities. Right lower extremity is more swollen than left, improved compared to yesterday. SKIN: No rashes, lesions NEURO: alert and interactive, moving all extremities spontaneously. Asterixis on exam. Pertinent Results: =============== Admission labs =============== ___ 02:42PM BLOOD WBC-9.1 RBC-1.38* Hgb-5.0* Hct-15.6* MCV-113* MCH-36.2* MCHC-32.1 RDW-19.9* RDWSD-78.3* Plt ___ ___ 02:42PM BLOOD ___ PTT-28.8 ___ ___ 02:42PM BLOOD Glucose-98 UreaN-52* Creat-7.1*# Na-134* K-5.6* Cl-95* HCO3-19* AnGap-20* ___ 02:42PM BLOOD ALT-42* AST-108* AlkPhos-316* TotBili-1.1 ___ 02:42PM BLOOD cTropnT-0.06* proBNP-1447* ___ 02:42PM BLOOD Albumin-3.4* ___ 01:17AM BLOOD Albumin-3.1* Calcium-7.8* Phos-6.6* Mg-1.9 ___ 02:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG =============== Pertinent labs =============== ___ 02:42PM BLOOD Neuts-71.0 Lymphs-15.1* Monos-12.3 Eos-0.8* Baso-0.1 Im ___ AbsNeut-6.46* AbsLymp-1.37 AbsMono-1.12* AbsEos-0.07 AbsBaso-0.01 ___ 01:17AM BLOOD CK-MB-11* cTropnT-0.07* ___ 06:37AM BLOOD CK-MB-9 cTropnT-0.07* ___ 02:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG =============== Discharge labs =============== ___ 05:19AM BLOOD WBC-9.0 RBC-2.27* Hgb-7.3* Hct-23.8* MCV-105* MCH-32.2* MCHC-30.7* RDW-24.9* RDWSD-90.6* Plt Ct-82* ___ 05:19AM BLOOD Plt Ct-82* ___ 05:19AM BLOOD ___ PTT-26.9 ___ ___ 05:19AM BLOOD Glucose-106* UreaN-28* Creat-5.2*# Na-141 K-3.9 Cl-100 HCO3-23 AnGap-18 ___ 05:19AM BLOOD ALT-27 AST-49* AlkPhos-289* TotBili-0.7 ___ 05:19AM BLOOD Albumin-3.1* Calcium-7.9* Phos-4.1 Mg-1.8 =============== Studies =============== EGD ___: Varices in distal esophagus s/p banding of grade III varcies. Stigmata of recent bleeding. RNY gastrojejunostomy. Large marginal ulcer with no evidence of active bleeding. CTA ___: IMPRESSION: 1. No evidence of active contrast extravasation within the gastrointestinal tract. 2. Diffuse mural edema involving the excluded stomach, small and large bowel in keeping with portal gastropathy and enteropathy. 3. Cirrhotic liver with moderate volume ascites and anterior abdominal portosystemic collaterals. 4. Cholelithiasis. Gallbladder wall is edematous, likely due to chronic liver disease and third-spacing. 5. Multiple renal hypodensities, some of which are simple cysts and others of which are indeterminate. Consider renal ultrasound for further assessment. 6. CT findings suggestive of anemia. 7. Evidence of chronic pancreatitis including mild ductal dilatation and pancreatic calcifications. CXR ___: No acute cardiopulmonary process. LENIs ___: IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Superficial edema is noted in the right calf. Renal US ___: IMPRESSION: Complex cyst in the midpole of the right kidney without internal vascularity likely a hemorrahgic cyst. Recommend follow up in 6 months to assess for interval change. Please note the left kidney was not well visualized in the current study. =============== Microbiology =============== ___ BCx: no growth ___ BCx: no growth Brief Hospital Course: BRIEF SUMMARY: ============= Ms. ___ is a ___ yo F with PMH EtOH cirrhosis c/b renal failure (HD ___, continued EtOH abuse (1 pint/day), and prior RLE DVT ___ ago) who presented from HD w/ SOB, then found to have dark stool and non-bleeding varices/ulcer on EGD, then transferred from ICU to ET for management of recent GI bleed and EtOH cirrhosis. She had variceal banding and was noted to have a large ulcer on EGD while in the ICU, these were considered to be the source of her bleeding, and she was medically optimized to prevent re-bleeding following the EGD on the ET service. She remained stable once out of the ICU, received HD, and was discharged home in stable condition. TRANSITIONAL ISSUES: ================== [ ] Complex cyst in the midpole of the right kidney, likely a hemorrahgic cyst. Recommend follow up in 6 months to assess for interval change. [ ] Unable to start BB inpatient due to low BPs (and patient is on high dose midodrine). If able to tolerate, please start BB given her varices. [ ] Requires a follow-up EGD in ___. [ ] 6 weeks of BID PPI, then recommend taper down to once daily. [ ] 2 weeks carafate due to recent banding. [ ] Recommend referral by PCP to outpatient/inpatient treatment for alcohol use disorder if patient is amenable. [ ] Patient discharged with home ___ and ___. CODE STATUS: Full CONTACT: ___, ___ ACUTE ISSUES: ============ #Acute blood loss anemia ___ upper GI bleed, likely ___ large marginal ulcer versus variceal bleeding The patient presented from HD due to shortness of breath believed to be ___ pulmonary edema from a previously missed HD session. Upon presentation to the ED, she was noted to have melena and her Hb was 5, and she was transferred to the ICU. She required 3u pRBCs while there. She had an EGD which showed one grade 3 varix in the distal esophagus with stigmata of recent bleeding s/p ligation, and at the RNY gastrojejunostomy encountered a large marginal ulcer with white mucous plug at anastomosis and no evidence of active bleeding. Following her EGD, she was transferred to ET and placed on high dose PPI, carafate BID (reduced given renal dysfunction), ceftriaxone 1g IV for SBP prophylaxis. Octreotide drip was discontinued. Due to her low blood pressures she is unable to tolerate nadolol. She was discharged with Hgb 7.3. #Alcoholic cirrhosis c/b hepatic encephalopathy The patient described an extensive history of alcohol use, including up to the day prior to her admission. On presentation she had asterixis on her exam and was noted to be somnolent. She was given lactulose TID and part of her encephalopathy was presumed related to uremia from missing HD; this was treated on her ___ HD session. Her bleeding was treated as above, and she was noted to have abdominal discomfort on exam, confirmed by moderate ascites on CT exam. She will require continued monitoring of GI bleed risk, ascites, and hepatic encephalopathy as an outpatient, especially in the setting of continued alcohol use. #Alcohol use disorder. Discharged from rehab for alcohol disorder a few weeks ago, but described her last drink as midnight the night prior to presentation to the ED. She was reported to be somnolent in the ED. She had no signs or symptoms of withdrawal but was placed on CIWA protocol and did not score. She was given high dose thiamine for 3 days, folate, and social work was consulted. On multiple occasions the team discussed with her the importance of stopping alcohol. We spoke to her mother on the day of discharge and instructed her to discard all alcohol from the home prior to discharge. #Peripheral edema. She had lower extremity swelling (R>L) and as a result had a lower extremity doppler ultrasound that showed no evidence of clot. The patient described this as a chronic issue for her, no further work-up was completed. CHRONIC ISSUES: ============== #ESRD on HD #Anion gap metabolic acidosis. Received HD while inpatient. Acidosis presumed ___ renal disease. #Chronic pancreatitis. Lipase elevated to 108, her diet was advanced as tolerated and tylenol for pain. #Macrocytic anemia ___ bone marrow suppression from alcohol use. Treated with folate, CBC trended daily. #Thrombocytopenia ___ bone marrow suppression from alcohol use. Observed and CBC trended daily. #Hypothyroidism. Continued home levothyroxine. #Gout. Continued home allopurinol. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Midodrine 20 mg PO TID 2. Allopurinol ___ mg PO EVERY OTHER DAY 3. Baclofen 5 mg PO TID 4. Epoetin Alfa Dose is Unknown IV Frequency is Unknown 5. Clobetasol Propionate 0.05% Ointment 1 Appl TP Frequency is Unknown 6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 7. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheeze 8. Levothyroxine Sodium 62.5 mcg PO DAILY 9. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 10. FoLIC Acid Dose is Unknown PO DAILY 11. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 3 Days starting ___. Lactulose 30 mL PO TID 3. Pantoprazole 40 mg PO Q12H 4. Sucralfate 1 gm PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Allopurinol ___ mg PO EVERY OTHER DAY 7. Baclofen 5 mg PO TID 8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID 9. Epoetin Alfa ___ UNIT IV ONCE Duration: 1 Dose 10. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 11. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheeze 12. Levothyroxine Sodium 62.5 mcg PO DAILY 13. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 14. Midodrine 20 mg PO TID 15. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Acute blood loss anemia ___ upper GI bleed, likely ___ marginal ulcer versus variceal bleed Alcoholic cirrhosis c/b hepatic encephalopathy Alcohol use disorder Peripheral edema SECONDARY DIAGNOSIS ESRD on HD Chronic pancreatitis Anion gap metabolic acidosis Macrocytic anemia ___ bone marrow suppression from alcohol use Thrombocytopenia ___ bone marrow suppression from alcohol use Hypothyroidism Gout 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 were short of breath and you had a bleed from your stomach. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You received blood because your blood count was low. - You had a procedure, called an "EGD," to see where you were bleeding. During that procedure you had some of your blood vessels tied off. - You were treated with medicines to help prevent you from bleeding again. - You received hemodialysis. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - You must never drink alcohol again or you will die - Be sure that ALL of the alcohol is thrown out at home so that you do not have access to it. - Please enroll in AA and work with your primary care doctor to determine the best strategy to help you stay sober. You can also talk with your doctor about doing ___ rehab. Your insurance may cover this for you. - If you notice dark stool, call you liver doctor right away - ___ you begin to vomit blood, go to the emergency department immediately - You should take your medication "carafate" twice a day for 2 weeks, then you can stop this medication. - You should continue to take your medication, pantoprazole, twice a day for six weeks, then start taking it once per day - You need to take antibiotics for three more days. Your next dose is on ___. - Take all of your medications as prescribed (listed below) - Keep your follow up appointments with your doctors - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight changes by more than 3 pounds - Please stick to a low salt diet and monitor your fluid intake - If you experience any of the danger signs listed below please call your primary care doctor or come to the emergency department immediately. It was a pleasure participating in your care. We wish you the best! - Your ___ Team Followup Instructions: ___
[ "K7031", "I8511", "K767", "N186", "K284", "D62", "K861", "E872", "K7040", "R600", "D539", "D6959", "E039", "M109", "R300", "R7989", "E875", "R2232", "N281", "F1010", "F17210", "Z992", "Z86718", "Z9884", "Z980" ]
Allergies: cats, dogs, dust, pollen Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [MASKED]: EGD w/ banding History of Present Illness: Ms. [MASKED] is a [MASKED] yo F with PMH EtOH cirrhosis c/b renal failure (HD [MASKED], continued EtOH abuse (1 pint/day), and prior RLE DVT [MASKED] ago) who presents from HD c/o SOB. She reports that she began feeling SOB "all of a sudden" while at HD after feeling slow and fatigued this AM upon awakening. She skipped her last HD session ([MASKED]). She also had nbnb emesis 4X's at HD and in the ED. She c/o RLE cramping and pain, this is chronic [MASKED] duration. She also endorsed dysuria, particularly at the start of her urination. She denied CP. She had chronic cough and belly pain. Had 1 "dark" and "sticky" bowel movement yesterday. Reports diarrhea [MASKED] a day of unknown duration. Had orthopnea, sleeps with [MASKED] pillows and legs propped up on pillow as well. Lightheaded. She denied recent sick contacts or travel. She consumes a pint of hard liquor (brandy/vodka), with last drink around 12AM the day before admission. She has had previous admissions for EtOH but denied seizures or withdrawal. Was discharged from rehab for alcohol a few weeks ago. Also concerned about lump in the left arm that she noticed on day of admission. In the ED, initial Vitals: T 98.0 HR 86 133/82 16 100% RA Exam: - General - drowsy but responsive - Cardiac - [MASKED] systolic ejection murmur, RRR - Pulmonary - CTAB - Abdomen - moderate TTP in LUQ>RUQ without guarding or rebound, soft, +BS - Extremities - RLE larger than LLE (pt reports chronic at baseline), TTP in bilateral calves - Neuro - strength/sensation intact and symmetric in BLEs/BUEs Labs: Trop-T: 0.06 K:5.1 Lactate:1.8 Hgb 5 from previous 9.9 in [MASKED]. Guaiac + on exam. AST 108, ALT 42, AP 316 Alb 3.4 T.bili 1 lipase 108 Serum ASA, etoh, acetam, tricyclics negative pBNP 1447 [MASKED]: 14.3 PTT: 28.8 INR: 1.3 Imaging: [MASKED] Cta Abd & Pelvis **1. No evidence of active contrast extravasation within the gastrointestinal tract. 2. Diffuse mural edema involving the excluded stomach, small and large bowel in keeping with portal gastropathy and enteropathy. **3. Cirrhotic liver with moderate volume ascites and anterior abdominal portosystemic collaterals. 4. Cholelithiasis. Gallbladder wall is edematous, likely due to chronic liver disease and third-spacing. 5. Multiple renal hypodensities, some of which are simple cysts and others of which are indeterminate. Consider renal ultrasound for further assessment. 6. CT findings suggestive of anemia. 7. Evidence of chronic pancreatitis including mild ductal dilatation and pancreatic calcifications. [MASKED] CXR FINDINGS: The lungs are clear. There is no consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IVC filter noted in the abdomen. IMPRESSION: No acute cardiopulmonary process. Consults: GI consulted: NPO at midnight for EGD in AM. 2u RBCs Nephrology/dialysis: HD tomorrow possibly Interventions: Consented for 2U PRBCs 2 PIV, T+S Octreotide and IV PPI CefTRIAXone 1 g IV Octreotide VS Prior to Transfer: T 98.3 HR 71 RR 16 BP 105/66 95% 2L O2 Past Medical History: EtOh Cirrhosis Stage IV CKD Anemia Wernicke's Encephalopathy Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT [MASKED] dt L patella fx s/p IVC filter (removed), w/ catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture S/P BARIATRIC SURGERY [MASKED] - [MASKED] w/ Dr. [MASKED] [MASKED] Seasonal allergies ascites esophageal varices malnutrition HEMORRHOIDS HEPATIC HYDROTHORAX COLONIC ADENOMA Social History: [MASKED] Family History: Mother ASTHMA DIABETES [MASKED] HYPERTENSION THYROID DISORDER OBESITY Father SUBSTANCE ABUSE CARDIAC HYPERTENSION Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.5 HR 73 105/53 RR 10 96% RA GEN: NAD, resting comfortably in bed HEENT: EOMI, NECK: CV: systolic ejection murmur, regular rate RESP: CTABL GI: Soft, tender to palpation in the RUQ, no rebound or guarding, +BS MSK: Has a lump approximately [MASKED] inches in diameter in the left arm Swelling in the bilateral lower extremities. Right lower extremity is more swollen than left, chronic at baseline. SKIN: No rashes, lesions NEURO: alert and interactive, moving all extremities spontaneously. BP dropped and became more confused when lying-->sitting. DISCHARGE PHYSICAL EXAM: ======================== VS:24 HR Data (last updated [MASKED] @ 836) Temp: 97.9 (Tm 98.2), BP: 96/51 (95-120/51-67), HR: 73 (72-76), RR: 16 ([MASKED]), O2 sat: 96% (96-100), O2 delivery: Ra, Wt: 170.5 lb/77.34 kg GEN: NAD, resting comfortably in bed, non-jaundiced; up and ambulating wit help of walker during part of examination HEENT: EOMI, no scleral icterus CV: systolic ejection murmur, regular rate RESP: CTABL, no increased work of breathing GI: Soft, non-tender to palpation, no rebound or guarding, +BS MSK: Swelling in the bilateral lower extremities. Right lower extremity is more swollen than left, improved compared to yesterday. SKIN: No rashes, lesions NEURO: alert and interactive, moving all extremities spontaneously. Asterixis on exam. Pertinent Results: =============== Admission labs =============== [MASKED] 02:42PM BLOOD WBC-9.1 RBC-1.38* Hgb-5.0* Hct-15.6* MCV-113* MCH-36.2* MCHC-32.1 RDW-19.9* RDWSD-78.3* Plt [MASKED] [MASKED] 02:42PM BLOOD [MASKED] PTT-28.8 [MASKED] [MASKED] 02:42PM BLOOD Glucose-98 UreaN-52* Creat-7.1*# Na-134* K-5.6* Cl-95* HCO3-19* AnGap-20* [MASKED] 02:42PM BLOOD ALT-42* AST-108* AlkPhos-316* TotBili-1.1 [MASKED] 02:42PM BLOOD cTropnT-0.06* proBNP-1447* [MASKED] 02:42PM BLOOD Albumin-3.4* [MASKED] 01:17AM BLOOD Albumin-3.1* Calcium-7.8* Phos-6.6* Mg-1.9 [MASKED] 02:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG =============== Pertinent labs =============== [MASKED] 02:42PM BLOOD Neuts-71.0 Lymphs-15.1* Monos-12.3 Eos-0.8* Baso-0.1 Im [MASKED] AbsNeut-6.46* AbsLymp-1.37 AbsMono-1.12* AbsEos-0.07 AbsBaso-0.01 [MASKED] 01:17AM BLOOD CK-MB-11* cTropnT-0.07* [MASKED] 06:37AM BLOOD CK-MB-9 cTropnT-0.07* [MASKED] 02:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG =============== Discharge labs =============== [MASKED] 05:19AM BLOOD WBC-9.0 RBC-2.27* Hgb-7.3* Hct-23.8* MCV-105* MCH-32.2* MCHC-30.7* RDW-24.9* RDWSD-90.6* Plt Ct-82* [MASKED] 05:19AM BLOOD Plt Ct-82* [MASKED] 05:19AM BLOOD [MASKED] PTT-26.9 [MASKED] [MASKED] 05:19AM BLOOD Glucose-106* UreaN-28* Creat-5.2*# Na-141 K-3.9 Cl-100 HCO3-23 AnGap-18 [MASKED] 05:19AM BLOOD ALT-27 AST-49* AlkPhos-289* TotBili-0.7 [MASKED] 05:19AM BLOOD Albumin-3.1* Calcium-7.9* Phos-4.1 Mg-1.8 =============== Studies =============== EGD [MASKED]: Varices in distal esophagus s/p banding of grade III varcies. Stigmata of recent bleeding. RNY gastrojejunostomy. Large marginal ulcer with no evidence of active bleeding. CTA [MASKED]: IMPRESSION: 1. No evidence of active contrast extravasation within the gastrointestinal tract. 2. Diffuse mural edema involving the excluded stomach, small and large bowel in keeping with portal gastropathy and enteropathy. 3. Cirrhotic liver with moderate volume ascites and anterior abdominal portosystemic collaterals. 4. Cholelithiasis. Gallbladder wall is edematous, likely due to chronic liver disease and third-spacing. 5. Multiple renal hypodensities, some of which are simple cysts and others of which are indeterminate. Consider renal ultrasound for further assessment. 6. CT findings suggestive of anemia. 7. Evidence of chronic pancreatitis including mild ductal dilatation and pancreatic calcifications. CXR [MASKED]: No acute cardiopulmonary process. LENIs [MASKED]: IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Superficial edema is noted in the right calf. Renal US [MASKED]: IMPRESSION: Complex cyst in the midpole of the right kidney without internal vascularity likely a hemorrahgic cyst. Recommend follow up in 6 months to assess for interval change. Please note the left kidney was not well visualized in the current study. =============== Microbiology =============== [MASKED] BCx: no growth [MASKED] BCx: no growth Brief Hospital Course: BRIEF SUMMARY: ============= Ms. [MASKED] is a [MASKED] yo F with PMH EtOH cirrhosis c/b renal failure (HD [MASKED], continued EtOH abuse (1 pint/day), and prior RLE DVT [MASKED] ago) who presented from HD w/ SOB, then found to have dark stool and non-bleeding varices/ulcer on EGD, then transferred from ICU to ET for management of recent GI bleed and EtOH cirrhosis. She had variceal banding and was noted to have a large ulcer on EGD while in the ICU, these were considered to be the source of her bleeding, and she was medically optimized to prevent re-bleeding following the EGD on the ET service. She remained stable once out of the ICU, received HD, and was discharged home in stable condition. TRANSITIONAL ISSUES: ================== [ ] Complex cyst in the midpole of the right kidney, likely a hemorrahgic cyst. Recommend follow up in 6 months to assess for interval change. [ ] Unable to start BB inpatient due to low BPs (and patient is on high dose midodrine). If able to tolerate, please start BB given her varices. [ ] Requires a follow-up EGD in [MASKED]. [ ] 6 weeks of BID PPI, then recommend taper down to once daily. [ ] 2 weeks carafate due to recent banding. [ ] Recommend referral by PCP to outpatient/inpatient treatment for alcohol use disorder if patient is amenable. [ ] Patient discharged with home [MASKED] and [MASKED]. CODE STATUS: Full CONTACT: [MASKED], [MASKED] ACUTE ISSUES: ============ #Acute blood loss anemia [MASKED] upper GI bleed, likely [MASKED] large marginal ulcer versus variceal bleeding The patient presented from HD due to shortness of breath believed to be [MASKED] pulmonary edema from a previously missed HD session. Upon presentation to the ED, she was noted to have melena and her Hb was 5, and she was transferred to the ICU. She required 3u pRBCs while there. She had an EGD which showed one grade 3 varix in the distal esophagus with stigmata of recent bleeding s/p ligation, and at the RNY gastrojejunostomy encountered a large marginal ulcer with white mucous plug at anastomosis and no evidence of active bleeding. Following her EGD, she was transferred to ET and placed on high dose PPI, carafate BID (reduced given renal dysfunction), ceftriaxone 1g IV for SBP prophylaxis. Octreotide drip was discontinued. Due to her low blood pressures she is unable to tolerate nadolol. She was discharged with Hgb 7.3. #Alcoholic cirrhosis c/b hepatic encephalopathy The patient described an extensive history of alcohol use, including up to the day prior to her admission. On presentation she had asterixis on her exam and was noted to be somnolent. She was given lactulose TID and part of her encephalopathy was presumed related to uremia from missing HD; this was treated on her [MASKED] HD session. Her bleeding was treated as above, and she was noted to have abdominal discomfort on exam, confirmed by moderate ascites on CT exam. She will require continued monitoring of GI bleed risk, ascites, and hepatic encephalopathy as an outpatient, especially in the setting of continued alcohol use. #Alcohol use disorder. Discharged from rehab for alcohol disorder a few weeks ago, but described her last drink as midnight the night prior to presentation to the ED. She was reported to be somnolent in the ED. She had no signs or symptoms of withdrawal but was placed on CIWA protocol and did not score. She was given high dose thiamine for 3 days, folate, and social work was consulted. On multiple occasions the team discussed with her the importance of stopping alcohol. We spoke to her mother on the day of discharge and instructed her to discard all alcohol from the home prior to discharge. #Peripheral edema. She had lower extremity swelling (R>L) and as a result had a lower extremity doppler ultrasound that showed no evidence of clot. The patient described this as a chronic issue for her, no further work-up was completed. CHRONIC ISSUES: ============== #ESRD on HD #Anion gap metabolic acidosis. Received HD while inpatient. Acidosis presumed [MASKED] renal disease. #Chronic pancreatitis. Lipase elevated to 108, her diet was advanced as tolerated and tylenol for pain. #Macrocytic anemia [MASKED] bone marrow suppression from alcohol use. Treated with folate, CBC trended daily. #Thrombocytopenia [MASKED] bone marrow suppression from alcohol use. Observed and CBC trended daily. #Hypothyroidism. Continued home levothyroxine. #Gout. Continued home allopurinol. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Midodrine 20 mg PO TID 2. Allopurinol [MASKED] mg PO EVERY OTHER DAY 3. Baclofen 5 mg PO TID 4. Epoetin Alfa Dose is Unknown IV Frequency is Unknown 5. Clobetasol Propionate 0.05% Ointment 1 Appl TP Frequency is Unknown 6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 7. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheeze 8. Levothyroxine Sodium 62.5 mcg PO DAILY 9. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 10. FoLIC Acid Dose is Unknown PO DAILY 11. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 3 Days starting [MASKED]. Lactulose 30 mL PO TID 3. Pantoprazole 40 mg PO Q12H 4. Sucralfate 1 gm PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Allopurinol [MASKED] mg PO EVERY OTHER DAY 7. Baclofen 5 mg PO TID 8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID 9. Epoetin Alfa [MASKED] UNIT IV ONCE Duration: 1 Dose 10. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 11. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheeze 12. Levothyroxine Sodium 62.5 mcg PO DAILY 13. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 14. Midodrine 20 mg PO TID 15. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: Acute blood loss anemia [MASKED] upper GI bleed, likely [MASKED] marginal ulcer versus variceal bleed Alcoholic cirrhosis c/b hepatic encephalopathy Alcohol use disorder Peripheral edema SECONDARY DIAGNOSIS ESRD on HD Chronic pancreatitis Anion gap metabolic acidosis Macrocytic anemia [MASKED] bone marrow suppression from alcohol use Thrombocytopenia [MASKED] bone marrow suppression from alcohol use Hypothyroidism Gout 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 were short of breath and you had a bleed from your stomach. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You received blood because your blood count was low. - You had a procedure, called an "EGD," to see where you were bleeding. During that procedure you had some of your blood vessels tied off. - You were treated with medicines to help prevent you from bleeding again. - You received hemodialysis. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - You must never drink alcohol again or you will die - Be sure that ALL of the alcohol is thrown out at home so that you do not have access to it. - Please enroll in AA and work with your primary care doctor to determine the best strategy to help you stay sober. You can also talk with your doctor about doing [MASKED] rehab. Your insurance may cover this for you. - If you notice dark stool, call you liver doctor right away - [MASKED] you begin to vomit blood, go to the emergency department immediately - You should take your medication "carafate" twice a day for 2 weeks, then you can stop this medication. - You should continue to take your medication, pantoprazole, twice a day for six weeks, then start taking it once per day - You need to take antibiotics for three more days. Your next dose is on [MASKED]. - Take all of your medications as prescribed (listed below) - Keep your follow up appointments with your doctors - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight changes by more than 3 pounds - Please stick to a low salt diet and monitor your fluid intake - If you experience any of the danger signs listed below please call your primary care doctor or come to the emergency department immediately. It was a pleasure participating in your care. We wish you the best! - Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "D62", "E872", "E039", "M109", "F17210", "Z86718" ]
[ "K7031: Alcoholic cirrhosis of liver with ascites", "I8511: Secondary esophageal varices with bleeding", "K767: Hepatorenal syndrome", "N186: End stage renal disease", "K284: Chronic or unspecified gastrojejunal ulcer with hemorrhage", "D62: Acute posthemorrhagic anemia", "K861: Other chronic pancreatitis", "E872: Acidosis", "K7040: Alcoholic hepatic failure without coma", "R600: Localized edema", "D539: Nutritional anemia, unspecified", "D6959: Other secondary thrombocytopenia", "E039: Hypothyroidism, unspecified", "M109: Gout, unspecified", "R300: Dysuria", "R7989: Other specified abnormal findings of blood chemistry", "E875: Hyperkalemia", "R2232: Localized swelling, mass and lump, left upper limb", "N281: Cyst of kidney, acquired", "F1010: Alcohol abuse, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z992: Dependence on renal dialysis", "Z86718: Personal history of other venous thrombosis and embolism", "Z9884: Bariatric surgery status", "Z980: Intestinal bypass and anastomosis status" ]
10,039,708
25,864,431
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: EGD (___) Paracentesis x3 (___) HD line placement (___) History of Present Illness: ___ with history of active alcohol abuse with cirrhosis, Wernicke encephalopathy, gastric bypass, severe anemia, stage IV CKD w/ history of temporary HD (last ___, HTN, DVT, p/w 2 weeks of abdominal distension and 2 days of abdominal pain. She reports worsening abdominal pain over the past 2 weeks, described as a constant dull pain diffusely through her abdomen. She has not been taking anything for pain, no Tylenol or NSAID use. She did try pepto-bismal, gas x without improvement She reports pain unchanged with position, hasn't been able to tolerating PO intake. She has noticed worsening abdominal distension. She reports nausea, dry heaves over the past few days and today had an episode of non-bloody emesis of clear fluid. She has been passing gas, denies diarrhea but has been having small non-bloody BMs. She has felt constipation and trialed Colace without improvement. She reports subjective fevers and chills over the past week, new palpitations over the past month, dyspnea with exertion and sometimes at rest. She reports chronic seasonal allergies with congestion and rhinorrhea. She reports chronic poor UOP, mild dysuria when starting stream. She denies any chest pain/pressure, confusion. She reports that she was seen at ___ about 2 weeks ago and treated with amoxicillin for a sinus infection. She had a blood transfusion a week ago. She is on pro-crit, increased to weekly recently. She reports that on day of presentation that she drank half a pint, usually drinks 1 pint daily but had been drinking less due to abdominal pain. At ___ had ethanol of 138, had diagnostic para done with 60 cc's removed results are pending, given IV CTX and IV thiamine. Past Medical History: EtOH Cirrhosis Stage IV CKD Wernicke's Encephalopathy Anemia Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT ___ s/p IVC filter (removed ___, with catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture. S/P BARIATRIC SURGERY ___ - ___ w/ Dr. ___ ___ History: ___ Family History: - T2DM - HTN - hypothyroidism - asthma - lung cancer (uncle) - ovarian cancer in ___ (MGM) Physical Exam: ADMISSION EXAM VS:98.7 PO 149 / 91 96 18 94 RA GENERAL: AOx3, mild distress HEENT: AT/NC, EOMI, PERRL, MM dry, icteric sclera HEART: RRR, S1/S2, ___ holosystolic murmur LUNGS: CTAB except crackles in bases (R>L), no wheezes, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: distended, diffusely tender in all quadrants (L>R), no rebound/guarding, hepatomegaly EXTREMITIES: bilateral edema, R>L, 1+ non-pitting PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose. Able to recount medical history and medications without difficulty. + asterixis SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM VS: 98.2 PO___ GENERAL: Cheerful, alert. HEENT: MMM. CV: RRR. RESP: CTAB without increased WOB ABDOMEN: Distended, soft, non-tender. EXTREMITIES: WWP. Bilateral ___ edema. NEURO: Alert, oriented, attentive. No asterixis. Pertinent Results: ADMISSION LABS ===================== ___ 12:30AM BLOOD WBC-10.4* RBC-2.47* Hgb-8.4* Hct-25.7* MCV-104* MCH-34.0* MCHC-32.7 RDW-21.2* RDWSD-79.6* Plt ___ ___ 12:30AM BLOOD Neuts-72.3* Lymphs-15.4* Monos-10.0 Eos-0.6* Baso-0.4 Im ___ AbsNeut-7.50* AbsLymp-1.60 AbsMono-1.04* AbsEos-0.06 AbsBaso-0.04 ___ 12:30AM BLOOD ___ PTT-29.9 ___ ___ 12:30AM BLOOD Glucose-67* UreaN-45* Creat-4.7* Na-140 K-3.5 Cl-100 HCO3-14* AnGap-26* ___ 12:30AM BLOOD ALT-32 AST-120* AlkPhos-239* TotBili-3.1* ___ 10:55AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.5* ___ 12:30AM BLOOD calTIBC-146* VitB12-868 Ferritn-560* TRF-112* ___ 11:46AM BLOOD ___ pO2-166* pCO2-35 pH-7.28* calTCO2-17* Base XS--9 Comment-GREEN TOP ___ 12:53AM BLOOD Lactate-3.7* MICRO ======================== __________________________________________________________ ___ 12:14 pm BLOOD CULTURE Source: Line-dialysis. Blood Culture, Routine (Pending): __________________________________________________________ ___ 10:53 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 3:47 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. __________________________________________________________ ___ 9:55 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FUID. **FINAL REPORT ___ Fluid Culture in Bottles (Final ___: NO GROWTH. __________________________________________________________ ___ FLUID GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___. difficile DNA amplification assay- negartiv ___ CULTURE GRAM NEGATIVE ROD(S). ~1000 CFU/mL. ___ CULTUREnegative ___ CULTUREnegative IMAGING & STUDIES ====================== ___ CT Abdomen and Pelvis: Fatty liver with large volume ascites. No splenomegaly. Patient is status post gastric bypass with the excluded stomach appears severely edematous with thickened walls. Diffuse anasarca. ___ RUQ US: 1. Patent portal vasculature. Patent right and middle hepatic veins as well as the main hepatic artery. The left hepatic vein was not visualized. 2. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 3. Large volume ascites. ___ CXR Bilateral low lung volumes with moderate bibasilar atelectasis. No evidence of intraperitoneal free air. ___ TTE IMPRESSION: A left pleural effusion is present. Late bubbles seen in the left heart suggesting intrapulmonary shunting (bubbles appear at 8 beats). Normal biventricular size and systolic function. No pathologic valvular flow. Compared with the prior study (images reviewed) of ___ global biventricular systolic function is more vigorous. ___ EGD Findings: Esophagus: Protruding Lesions1-2 small varices were seen in the lower esophagus with no stigmata of bleeding. Stomach: Lumen:Evidence of a previous RNYGB was seen with a gastrojejunostomy. Duodenum: Flat LesionsA single small angioectasia was seen in the jejunal efferent limb. There was no evidence of bleeding. Otherduodenum not seen due to post surgical anatomy. Other findings:A jejunal feeding tube was placed into the small intestine endoscopically, however during oro-nasal conversion was noted to have become dislodged and was no longer as deep at the nares as when endoscopically placed. It was then advanced and bridled at 70 cm, however due to the fact it moved after endoscopic visualization it will require CXR prior to use. ___ CXR Increased opacities at the right lung base may reflect a combination of atelectasis and pneumonia. ___ Duplex Abdominal U/S 1. No evidence of portal vein thrombosis. Intermittent reversal flow within the left portal vein. Slow flow within the main portal, splenic, and superior mesenteric veins. 2. Cirrhotic liver without focal liver lesions. 3. Circumferential gallbladder wall edema, likely due to third spacing/underlying liver disease. 4. Small volume ascites. DISCHARGE LABS ====================== ___ 07:55AM BLOOD WBC-14.2* RBC-2.12* Hgb-7.1* Hct-21.1* MCV-100* MCH-33.5* MCHC-33.6 RDW-20.7* RDWSD-68.7* Plt ___ ___ 07:55AM BLOOD ___ PTT-35.3 ___ ___ 07:55AM BLOOD Glucose-121* UreaN-28* Creat-3.7* Na-136 K-4.3 Cl-95* HCO3-27 AnGap-14 ___ 07:55AM BLOOD ALT-20 AST-66* AlkPhos-219* TotBili-1.7* ___ 07:55AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.5 Brief Hospital Course: ================== BRIEF SUMMARY ================== ___ with active alcohol use, alcoholic cirrhosis, Stage IV CKD, admitted for alcoholic hepatitis, decompensated cirrhosis, and anuric ___ requiring initiation of HD. Patient was alert, oriented, and feeling well at discharge. Outpatient HD and Hepatology follow-up were arranged. ================== ACUTE ISSUES ================== # Decompensated alcoholic cirrhosis with ascites # Alcoholic hepatitis # Hepatic encephalopathy MELD Na 26 and Child C on presentation. LFTs and symptoms consistent with alcoholic hepatitis on cirrhosis; DF not high enough to warrant steroids. Had confusion and asterixis on admission consistent with HE. Had goals of care discussion with patient and family on ___ and confirmed she wants to pursue aggressive therapy, including EGD and HD; DNR/DNI in the event of arrest. She wants to be abstinent and eventually be placed on the transplant list. EGD showed ___ small varices with no stigmata of bleeding. She started lactulose and rifaximin for HE. Serial diagnostic paracentesis were negative for SBP. She had large-volume paracentesis on ___ for relief of tense ascites. ___ need outpatient LVP depending on whether she continues to be able to remove fluid via UF. She was maintained on high protein, ___ gm sodium diet and tube feeds. She will follow up with hepatology as an outpatient. # Anuric ___ on CKD Stage IV # ?Hepatorenal syndrome She did not respond to albumin challenge, nor to octreotide/midodrine for possible HRS. Octreotide was stopped but she was maintained on midodrine for soft BPs. Outpatient HD ___ arranged. PPD negative. # Abdominal pain Multifactorial - alcoholic hepatitis, tense ascites, and possible acute on chronic pancreatitis (lipase 190). Was initially treated empirically for possible SBP but cell counts were not consistent; prophylaxis not indicated per Hepatology. Pain much improved after LVP ___. Repeat diagnostic para ___ remained negative. # Severe protein calorie malnutrition Nutrition was consulted. Dobhoff was placed for ongoing tube feeds, and high-protein diet and supplements were prescribed. # Hypoxemia # Hepatic hydrothorax # ?Hepatopulmonary syndrome Patient had new 2L O2 requirement in setting of large R pleural effusion/hepatic hydrothorax, resolved after LVP. TTE did show evidence of pulmonary shunting which could represent HPS. # Leukocytosis Patient developed a new leukocytosis several days prior to discharge. Also had slight rise in bili and alk phos around this time. No fevers or localizing symptoms. Repeat infectious workup was unrevealing, including repeat diagnostic paracentesis, except for CXR equivocal for pneumonia. She was started on empiric oral levofloxacin for possible pneumonia, and leukocytosis stabilized for several days and LFTs improved somewhat prior to discharge. # Chronic macrocytic anemia Retics inappropriately low, consistent with marrow suppression. Likely multifactorial - EtOH, cirrhosis, splenomegaly, malnutrition, renal failure. No evidence of acute bleeding and not iron deficient on labs. B12 wnl. Hemolysis labs negative. EGD results as above. Will need continued attention as outpatient. # Chronic thrombocytopenia Likely multifactorial - EtOH, cirrhosis, splenomegaly, malnutrition. No evidence for DIC or other consumptive process. # Coagulopathy PTT was elevated due to SC heparin, normalized after this was held and dose decreased to 2500 units BID. ___ were elevated due to cirrhosis. No evidence of bleeding, DIC, or other acute pathology. # Alcohol use disorder Reports daily drinking prior to admission, about ___ pint qod to 1 pint/day. Last drink ___. Denies h/o withdrawal. She received IV thiamine x 3 days and maintained on oral thiamine, folate and MVI. We discussed the importance of abstinence and SW helped arrange outpatient supports. We also discussed pharmacological assistance to treat alcohol use disorder and depression, however patient deferred at this time. # Chronic RLE edema # History of RLE provoked DVT DVT occurred after left knee fracture. IVC filter was placed in ___. Course complicated by need for catheter lysis and extravasation into right thigh per patient. No longer on anticoagulation. Repeat Doppler this admission negative for persistent DVT. She continued on half-dose heparin SC. ===================== CHRONIC ISSUES ===================== # Hypothyroidism TSH 2.1 this admission. Continued home levothyroxine. # Gout Reduced home allopurinol from 100 mg daily to every other day due to renal failure. ================== TRANSITIONAL ISSUES =================== - WBC elevated to 14.0 on discharge. Please recheck at HD on ___ and evaluate for signs of infection. Discharged on empiric levofloxacin for possible pneumonia (500mg q48h, last day ___. - Other medications started: midodrine 20mg TID, lactulose titrated to ___ BM/day, rifaximin 550mg BID. - HD arranged ___ - ___ follow-up arranged - Discharged with tube feeds - ___ need intermittent LVP depending on whether she tolerates UF - Did not start beta blocker for varices b/c HR ___ - Patient should have CBC and MELD labs checked checked within 1 week of discharge. Script provided. # CODE: DNR/DNI # CONTACT: ___ (son, HCP) ___ > 30 minutes in patient care and coordination of discharge on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Levothyroxine Sodium 62.5 mcg PO DAILY 3. Multivitamins W/minerals 1 TAB PO BID 4. Thiamine 100 mg PO DAILY 5. Allopurinol ___ mg PO DAILY 6. Ascorbic Acid ___ mg PO BID 7. Cyanocobalamin 50 mcg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Pyridoxine 100 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Vitamin E 400 UNIT PO QD 12. Epoetin ___ ___ units SC EVERY 2 WEEKS (MO) Discharge Medications: 1. Lactulose 30 mL PO TID RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth ___ times per day Disp #*50 Package Refills:*0 2. Levofloxacin 500 mg PO Q48H Duration: 5 Days RX *levofloxacin 500 mg 1 tablet(s) by mouth every other day Disp #*3 Tablet Refills:*0 3. Midodrine 20 mg PO TID RX *midodrine 10 mg 2 tablet(s) by mouth three times a day Disp #*180 Tablet Refills:*3 4. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*5 5. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID RX *nut.tx.imp.renal fxn,lac-reduc [Nepro Carb Steady] 0.08 gram-1.8 kcal/mL 237 mL by mouth three times a day Refills:*0 6. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*5 7. Allopurinol ___ mg PO EVERY OTHER DAY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Levothyroxine Sodium 62.5 mcg PO DAILY 10.Outpatient Lab Work ICD-10 Code: ___ Please obtain by ___ and fax to: Dr. ___ ___ CBC; Chem-10 (Na, K, Bicarb, Cl, BUN, Cr, Ca, Mg, Phos); Hepatic Panel (AST, ALT, Alk Phos, Tbili, Albumin, INR) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= Alcoholic hepatitis Decompensated alcoholic cirrhosis with ascites Acute on chronic renal failure Hepatic encephalopathy Severe protein calorie malnutrition Alcohol use disorder Thrombocytopenia Coagulopathy Anemia Community-acquired pneumonia Secondary Diagnoses ==================== Hypothyroidism Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure taking care of you. WHY WAS I ADMITTED? You were admitted because alcohol damaged your liver and your kidneys. WHAT HAPPENED TO ME WHILE I WAS IN THE HOSPITAL? -You were followed closely by our liver and kidney experts. -You were started on dialysis for your kidneys. This helps remove fluid from your body since you are unable to urinate. -You had an endoscopy test which showed some dilated veins in your esophagus. -You had a tube placed from your nose into your intestine to give you more nutrition to help you recover. WHAT SHOULD I DO WHEN I GET HOME? -Follow up with your liver doctors, kidney doctors ___ see them at dialysis), and your primary care doctor. -___ will need to go to dialysis three times a week ___, ___. -You may need to have fluid drained from your abdomen from time to time. This can be arranged through your liver doctor. -___ all your medicines and continue your tube feeds. -Do not drink any alcohol. We strongly recommend you sign up for a program such as Alcoholic Anonymous to help you stay sober. We wish you all the best. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "K7290", "K8520", "K767", "E43", "J189", "K7681", "D689", "N184", "N179", "D62", "I8510", "K860", "D6959", "K7011", "K7031", "F1020", "M109", "E039", "D539", "I129", "F17210", "R0902", "Z66", "Z9884", "Z86718", "Z6830" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: EGD ([MASKED]) Paracentesis x3 ([MASKED]) HD line placement ([MASKED]) History of Present Illness: [MASKED] with history of active alcohol abuse with cirrhosis, Wernicke encephalopathy, gastric bypass, severe anemia, stage IV CKD w/ history of temporary HD (last [MASKED], HTN, DVT, p/w 2 weeks of abdominal distension and 2 days of abdominal pain. She reports worsening abdominal pain over the past 2 weeks, described as a constant dull pain diffusely through her abdomen. She has not been taking anything for pain, no Tylenol or NSAID use. She did try pepto-bismal, gas x without improvement She reports pain unchanged with position, hasn't been able to tolerating PO intake. She has noticed worsening abdominal distension. She reports nausea, dry heaves over the past few days and today had an episode of non-bloody emesis of clear fluid. She has been passing gas, denies diarrhea but has been having small non-bloody BMs. She has felt constipation and trialed Colace without improvement. She reports subjective fevers and chills over the past week, new palpitations over the past month, dyspnea with exertion and sometimes at rest. She reports chronic seasonal allergies with congestion and rhinorrhea. She reports chronic poor UOP, mild dysuria when starting stream. She denies any chest pain/pressure, confusion. She reports that she was seen at [MASKED] about 2 weeks ago and treated with amoxicillin for a sinus infection. She had a blood transfusion a week ago. She is on pro-crit, increased to weekly recently. She reports that on day of presentation that she drank half a pint, usually drinks 1 pint daily but had been drinking less due to abdominal pain. At [MASKED] had ethanol of 138, had diagnostic para done with 60 cc's removed results are pending, given IV CTX and IV thiamine. Past Medical History: EtOH Cirrhosis Stage IV CKD Wernicke's Encephalopathy Anemia Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT [MASKED] s/p IVC filter (removed [MASKED], with catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture. S/P BARIATRIC SURGERY [MASKED] - [MASKED] w/ Dr. [MASKED] [MASKED] History: [MASKED] Family History: - T2DM - HTN - hypothyroidism - asthma - lung cancer (uncle) - ovarian cancer in [MASKED] (MGM) Physical Exam: ADMISSION EXAM VS:98.7 PO 149 / 91 96 18 94 RA GENERAL: AOx3, mild distress HEENT: AT/NC, EOMI, PERRL, MM dry, icteric sclera HEART: RRR, S1/S2, [MASKED] holosystolic murmur LUNGS: CTAB except crackles in bases (R>L), no wheezes, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: distended, diffusely tender in all quadrants (L>R), no rebound/guarding, hepatomegaly EXTREMITIES: bilateral edema, R>L, 1+ non-pitting PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose. Able to recount medical history and medications without difficulty. + asterixis SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM VS: 98.2 PO GENERAL: Cheerful, alert. HEENT: MMM. CV: RRR. RESP: CTAB without increased WOB ABDOMEN: Distended, soft, non-tender. EXTREMITIES: WWP. Bilateral [MASKED] edema. NEURO: Alert, oriented, attentive. No asterixis. Pertinent Results: ADMISSION LABS ===================== [MASKED] 12:30AM BLOOD WBC-10.4* RBC-2.47* Hgb-8.4* Hct-25.7* MCV-104* MCH-34.0* MCHC-32.7 RDW-21.2* RDWSD-79.6* Plt [MASKED] [MASKED] 12:30AM BLOOD Neuts-72.3* Lymphs-15.4* Monos-10.0 Eos-0.6* Baso-0.4 Im [MASKED] AbsNeut-7.50* AbsLymp-1.60 AbsMono-1.04* AbsEos-0.06 AbsBaso-0.04 [MASKED] 12:30AM BLOOD [MASKED] PTT-29.9 [MASKED] [MASKED] 12:30AM BLOOD Glucose-67* UreaN-45* Creat-4.7* Na-140 K-3.5 Cl-100 HCO3-14* AnGap-26* [MASKED] 12:30AM BLOOD ALT-32 AST-120* AlkPhos-239* TotBili-3.1* [MASKED] 10:55AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.5* [MASKED] 12:30AM BLOOD calTIBC-146* VitB12-868 Ferritn-560* TRF-112* [MASKED] 11:46AM BLOOD [MASKED] pO2-166* pCO2-35 pH-7.28* calTCO2-17* Base XS--9 Comment-GREEN TOP [MASKED] 12:53AM BLOOD Lactate-3.7* MICRO ======================== [MASKED] [MASKED] 12:14 pm BLOOD CULTURE Source: Line-dialysis. Blood Culture, Routine (Pending): [MASKED] [MASKED] 10:53 am BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 3:47 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [MASKED] [MASKED] 9:55 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FUID. **FINAL REPORT [MASKED] Fluid Culture in Bottles (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] FLUID GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED]. difficile DNA amplification assay- negartiv [MASKED] CULTURE GRAM NEGATIVE ROD(S). ~1000 CFU/mL. [MASKED] CULTUREnegative [MASKED] CULTUREnegative IMAGING & STUDIES ====================== [MASKED] CT Abdomen and Pelvis: Fatty liver with large volume ascites. No splenomegaly. Patient is status post gastric bypass with the excluded stomach appears severely edematous with thickened walls. Diffuse anasarca. [MASKED] RUQ US: 1. Patent portal vasculature. Patent right and middle hepatic veins as well as the main hepatic artery. The left hepatic vein was not visualized. 2. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 3. Large volume ascites. [MASKED] CXR Bilateral low lung volumes with moderate bibasilar atelectasis. No evidence of intraperitoneal free air. [MASKED] TTE IMPRESSION: A left pleural effusion is present. Late bubbles seen in the left heart suggesting intrapulmonary shunting (bubbles appear at 8 beats). Normal biventricular size and systolic function. No pathologic valvular flow. Compared with the prior study (images reviewed) of [MASKED] global biventricular systolic function is more vigorous. [MASKED] EGD Findings: Esophagus: Protruding Lesions1-2 small varices were seen in the lower esophagus with no stigmata of bleeding. Stomach: Lumen:Evidence of a previous RNYGB was seen with a gastrojejunostomy. Duodenum: Flat LesionsA single small angioectasia was seen in the jejunal efferent limb. There was no evidence of bleeding. Otherduodenum not seen due to post surgical anatomy. Other findings:A jejunal feeding tube was placed into the small intestine endoscopically, however during oro-nasal conversion was noted to have become dislodged and was no longer as deep at the nares as when endoscopically placed. It was then advanced and bridled at 70 cm, however due to the fact it moved after endoscopic visualization it will require CXR prior to use. [MASKED] CXR Increased opacities at the right lung base may reflect a combination of atelectasis and pneumonia. [MASKED] Duplex Abdominal U/S 1. No evidence of portal vein thrombosis. Intermittent reversal flow within the left portal vein. Slow flow within the main portal, splenic, and superior mesenteric veins. 2. Cirrhotic liver without focal liver lesions. 3. Circumferential gallbladder wall edema, likely due to third spacing/underlying liver disease. 4. Small volume ascites. DISCHARGE LABS ====================== [MASKED] 07:55AM BLOOD WBC-14.2* RBC-2.12* Hgb-7.1* Hct-21.1* MCV-100* MCH-33.5* MCHC-33.6 RDW-20.7* RDWSD-68.7* Plt [MASKED] [MASKED] 07:55AM BLOOD [MASKED] PTT-35.3 [MASKED] [MASKED] 07:55AM BLOOD Glucose-121* UreaN-28* Creat-3.7* Na-136 K-4.3 Cl-95* HCO3-27 AnGap-14 [MASKED] 07:55AM BLOOD ALT-20 AST-66* AlkPhos-219* TotBili-1.7* [MASKED] 07:55AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.5 Brief Hospital Course: ================== BRIEF SUMMARY ================== [MASKED] with active alcohol use, alcoholic cirrhosis, Stage IV CKD, admitted for alcoholic hepatitis, decompensated cirrhosis, and anuric [MASKED] requiring initiation of HD. Patient was alert, oriented, and feeling well at discharge. Outpatient HD and Hepatology follow-up were arranged. ================== ACUTE ISSUES ================== # Decompensated alcoholic cirrhosis with ascites # Alcoholic hepatitis # Hepatic encephalopathy MELD Na 26 and Child C on presentation. LFTs and symptoms consistent with alcoholic hepatitis on cirrhosis; DF not high enough to warrant steroids. Had confusion and asterixis on admission consistent with HE. Had goals of care discussion with patient and family on [MASKED] and confirmed she wants to pursue aggressive therapy, including EGD and HD; DNR/DNI in the event of arrest. She wants to be abstinent and eventually be placed on the transplant list. EGD showed [MASKED] small varices with no stigmata of bleeding. She started lactulose and rifaximin for HE. Serial diagnostic paracentesis were negative for SBP. She had large-volume paracentesis on [MASKED] for relief of tense ascites. [MASKED] need outpatient LVP depending on whether she continues to be able to remove fluid via UF. She was maintained on high protein, [MASKED] gm sodium diet and tube feeds. She will follow up with hepatology as an outpatient. # Anuric [MASKED] on CKD Stage IV # ?Hepatorenal syndrome She did not respond to albumin challenge, nor to octreotide/midodrine for possible HRS. Octreotide was stopped but she was maintained on midodrine for soft BPs. Outpatient HD [MASKED] arranged. PPD negative. # Abdominal pain Multifactorial - alcoholic hepatitis, tense ascites, and possible acute on chronic pancreatitis (lipase 190). Was initially treated empirically for possible SBP but cell counts were not consistent; prophylaxis not indicated per Hepatology. Pain much improved after LVP [MASKED]. Repeat diagnostic para [MASKED] remained negative. # Severe protein calorie malnutrition Nutrition was consulted. Dobhoff was placed for ongoing tube feeds, and high-protein diet and supplements were prescribed. # Hypoxemia # Hepatic hydrothorax # ?Hepatopulmonary syndrome Patient had new 2L O2 requirement in setting of large R pleural effusion/hepatic hydrothorax, resolved after LVP. TTE did show evidence of pulmonary shunting which could represent HPS. # Leukocytosis Patient developed a new leukocytosis several days prior to discharge. Also had slight rise in bili and alk phos around this time. No fevers or localizing symptoms. Repeat infectious workup was unrevealing, including repeat diagnostic paracentesis, except for CXR equivocal for pneumonia. She was started on empiric oral levofloxacin for possible pneumonia, and leukocytosis stabilized for several days and LFTs improved somewhat prior to discharge. # Chronic macrocytic anemia Retics inappropriately low, consistent with marrow suppression. Likely multifactorial - EtOH, cirrhosis, splenomegaly, malnutrition, renal failure. No evidence of acute bleeding and not iron deficient on labs. B12 wnl. Hemolysis labs negative. EGD results as above. Will need continued attention as outpatient. # Chronic thrombocytopenia Likely multifactorial - EtOH, cirrhosis, splenomegaly, malnutrition. No evidence for DIC or other consumptive process. # Coagulopathy PTT was elevated due to SC heparin, normalized after this was held and dose decreased to 2500 units BID. [MASKED] were elevated due to cirrhosis. No evidence of bleeding, DIC, or other acute pathology. # Alcohol use disorder Reports daily drinking prior to admission, about [MASKED] pint qod to 1 pint/day. Last drink [MASKED]. Denies h/o withdrawal. She received IV thiamine x 3 days and maintained on oral thiamine, folate and MVI. We discussed the importance of abstinence and SW helped arrange outpatient supports. We also discussed pharmacological assistance to treat alcohol use disorder and depression, however patient deferred at this time. # Chronic RLE edema # History of RLE provoked DVT DVT occurred after left knee fracture. IVC filter was placed in [MASKED]. Course complicated by need for catheter lysis and extravasation into right thigh per patient. No longer on anticoagulation. Repeat Doppler this admission negative for persistent DVT. She continued on half-dose heparin SC. ===================== CHRONIC ISSUES ===================== # Hypothyroidism TSH 2.1 this admission. Continued home levothyroxine. # Gout Reduced home allopurinol from 100 mg daily to every other day due to renal failure. ================== TRANSITIONAL ISSUES =================== - WBC elevated to 14.0 on discharge. Please recheck at HD on [MASKED] and evaluate for signs of infection. Discharged on empiric levofloxacin for possible pneumonia (500mg q48h, last day [MASKED]. - Other medications started: midodrine 20mg TID, lactulose titrated to [MASKED] BM/day, rifaximin 550mg BID. - HD arranged [MASKED] - [MASKED] follow-up arranged - Discharged with tube feeds - [MASKED] need intermittent LVP depending on whether she tolerates UF - Did not start beta blocker for varices b/c HR [MASKED] - Patient should have CBC and MELD labs checked checked within 1 week of discharge. Script provided. # CODE: DNR/DNI # CONTACT: [MASKED] (son, HCP) [MASKED] > 30 minutes in patient care and coordination of discharge on [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Levothyroxine Sodium 62.5 mcg PO DAILY 3. Multivitamins W/minerals 1 TAB PO BID 4. Thiamine 100 mg PO DAILY 5. Allopurinol [MASKED] mg PO DAILY 6. Ascorbic Acid [MASKED] mg PO BID 7. Cyanocobalamin 50 mcg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Pyridoxine 100 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Vitamin E 400 UNIT PO QD 12. Epoetin [MASKED] [MASKED] units SC EVERY 2 WEEKS (MO) Discharge Medications: 1. Lactulose 30 mL PO TID RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth [MASKED] times per day Disp #*50 Package Refills:*0 2. Levofloxacin 500 mg PO Q48H Duration: 5 Days RX *levofloxacin 500 mg 1 tablet(s) by mouth every other day Disp #*3 Tablet Refills:*0 3. Midodrine 20 mg PO TID RX *midodrine 10 mg 2 tablet(s) by mouth three times a day Disp #*180 Tablet Refills:*3 4. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*5 5. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID RX *nut.tx.imp.renal fxn,lac-reduc [Nepro Carb Steady] 0.08 gram-1.8 kcal/mL 237 mL by mouth three times a day Refills:*0 6. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*5 7. Allopurinol [MASKED] mg PO EVERY OTHER DAY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Levothyroxine Sodium 62.5 mcg PO DAILY 10.Outpatient Lab Work ICD-10 Code: [MASKED] Please obtain by [MASKED] and fax to: Dr. [MASKED] [MASKED] CBC; Chem-10 (Na, K, Bicarb, Cl, BUN, Cr, Ca, Mg, Phos); Hepatic Panel (AST, ALT, Alk Phos, Tbili, Albumin, INR) Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis ================= Alcoholic hepatitis Decompensated alcoholic cirrhosis with ascites Acute on chronic renal failure Hepatic encephalopathy Severe protein calorie malnutrition Alcohol use disorder Thrombocytopenia Coagulopathy Anemia Community-acquired pneumonia Secondary Diagnoses ==================== Hypothyroidism Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], It was a pleasure taking care of you. WHY WAS I ADMITTED? You were admitted because alcohol damaged your liver and your kidneys. WHAT HAPPENED TO ME WHILE I WAS IN THE HOSPITAL? -You were followed closely by our liver and kidney experts. -You were started on dialysis for your kidneys. This helps remove fluid from your body since you are unable to urinate. -You had an endoscopy test which showed some dilated veins in your esophagus. -You had a tube placed from your nose into your intestine to give you more nutrition to help you recover. WHAT SHOULD I DO WHEN I GET HOME? -Follow up with your liver doctors, kidney doctors [MASKED] see them at dialysis), and your primary care doctor. -[MASKED] will need to go to dialysis three times a week [MASKED], [MASKED]. -You may need to have fluid drained from your abdomen from time to time. This can be arranged through your liver doctor. -[MASKED] all your medicines and continue your tube feeds. -Do not drink any alcohol. We strongly recommend you sign up for a program such as Alcoholic Anonymous to help you stay sober. We wish you all the best. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "D62", "M109", "E039", "I129", "F17210", "Z66", "Z86718" ]
[ "K7290: Hepatic failure, unspecified without coma", "K8520: Alcohol induced acute pancreatitis without necrosis or infection", "K767: Hepatorenal syndrome", "E43: Unspecified severe protein-calorie malnutrition", "J189: Pneumonia, unspecified organism", "K7681: Hepatopulmonary syndrome", "D689: Coagulation defect, unspecified", "N184: Chronic kidney disease, stage 4 (severe)", "N179: Acute kidney failure, unspecified", "D62: Acute posthemorrhagic anemia", "I8510: Secondary esophageal varices without bleeding", "K860: Alcohol-induced chronic pancreatitis", "D6959: Other secondary thrombocytopenia", "K7011: Alcoholic hepatitis with ascites", "K7031: Alcoholic cirrhosis of liver with ascites", "F1020: Alcohol dependence, uncomplicated", "M109: Gout, unspecified", "E039: Hypothyroidism, unspecified", "D539: Nutritional anemia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R0902: Hypoxemia", "Z66: Do not resuscitate", "Z9884: Bariatric surgery status", "Z86718: Personal history of other venous thrombosis and embolism", "Z6830: Body mass index [BMI]30.0-30.9, adult" ]
10,039,708
26,793,610
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Elevated Creatinine Major Surgical or Invasive Procedure: None History of Present Illness: is a ___ woman with a history of ETOH abuse, hypotension likely ___ autonomic instability, and recent ATN requiring temporary HD who was admitted from OSH for elevated Cr. In ___ clinic on ___ for a colposcopy for an abnormal Pap smear, she was noted to be hypotensive at that time. She had labs drawn and was later called and instructed to present to the ED for Cr 4.0. She notes increased frequency and volume of urination but denies dysuria or hematuria. She endorses nausea, bilateral lower abdominal pain and stabbing left flank pain when she needs to have a bowel movement, none of which are new. She denies fevers, chills, vomiting, diarrhea, dysuria, hematuria. Of note, she was requiring dialysis for ATN earlier this year. She is not sure of the time course but believes this ended in ___ or ___. In the ED, her course was notable for initial BP 86/51, Cr 3.9, bicarb 18, Lactate 3.0 -> ___ s/p 3L boluses IVF. Her blood pressure improved to ___ s/p IVF. UA with few bacteria, trace leuk. Her CT Abd/Pelv without contrast ___ showed no abnormalities to explain the patient's abdominal pain, including no e/o colitis. The appendix is not definitively visualized but there is no secondary signs of appendicitis and no free fluid. She had hospital stay in ___ for sepsis (likely abdominal source) and klebsiella bacteremia treated with cipro, initially requiring levophed in the MICU. Also had hospitalization ___ for hypotension and anemia of largely unknown origin (flex sig only showed minor bleeding). Fluid resuscitated and developed volume overload, ___ with Cr trend 3.3 -> 1.8 with fluids. Required CRRT for volume overload for 1 month ___ in ___. Now off CRRT. This morning she endorses her usual bilateral lower abdominal pain and nausea. She does not feel shaky or have symptoms that concern her for ETOH withdrawal. CIWA is 1 for nausea. She denies fevers, chills, chest pain, dyspnea. Social History: She reports she drinks a half pint per day, last drink on ___ at 6pm. She denies a history of DTs, withdrawal seizures, or hospitalizations for withdrawal. Past Medical History: ___'S ENCEPHELOPATHY ASTHMA TOBACCO DEPENDENCE ALCOHOL DEPENDENCE HYPOTHYROIDISM HYPERTENSION S/P BARIATRIC SURGERY H/O ALCOHOLIC HEPATITIS GOUT Social History: ___ Family History: Family history significant for T2DM, HTN, hypothyroidism and asthma. Physical Exam: ADMISSION EXAM: ======================================= VITALS: 98.2, 115/66, 59, 16, 100% GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM RESP: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops ABD: +BS, soft, non-distended, tender to palpation in RLQ and LLQ. No CVA tenderness. GU: no foley EXT: warm, well perfused, 2+ pulses, no cyanosis or edema. Tenderness to calf squeeze b/l. NEURO: motor function grossly normal DISCHARGE EXAM ======================================= Vitals: 97.7, 105/65, 60, 18, 100% on RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - Sclerae anicteric, MMM, no palatal or sublingual jaundice HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB, no wheezes ABDOMEN - +BS, soft, non-distended, tender to palpation in RLQ and LLQ. No CVA tenderness. EXTREMITIES - WWP, no edema, 2+ peripheral pulses, tenderness to calf squeeze bilaterally NEURO - awake, A&Ox3 Pertinent Results: ADMISSION LABS ___ 09:32PM BLOOD WBC-7.2 RBC-2.61* Hgb-8.7* Hct-27.7* MCV-106*# MCH-33.3*# MCHC-31.4* RDW-16.4* RDWSD-64.2* Plt ___ ___ 09:32PM BLOOD Neuts-47.7 ___ Monos-10.7 Eos-2.1 Baso-0.4 Im ___ AbsNeut-3.44# AbsLymp-2.80 AbsMono-0.77 AbsEos-0.15 AbsBaso-0.03 ___ 10:00PM BLOOD ___ PTT-30.3 ___ ___ 09:32PM BLOOD Glucose-105* UreaN-102* Creat-3.9*# Na-136 K-4.7 Cl-100 HCO3-18* AnGap-23* ___ 09:32PM BLOOD ALT-79* AST-94* AlkPhos-278* TotBili-0.5 ___ 09:32PM BLOOD cTropnT-<0.01 ___ 09:32PM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.5 Mg-2.0 ___ 09:53PM BLOOD Lactate-3.0* PERTINENT LABS ___ 08:53AM BLOOD ALT-64* AST-72* LD(LDH)-126 AlkPhos-231* TotBili-0.7 ___ 08:53AM BLOOD Lipase-39 ___ 03:18PM BLOOD TotProt-6.3* ___ 08:53AM BLOOD calTIBC-189* VitB12-527 Ferritn-3080* TRF-145* ___ 07:40AM BLOOD Cortsol-9.2 ___ 01:03AM BLOOD Lactate-2.6* DISCHARGE LABS ___ 07:40AM BLOOD WBC-5.1 RBC-2.35* Hgb-7.9* Hct-25.8* MCV-110* MCH-33.6* MCHC-30.6* RDW-16.5* RDWSD-67.1* Plt ___ ___ 07:40AM BLOOD Glucose-90 UreaN-67* Creat-2.3* Na-141 K-4.0 Cl-108 HCO3-18* AnGap-19 ___ 07:40AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.6 ___ 07:46AM BLOOD Lactate-3.8* IMAGING CXR (___): FINDINGS: The lungs are clear. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IVC filter is partially visualized. IMPRESSION: No acute cardiopulmonary process. CT A/P (___): IMPRESSION: 1. Mildly limited exam without oral or IV contrast. No abnormality identified to explain the patient's left lower quadrant abdominal pain. 2. Post gastric bypass surgery without evidence of obstruction. MICROBIOLOGY ___: Urine culture negative, blood cultures pending Brief Hospital Course: Ms. ___ is a ___ woman with a history of ETOH abuse, hypotension likely ___ autonomic instability, and recent ATN requiring temporary hemodialysis who was admitted for elevated Cr. #AoCKD, stage 3B: On initial presentation, her Cr was elevated to 3.9. Urine electrolytes were notable for FeNa of 2.6, concerning for possible ischemic ATN in the setting of her hypotension (see below). However, her Cr improved each day s/p IVF and was 2.3 at discharge (baseline ~1.8) which was reassuring. No known recent nephrotoxic drugs to raise concern for toxic ATN, though she may have been taking ibuprofen (she couldn't remember which pain reliever she has). She endorsed left flank pain, but this was chronic and she had no hematuria or dysuria to raise concern for nephrolithiasis or other obstruction. She continued to make appropriate volumes of urine and CT abdomen showed no hydronephrosis, which was reassuring against a post-renal process. #Hypotension: On initial presentation, she had systolic blood pressures in the ___ in ED, which improved to 117/69 with IV fluids. Her systolic blood pressures remained 100s-110s throughout admission. The cause of her initial hypotension is unclear. The most likely etiology is her known autonomic instability v. poor PO intake that the patient endorsed. Her AM cortisol was within an indeterminate range. She was afebrile with normal heart rates and no leukocytosis, so sepsis was unlikely. She denied chest pain, EKG without e/o ischemia or arrhythmia, and trop negative, so cardiac cause is unlikely. Patient denied history of vomiting/diarrhea to cause hypovolemia. She does endorse increased frequency and volume of urination, though seems unlikely that this would be significant enough to cause hypotension to the ___. #Anemia - Patient with stable macrocytic anemia (Hb 7.9-8.7) with elevated RDW and low MCHC, consistent with baseline. Her ferritin is elevated to 3080, TIBC is low, and transferrin saturation is 65%, likely consistent with anemia of chronic inflammation. She reports recent weight loss. Notably, she had negative HIV test in ___. She may also have bone marrow suppression from alcohol use. B12 and iron levels are wnl. In the setting of CKD, she may have reduced EPO production. Lastly, given anemia and kidney disease, multiple myeloma is on the differential. Her total protein is elevated and SPEP is pending. Notably, her calcium level is normal and she denies bone pain. #ETOH dependence: Reports drinking a pint of brandy daily, with last drink 6pm the night before admission. Throughout her stay, she denied shakiness or symptoms concerning for withdrawal, with stable CIWA of 1 for nausea. #Transaminitis: AST/ALT were mildly elevated on admission but were down-trending. INR was 1.0 and platelets within normal limits, indicating good synthetic function of liver. History and AST > ALT both argue for EtoH hepatitis. CT scan without evidence of ascites. TRANSITIONAL ISSUES: ===================== [ ] Patient should have chemistry panel drawn on ___ and faxed to ___'s office (to ensure resolution of ___. [ ] Patient encouraged to monitor BPs at home. [ ] Pending labs: SPEP, UPEP. [ ] Given indeterminate AM cortisol, consider ACTH stimulation test if concern for adrenal insufficiency is high. [ ] Patient should not take HCTZ, lisinopril, or any other potentially nephrotoxic medication. [ ] Of note, lactate elevated on discharge despite normal BP. Thought to be secondary to poor clearance in the setting of chronic liver disease. [ ] Ferritin 3000, consistent with anemia of chronic disease. Patient reported anorexia and weight loss. Consider further work-up as outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Allopurinol ___ mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. FoLIC Acid 1 mg PO DAILY 5. Levothyroxine Sodium 62.5 mcg PO DAILY 6. Multivitamins W/minerals 1 TAB PO BID 7. Ascorbic Acid ___ mg PO BID 8. Cyanocobalamin 50 mcg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. Thiamine 100 mg PO DAILY 11. Vitamin E 400 UNIT PO QD 12. Vitamin D Dose is Unknown PO DAILY 13. Pyridoxine Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Allopurinol ___ mg PO DAILY 3. Ascorbic Acid ___ mg PO BID 4. Cyanocobalamin 50 mcg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Fluticasone Propionate NASAL 1 SPRY NU BID 7. FoLIC Acid 1 mg PO DAILY 8. Levothyroxine Sodium 62.5 mcg PO DAILY 9. Multivitamins W/minerals 1 TAB PO BID 10. Pyridoxine 100 mg PO DAILY 11. Thiamine 100 mg PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. Vitamin E 400 UNIT PO QD 14.Outpatient Lab Work Check chem-10 panel on ___ and fax results to patient's PCP ___ # ___. ICD-9: 584. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypotension, Acute on chronic kidney disease, stage 3B Secondary: Anemia, alcohol dependence 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 low blood pressures and your blood tests showed abnormal kidney function. We gave you IV fluids, which brought your blood pressures back up to the normal range. Your blood tests also showed that your kidney function was improving after getting more fluid. When you go home, you should try to drink fluids to help your blood pressure and kidneys. You should NOT take your lisinopril because this can cause low blood pressure and kidney damange. You also mentioned that you have taken hydrochlorothiazide in the past. You should NOT take this medicine because it can cause low blood pressures and can damage your kidneys more. Please keep the follow up appointment with your primary care physician on ___, see below). You should have repeat blood work done on ___ to ensure that your kidney function is back to normal. Please monitor your blood pressure periodically at home. You can buy a blood pressure cuff or check your blood pressure at a drugstore ___, ___, etc). Please bring a lot of your blood pressure to your primary care physician. It was a pleasure to participate in your care. Best, Your ___ team Followup Instructions: ___
[ "N179", "E872", "I959", "N183", "I129", "F1020", "E039", "D539", "F17210", "R740" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Elevated Creatinine Major Surgical or Invasive Procedure: None History of Present Illness: is a [MASKED] woman with a history of ETOH abuse, hypotension likely [MASKED] autonomic instability, and recent ATN requiring temporary HD who was admitted from OSH for elevated Cr. In [MASKED] clinic on [MASKED] for a colposcopy for an abnormal Pap smear, she was noted to be hypotensive at that time. She had labs drawn and was later called and instructed to present to the ED for Cr 4.0. She notes increased frequency and volume of urination but denies dysuria or hematuria. She endorses nausea, bilateral lower abdominal pain and stabbing left flank pain when she needs to have a bowel movement, none of which are new. She denies fevers, chills, vomiting, diarrhea, dysuria, hematuria. Of note, she was requiring dialysis for ATN earlier this year. She is not sure of the time course but believes this ended in [MASKED] or [MASKED]. In the ED, her course was notable for initial BP 86/51, Cr 3.9, bicarb 18, Lactate 3.0 -> [MASKED] s/p 3L boluses IVF. Her blood pressure improved to [MASKED] s/p IVF. UA with few bacteria, trace leuk. Her CT Abd/Pelv without contrast [MASKED] showed no abnormalities to explain the patient's abdominal pain, including no e/o colitis. The appendix is not definitively visualized but there is no secondary signs of appendicitis and no free fluid. She had hospital stay in [MASKED] for sepsis (likely abdominal source) and klebsiella bacteremia treated with cipro, initially requiring levophed in the MICU. Also had hospitalization [MASKED] for hypotension and anemia of largely unknown origin (flex sig only showed minor bleeding). Fluid resuscitated and developed volume overload, [MASKED] with Cr trend 3.3 -> 1.8 with fluids. Required CRRT for volume overload for 1 month [MASKED] in [MASKED]. Now off CRRT. This morning she endorses her usual bilateral lower abdominal pain and nausea. She does not feel shaky or have symptoms that concern her for ETOH withdrawal. CIWA is 1 for nausea. She denies fevers, chills, chest pain, dyspnea. Social History: She reports she drinks a half pint per day, last drink on [MASKED] at 6pm. She denies a history of DTs, withdrawal seizures, or hospitalizations for withdrawal. Past Medical History: [MASKED]'S ENCEPHELOPATHY ASTHMA TOBACCO DEPENDENCE ALCOHOL DEPENDENCE HYPOTHYROIDISM HYPERTENSION S/P BARIATRIC SURGERY H/O ALCOHOLIC HEPATITIS GOUT Social History: [MASKED] Family History: Family history significant for T2DM, HTN, hypothyroidism and asthma. Physical Exam: ADMISSION EXAM: ======================================= VITALS: 98.2, 115/66, 59, 16, 100% GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM RESP: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops ABD: +BS, soft, non-distended, tender to palpation in RLQ and LLQ. No CVA tenderness. GU: no foley EXT: warm, well perfused, 2+ pulses, no cyanosis or edema. Tenderness to calf squeeze b/l. NEURO: motor function grossly normal DISCHARGE EXAM ======================================= Vitals: 97.7, 105/65, 60, 18, 100% on RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - Sclerae anicteric, MMM, no palatal or sublingual jaundice HEART - RRR, nl S1-S2, no MRG LUNGS - CTAB, no wheezes ABDOMEN - +BS, soft, non-distended, tender to palpation in RLQ and LLQ. No CVA tenderness. EXTREMITIES - WWP, no edema, 2+ peripheral pulses, tenderness to calf squeeze bilaterally NEURO - awake, A&Ox3 Pertinent Results: ADMISSION LABS [MASKED] 09:32PM BLOOD WBC-7.2 RBC-2.61* Hgb-8.7* Hct-27.7* MCV-106*# MCH-33.3*# MCHC-31.4* RDW-16.4* RDWSD-64.2* Plt [MASKED] [MASKED] 09:32PM BLOOD Neuts-47.7 [MASKED] Monos-10.7 Eos-2.1 Baso-0.4 Im [MASKED] AbsNeut-3.44# AbsLymp-2.80 AbsMono-0.77 AbsEos-0.15 AbsBaso-0.03 [MASKED] 10:00PM BLOOD [MASKED] PTT-30.3 [MASKED] [MASKED] 09:32PM BLOOD Glucose-105* UreaN-102* Creat-3.9*# Na-136 K-4.7 Cl-100 HCO3-18* AnGap-23* [MASKED] 09:32PM BLOOD ALT-79* AST-94* AlkPhos-278* TotBili-0.5 [MASKED] 09:32PM BLOOD cTropnT-<0.01 [MASKED] 09:32PM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.5 Mg-2.0 [MASKED] 09:53PM BLOOD Lactate-3.0* PERTINENT LABS [MASKED] 08:53AM BLOOD ALT-64* AST-72* LD(LDH)-126 AlkPhos-231* TotBili-0.7 [MASKED] 08:53AM BLOOD Lipase-39 [MASKED] 03:18PM BLOOD TotProt-6.3* [MASKED] 08:53AM BLOOD calTIBC-189* VitB12-527 Ferritn-3080* TRF-145* [MASKED] 07:40AM BLOOD Cortsol-9.2 [MASKED] 01:03AM BLOOD Lactate-2.6* DISCHARGE LABS [MASKED] 07:40AM BLOOD WBC-5.1 RBC-2.35* Hgb-7.9* Hct-25.8* MCV-110* MCH-33.6* MCHC-30.6* RDW-16.5* RDWSD-67.1* Plt [MASKED] [MASKED] 07:40AM BLOOD Glucose-90 UreaN-67* Creat-2.3* Na-141 K-4.0 Cl-108 HCO3-18* AnGap-19 [MASKED] 07:40AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.6 [MASKED] 07:46AM BLOOD Lactate-3.8* IMAGING CXR ([MASKED]): FINDINGS: The lungs are clear. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IVC filter is partially visualized. IMPRESSION: No acute cardiopulmonary process. CT A/P ([MASKED]): IMPRESSION: 1. Mildly limited exam without oral or IV contrast. No abnormality identified to explain the patient's left lower quadrant abdominal pain. 2. Post gastric bypass surgery without evidence of obstruction. MICROBIOLOGY [MASKED]: Urine culture negative, blood cultures pending Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with a history of ETOH abuse, hypotension likely [MASKED] autonomic instability, and recent ATN requiring temporary hemodialysis who was admitted for elevated Cr. #AoCKD, stage 3B: On initial presentation, her Cr was elevated to 3.9. Urine electrolytes were notable for FeNa of 2.6, concerning for possible ischemic ATN in the setting of her hypotension (see below). However, her Cr improved each day s/p IVF and was 2.3 at discharge (baseline ~1.8) which was reassuring. No known recent nephrotoxic drugs to raise concern for toxic ATN, though she may have been taking ibuprofen (she couldn't remember which pain reliever she has). She endorsed left flank pain, but this was chronic and she had no hematuria or dysuria to raise concern for nephrolithiasis or other obstruction. She continued to make appropriate volumes of urine and CT abdomen showed no hydronephrosis, which was reassuring against a post-renal process. #Hypotension: On initial presentation, she had systolic blood pressures in the [MASKED] in ED, which improved to 117/69 with IV fluids. Her systolic blood pressures remained 100s-110s throughout admission. The cause of her initial hypotension is unclear. The most likely etiology is her known autonomic instability v. poor PO intake that the patient endorsed. Her AM cortisol was within an indeterminate range. She was afebrile with normal heart rates and no leukocytosis, so sepsis was unlikely. She denied chest pain, EKG without e/o ischemia or arrhythmia, and trop negative, so cardiac cause is unlikely. Patient denied history of vomiting/diarrhea to cause hypovolemia. She does endorse increased frequency and volume of urination, though seems unlikely that this would be significant enough to cause hypotension to the [MASKED]. #Anemia - Patient with stable macrocytic anemia (Hb 7.9-8.7) with elevated RDW and low MCHC, consistent with baseline. Her ferritin is elevated to 3080, TIBC is low, and transferrin saturation is 65%, likely consistent with anemia of chronic inflammation. She reports recent weight loss. Notably, she had negative HIV test in [MASKED]. She may also have bone marrow suppression from alcohol use. B12 and iron levels are wnl. In the setting of CKD, she may have reduced EPO production. Lastly, given anemia and kidney disease, multiple myeloma is on the differential. Her total protein is elevated and SPEP is pending. Notably, her calcium level is normal and she denies bone pain. #ETOH dependence: Reports drinking a pint of brandy daily, with last drink 6pm the night before admission. Throughout her stay, she denied shakiness or symptoms concerning for withdrawal, with stable CIWA of 1 for nausea. #Transaminitis: AST/ALT were mildly elevated on admission but were down-trending. INR was 1.0 and platelets within normal limits, indicating good synthetic function of liver. History and AST > ALT both argue for EtoH hepatitis. CT scan without evidence of ascites. TRANSITIONAL ISSUES: ===================== [ ] Patient should have chemistry panel drawn on [MASKED] and faxed to [MASKED]'s office (to ensure resolution of [MASKED]. [ ] Patient encouraged to monitor BPs at home. [ ] Pending labs: SPEP, UPEP. [ ] Given indeterminate AM cortisol, consider ACTH stimulation test if concern for adrenal insufficiency is high. [ ] Patient should not take HCTZ, lisinopril, or any other potentially nephrotoxic medication. [ ] Of note, lactate elevated on discharge despite normal BP. Thought to be secondary to poor clearance in the setting of chronic liver disease. [ ] Ferritin 3000, consistent with anemia of chronic disease. Patient reported anorexia and weight loss. Consider further work-up as outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Allopurinol [MASKED] mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. FoLIC Acid 1 mg PO DAILY 5. Levothyroxine Sodium 62.5 mcg PO DAILY 6. Multivitamins W/minerals 1 TAB PO BID 7. Ascorbic Acid [MASKED] mg PO BID 8. Cyanocobalamin 50 mcg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. Thiamine 100 mg PO DAILY 11. Vitamin E 400 UNIT PO QD 12. Vitamin D Dose is Unknown PO DAILY 13. Pyridoxine Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Allopurinol [MASKED] mg PO DAILY 3. Ascorbic Acid [MASKED] mg PO BID 4. Cyanocobalamin 50 mcg PO DAILY 5. Ferrous Sulfate 325 mg PO DAILY 6. Fluticasone Propionate NASAL 1 SPRY NU BID 7. FoLIC Acid 1 mg PO DAILY 8. Levothyroxine Sodium 62.5 mcg PO DAILY 9. Multivitamins W/minerals 1 TAB PO BID 10. Pyridoxine 100 mg PO DAILY 11. Thiamine 100 mg PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. Vitamin E 400 UNIT PO QD 14.Outpatient Lab Work Check chem-10 panel on [MASKED] and fax results to patient's PCP [MASKED] # [MASKED]. ICD-9: 584. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypotension, Acute on chronic kidney disease, stage 3B Secondary: Anemia, alcohol dependence 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 low blood pressures and your blood tests showed abnormal kidney function. We gave you IV fluids, which brought your blood pressures back up to the normal range. Your blood tests also showed that your kidney function was improving after getting more fluid. When you go home, you should try to drink fluids to help your blood pressure and kidneys. You should NOT take your lisinopril because this can cause low blood pressure and kidney damange. You also mentioned that you have taken hydrochlorothiazide in the past. You should NOT take this medicine because it can cause low blood pressures and can damage your kidneys more. Please keep the follow up appointment with your primary care physician on [MASKED], see below). You should have repeat blood work done on [MASKED] to ensure that your kidney function is back to normal. Please monitor your blood pressure periodically at home. You can buy a blood pressure cuff or check your blood pressure at a drugstore [MASKED], [MASKED], etc). Please bring a lot of your blood pressure to your primary care physician. It was a pleasure to participate in your care. Best, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "N179", "E872", "I129", "E039", "F17210" ]
[ "N179: Acute kidney failure, unspecified", "E872: Acidosis", "I959: Hypotension, 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", "F1020: Alcohol dependence, uncomplicated", "E039: Hypothyroidism, unspecified", "D539: Nutritional anemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]" ]
10,039,708
28,258,130
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chief Complaint: Hypotension Reason for MICU transfer: Refractory hypotension, severe anemia Major Surgical or Invasive Procedure: Intubation: ___ Sigmoidoscopy ___ EGD ___ Tunneled hemodialysis line placement ___ Colonoscopy ___ History of Present Illness: ___ with a PMH of EtOH abuse, liver disease, hypothyroidism, and hypertension who presents with hypotension and severe anemia. The patient was seen at her PCPs office today for a a few days of fatigue and weakness. There she was found to be hypotensive to the 64/34, pulse 93. She was sent to ___ by ambulance. She has also been having diarrhea for the past few days with normal stool color. She denies CP, SOB, Abd pain, N/V, dysuria. No hx of GIB. No previous EGDs or colonoscopies. Of note, the patient had a recent admission to ___ ___ for dizziness and hypotension that responded to IVF. At that time her H/H was 9.9/29, cr 1.3. In the ED, initial vitals: 97.8 90 70/42 18 100% RA. She was hypothermic in the ED to 34 degrees C after getting 3L IVF; was given a bear hugger. Labs were notable for: H/H 4.3/14.4 with MCV 107, PTT 140 with INR 1.1, transaminitis with AST 168 and ALT 89, Tbili 0.7, alb 2.3, creatinine 2.9->2.5 (baseline 0.9), bicarb 8->11, VBG 7.25/33/40/15, lactate 2.1-> 1.5, neg UA. Exam was significant for normal mentation and brown, guaiac negative stool. CXR was without acute findings, and CTA abd/pelvis was without source of bleed, but showed hepatic steatosis, colitis versus portal colopathy, and heterogenous kidneys. A cordis was placed in the R femoral vein for resuscitation. The patient was given: ___ 13:12 IVF 1000 mL NS 1000 mL ___ 13:53 IVF 1000 mL NS 1000 mL ___ 15:23 IVF 1000 mL NS 1000 mL ___ 15:34 IV Piperacillin-Tazobactam 4.5 g ___ 15:34 PO Acetaminophen 1000 mg ___ 15:34 IV BOLUS Pantoprazole 80 mg ___ 16:16 IVF 1000 mL NS 1000 mL ___ 16:16 IV Vancomycin 1000 mg ___ 16:30 IV DRIP Pantoprazole Started 8 mg/hr 4 units pRBCs. On arrival to the MICU, the patient's vitals were 97.8 77 81/43 18 99% on RA. She was persistently hypotensive to ___. She was mentating well. She was given a total of 4L IVF and started on levophed without blood pressure response. A-line was placed. Past Medical History: ___'S ENCEPHELOPATHY ASTHMA TOBACCO DEPENDENCE ALCOHOL DEPENDENCE HYPOTHYROIDISM HYPERTENSION S/P BARIATRIC SURGERY H/O ALCOHOLIC HEPATITIS GOUT Social History: ___ Family History: Family history significant for T2DM, HTN, hypothyroidism and asthma. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 97.8 90 70/42 18 100% RA. GENERAL: Alert, oriented, no acute distress. HEENT: PERRL, MMM NECK: supple, JVP not elevated LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, mildly distended, no tenderness to palpation. EXT: Warm, no edema LINES: right femoral CVL, right PIV, foley in place DISCHARGE PHYSICAL EXAM: ======================== VS 98.3 124/84 66 18 100%RA FSBG 67 (getting juice) GENERAL: NAD, ill appearing, awake and interactive HEENT: AT/NC, MMM, NGT in place Chest: R anterior chest wall improved tenderness at tunneled HD site. without erythema or fluctance. CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTA in anterior and axillary fields ABDOMEN: scaphoid. +BS, minimal tenderness diffusely EXTREMITIES: RLE edema present 1+ to around mid thigh asymmetrically w/ LLE with no edema. SKIN: warm, DP 2+ b/l Pertinent Results: ADMISSION LABS ============== ___ 01:40PM BLOOD WBC-7.5# RBC-1.35*# Hgb-4.3*# Hct-14.4*# MCV-107*# MCH-31.9# MCHC-29.9* RDW-19.8* RDWSD-74.3* Plt ___ ___ 01:40PM BLOOD Neuts-60.3 ___ Monos-11.2 Eos-0.8* Baso-0.0 Im ___ AbsNeut-4.54 AbsLymp-1.99 AbsMono-0.84* AbsEos-0.06 AbsBaso-0.00* ___ 01:40PM BLOOD ___ PTT-140.0* ___ ___ 02:39PM BLOOD ___ 01:40PM BLOOD Glucose-123* UreaN-62* Creat-2.9*# Na-140 K-5.4* Cl-123* HCO3-8* AnGap-14 ___ 01:40PM BLOOD ALT-89* AST-168* AlkPhos-259* TotBili-0.7 ___ 07:30PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 02:39PM BLOOD Albumin-2.1* ___ 07:14PM BLOOD Calcium-6.4* Phos-3.7# Mg-1.2* ___ 11:51PM BLOOD calTIBC-90* VitB12-GREATER TH Folate-GREATER TH ___ Ferritn-1085* TRF-69* ___ 07:30PM BLOOD Cortsol-7.4 ___ 07:30PM BLOOD ASA-NEG Acetmnp-9* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:43PM BLOOD ___ pO2-40* pCO2-33* pH-7.25* calTCO2-15* Base XS--11 ___ 01:43PM BLOOD Lactate-2.1* PERTINENT LABS: =============== Lactate trend: ___ 02:44PM BLOOD Lactate-1.5 ___ 07:48PM BLOOD Lactate-3.4* ___ 12:10AM BLOOD Lactate-3.9* ___ 12:49AM BLOOD Lactate-3.6* ___ 12:15PM BLOOD Lactate-6.7* ___ 05:30PM BLOOD Lactate-7.2* ___ 09:55PM BLOOD Glucose-187* Lactate-5.8* Na-133 K-3.3 Cl-112* ___ 01:49AM BLOOD Lactate-4.9* ___ 11:35AM BLOOD Lactate-3.4* ___ 03:54AM BLOOD Lactate-2.5* ___ 06:27PM BLOOD Lactate-1.7 Troponin trend: ___ 07:30PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 05:51AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 08:45AM BLOOD CK-MB-1 cTropnT-0.04* ___ 06:41PM BLOOD CK-MB-2 cTropnT-0.07* ___ 12:04AM BLOOD CK-MB-2 cTropnT-0.09* ___ 03:38AM BLOOD cTropnT-0.05* ___ 01:36AM BLOOD cTropnT-0.03* ___ 07:19AM BLOOD CK-MB-3 cTropnT-0.02* BNP: ___ 12:04AM BLOOD ___ ___ 05:32AM BLOOD Ret Aut-6.0* Abs Ret-0.16* ___ 04:15AM BLOOD ALT-19 AST-32 LD(LDH)-201 AlkPhos-217* TotBili-1.0 ___ 04:15AM BLOOD calTIBC-104* VitB12-GREATER TH Hapto-8* TRF-80* ___ 03:06AM BLOOD Ferritn-2632* ___ 11:10AM BLOOD %HbA1c-5.6 eAG-114 ___ 02:30PM BLOOD Triglyc-59 ___ 05:08PM BLOOD Osmolal-308 ___ 07:30PM BLOOD TSH-0.82 ___ 05:25AM BLOOD Cortsol-13.8 ___ 05:44AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE ___ 03:29PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 02:39PM BLOOD ANCA-NEGATIVE B ___ 05:41AM BLOOD AMA-NEGATIVE ___ 05:41AM BLOOD ___ ___ 05:45AM BLOOD C3-88* C4-27 ___ 07:30PM BLOOD HIV Ab-Negative ___ 05:27PM BLOOD ANTI-PLATELET ANTIBODY-Test Test Flag Result Unit Reference Value ---- ---- ------ ---- --------------- Platelet Ab, S Positive Not Applicable Comment Antibody reacts with glycoprotein to HLA Class I, probable alloimmunization due to pregnancy/transplant/transfusion. ___ 12:00AM BLOOD COPPER (SERUM)-Test Test Result Reference Range/Units COPPER 91 70-175 mcg/dL ___ 12:00AM BLOOD ZINC-Test Test Result Reference Range/Units ZINC 48 L 60-130 mcg/dL ___ 11:55PM BLOOD VITAMIN B1-WHOLE BLOOD-Test Test Result Reference Range/Units VITAMIN B1 (THIAMINE), 1118 H 78-185 nmol/L BLOOD, LC/MS/MS ___ 11:55PM BLOOD VITAMIN C-Test Test Result Reference Range/Units VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL ___ 09:10PM BLOOD SELENIUM-Test Test Result Reference Range/Units SELENIUM 29 L 63-160 mcg/L ___ 09:10PM BLOOD COPPER (SERUM)-Test Test Result Reference Range/Units COPPER 34 L 70-175 mcg/dL ___ 09:10PM BLOOD ZINC-Test Test Result Reference Range/Units ZINC 32 L 60-130 mcg/dL ZINC Test Result Reference Range/Units ZINC (repeat on ___ 27 L 60-130 mcg/dL ___ 09:10PM BLOOD VITAMIN C-Test Test Result Reference Range/Units VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL ___ 09:10PM BLOOD CERULOPLASMIN-Test Test Result Reference Range/Units CERULOPLASMIN 14 L ___ mg/dL ___ 06:35PM BLOOD VITAMIN B1-WHOLE BLOOD-Test Test Result Reference Range/Units VITAMIN B1 (THIAMINE), >1200 H 78-185 nmol/L BLOOD, LC/MS/MS ___ 01:17PM BLOOD HEPARIN DEPENDENT ANTIBODIES-TEST TEST RESULTS REFERENCE RANGE UNITS ____________________ _______ _______________ _____ PF4 Heparin Antibody .10 0.00 - 0.39 ___ 01:17PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test Test Result Reference Range/Units SOURCE Whole Blood EBV DNA, QN PCR <200 <200 copies/mL ___ 10:28AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-Test Test Result Reference Range/Units PARVOVIRUS B19 ANTIBODY 8.48 H (IGG) Reference Range <0.9 Negative 0.9-1.1 Equivocal >1.1 Positive IgG persists for years and provides life-long immunity. To diagnose current infection, consider Parvovirus B19 DNA, PCR. Test Result Reference Range/Units PARVOVIRUS B19 ANTIBODY <0.9 (IGM) Reference Range <0.9 Negative 0.9-1.1 Equivocal >1.1 Positive Results from any one IgM assay should not be used as a sole determinant of a current or recent infection. Because IgM tests can yield false positive results and low levels of IgM antibody may persist for months post infection, reliance on a single test result could be misleading. If an acute infection is suspected, consider obtaining a new specimen and submit for both IgG and IgM testing in two or more weeks. To diagnose current infection, consider parvovirus B19 DNA,PCR. ___ 11:56AM BLOOD T4, FREE, DIRECT DIALYSIS-Test Test Result Reference Range/Units T4, FREE, DIRECT DIALYSIS 3.3 H 0.8-2.7 ng/dL Urine studies: ___ 09:33AM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 09:33AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 10:39PM URINE RBC-151* WBC->182* Bacteri-FEW Yeast-NONE Epi-2 TransE-1 ___ 01:20PM URINE AmorphX-FEW ___ 09:33AM URINE Hours-RANDOM UreaN-332 Creat-101 Na-41 K-43 Cl-12 TotProt-171 Prot/Cr-1.7* Albumin-36.1 Alb/Cre-357.4* DISCHARGE LABS: =============== ___ 04:57AM BLOOD WBC-9.6 RBC-2.84* Hgb-9.0* Hct-27.5* MCV-97 MCH-31.7 MCHC-32.7 RDW-19.0* RDWSD-67.4* Plt ___ ___ 12:30PM BLOOD ___ PTT-56.4* ___ ___ 04:57AM BLOOD Glucose-61* UreaN-33* Creat-2.9*# Na-137 K-4.6 Cl-100 HCO3-24 AnGap-18 ___ 05:45AM BLOOD Glucose-75 UreaN-59* Creat-4.1* Na-138 K-5.4* Cl-106 HCO3-20* AnGap-17 ___ 04:15AM BLOOD ALT-19 AST-32 LD(LDH)-201 AlkPhos-217* TotBili-1.0 ___ 04:57AM BLOOD Calcium-8.7 Phos-5.8*# Mg-2.1 ___ 04:15AM BLOOD calTIBC-104* VitB12-GREATER TH Hapto-8* TRF-80* ___ 03:06AM BLOOD Ferritn-2632* ___ 02:30PM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND ___ 05:44AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE ___ 03:29PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE ___ 07:30PM BLOOD HIV Ab-Negative ___ 02:30PM BLOOD HCV Ab-PND ___ 03:29PM BLOOD HCV Ab-NEGATIVE ___ 06:27AM BLOOD freeCa-1.17 MICROBIOLOGY: ============= __________________________________________________________ ___ 11:53 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). __________________________________________________________ ___ 1:29 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 9:07 am BLOOD CULTURE Source: Line-hd line. Blood Culture, Routine (Pending): __________________________________________________________ ___ 9:07 am BLOOD CULTURE Source: Line-aline 1 OF 2. Blood Culture, Routine (Pending): __________________________________________________________ ___ 3:39 pm Mini-BAL GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: YEAST. ~3000/ML. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): YEAST. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. __________________________________________________________ ___ 1:39 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. YEAST. ~3000/ML. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): Negative results: ___ URINE URINE CULTURE-FINAL INPATIENT ___ Immunology (CMV) CMV Viral Load-FINAL INPATIENT ___ SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT ___ SWAB Chlamydia trachomatis, Nucleic Acid Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT ___ URINE Chlamydia trachomatis, Nucleic Acid Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT ___ STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; FECAL CULTURE - R/O VIBRIO-FINAL; FECAL CULTURE - R/O YERSINIA-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ STOOL C. difficile DNA amplification assay-FINAL INPATIENT ___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___- urine cultures x2 URINE CULTURE (Final ___: YEAST. 10,000-100,000 ORGANISMS/ML.. URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION ___ - blood cultures x2 - no growth PERTINENT STUDIES: ================== ___ CXR: FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. Chain sutures are noted in the left upper quadrant of the abdomen. IMPRESSION: No acute cardiopulmonary abnormality ___ CT abd/pelvis: IMPRESSION: 1. No active extravasation of contrast to suggest active GI bleeding at this time. 2. Profound hepatic steatosis. Enlarged periportal lymph nodes with hazy mesentery and retroperitoneum likely reflect underlying liver disease. 3. Colonic and rectal wall thickening which may reflect colitis versus portal colopathy. 4. Heterogeneous appearance of the kidneys with possible striated nephrograms. Correlate with urinalysis to exclude pyelonephritis. ___ TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 65%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are mildly myxomatous. Frank mitral valve prolapse is not seen but cannot be excluded with certainty. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. ___ ___ IMPRESSION: 1. Occlusive thrombus of all right lower extremity deep veins from the common femoral vein down to the calf veins. 2. Patent left lower extremity veins. ___ ECHO The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. LV systolic function appears depressed (LVEF = 40%) secondary to hypokinesis of the basal two-thirds of the left ventricle. The apical one-third of the left ventricle is hyperdynamic. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. The pulmonary artery is not well visualized. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, left ventricular systolic dysfunction is now present. Findings suggestive of stress cardiomyopathy with inverse Takotsubo pattern of left ventricular contractile dysfunction. ___ CTH: IMPRESSION: 1. There is mild progression of global cerebral atrophy since the prior examination of ___, greater than would be expected for the patient's age. 2. No intracranial hemorrhage or territorial infarct. ___ LIVER US: IMPRESSION: 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. Trace ascites and small right pleural effusion. ___ IVC filter placement: FINDINGS: 1. Patent normal sized, non-duplicated IVC with no evidence of a IVC thrombus. A small circumaortic renal vein originating from the IVC just above the bifurcation was noted however is very small in caliber and likely of no clinical significance. 2. Successful deployment of an infra-renal retrievable IVC filter. IMPRESSION: Successful deployment of an infra-renal removable IVC filter. ___ ECHO: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve 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 trivial/physiologic pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved regional and low normal global biventricular systolic function. No valvular pathology or pathologic flow identified. Trivial pericardial effusion. ___ Unilateral RLE veins IMPRESSION: Extensive deep venous thrombosis involving the wall of the right lower extremity veins, overall similar to ___, but now with perhaps minimal flow in the distal right SFV. ___ Video oropharyngeal swallow study Aspiration with thin liquid consistency. ___ Portable abdomen x-ray Patient is post gastric bypass surgery. The Dobbhoff tube ends in the proximal jejunum. ___ Renal ultrasound No evidence of hydronephrosis. Increased renal echogenicity consistent with diffuse parenchymal renal disease. Small bilateral effusions and small to moderate volume ascites. ___ - EGD Duodenum was not examined. Small gastric pouch consistent with Roux en y anatomy the blind limb and jejunal limb were both visualized. No varices. Otherwise normal EGD to the jejunum. Brief Hospital Course: ___ hx gastric bypass surgery, alcohol abuse complicated by Wernicke's encephalopathy, concern for autonomic insufficiency, presented originally with hypotension, anemia and academia. Her course in the MICU was complicated by severe nutritional deficiency, volume overload, renal failure, cardiomyopathy, hypoxemia and hypoxemic respiratory failure, and deep vein thrombosis. # Hypotension: # Cardiomyopathy: # Presumed alcoholic liver disease: Patient was given 4u PRBCs in the ED prior to FICU admission; her Hgb was stable for days afterward, and there was low suspicion for active GIB initially in her MICU course. She was empirically antiobiosed for concern of sepsis, but no source was found, and these antibiotics were held until a series of presumed aspiration events that will be discussed below. Morning cortisol was within normal limits twice; TSH was also within normal limits. She underwent several echocardiograms to explain her persistent hypotension with pressor requirement that showed in sequence: mitral regurgitation with eccentric jet; inverse Takutsubo's cardiomyopathy; and then resolution of these issues. Of note, the resolution occurred after initiation of high-dose thiamine repletion, which may suggest an element of wet beriberbi from severe nutritional deficiency in the setting of gastric bypass and alcoholism. There was also strong suspicion of cirrhosis given her imaging and alcohol abuse history, for which she was started on midodrine. With these measures, she was successfully weaned from pressors. Unresolved at the time of her MICU discharge was a question of autonomic insufficiency raised in her last Discharge Summary of ___ where it was thought her alcohol abuse could be contributing to baseline systolic pressures in the ___. This in part resolved on the floor as the patient was weaned off midodrine and maintained systolic blood pressure in the 100s. # Anemia: -Unexplained, possible GI source with lack of erythropoietin in the setting of subacute renal failure . Patient had decreasing pRBC transfusion requirements over the course of her stay, ultimately needing 1U pRBC every 4 days. She was evaluated by Hem/Onc who felt there was no evidence of significant hemolysis or malignancy and felt that there was an element of anemia of chronic inflammation, as well as decreased erythropoietin in the setting of subacute renal failure. She was evaluated by GI who found no source of bleed on sigmoidoscopy early in her course and no varices or bleeding on EGD. She had an episode of guaiac positive stool but had no significant bleeding on colonoscopy. Patient may benefit from outpatient capsule study if bleeding is ongoing. # Thrombocytopenia: There was no evidence of active bleed on presentation (stool normal color, not tachycardic, no clinical or radiographic evidence of extravasation into a compartment). Surgery and GI were consulted early in her MICU course for concern of ischemic gut in the setting of rising lactate, but flexible sigmoidoscopy was negative for this and lactate resolved with fluid resuscitation. ___ Hematology consulted, and believe her anemia and thrombocytopenia are likely a combination of alcoholic bone marrow suppression, malnutrition and critical illness. She may benefit from a bone marrow biopsy when more stable; additionally, given her renal failure, she may have a developing EPO deficiency. She was transfused by ED prior to MICU admission and did not require further blood products until ___ (gradually dropping Hct attributed to anemia of chronic illness/inflammation/underproduction; she held her Hct each time after transfusion). # Diarrhea: Negative c. diff, improved over the course of the hospital stay. Possibly related to tube feeding formulas as this improved with changing to a higher fiber formula and with the addition of banana flakes. Recommend continued loperamide as needed and optimization of tube feeds in patient s/p gastric bypass. # Renal Failure (Addressed Separately Below): Presented with serum bicarbonate of 8 of unclear etiology. She manifested diarrhea in the early part of her ICU stay (C diff assay negative, thought related to either alcohol abuse or early course of antibiotics administered empirically for presumed sepsis, resolved); her renal function markers may also have been under-estimates of her true GFR given her nutritionally deficient state. Acidemia corrected with bicarbonate drip, but recurrence remains in a concern in the setting of her renal failure with poor UOP. CRRT was started in the setting of volume overload in the ICU as described above, though she was noted to have ATN by muddy brown casts in her urine as well as persistently poor UOP. At time of FICU discharge she is being trialed off CRRT, though with her poor UOP she may need to be initiated on standing dialysis. Upon transfer to the floor, her renal function did not improve and she remained oliguric. She was evaluated by nephrology who felt that ATN without renal recovery was the most likely diagnosis based on her urine sediment and history. A renal biopsy was considered, but nephrology felt that the risks of the biopsy on a patient already requiring heparin for DVT would outweigh the benefits with the suspicion of ATN being high already. Urine output remained low prior to discharge, and tunneled HD line was placed for longer-term access. # Respiratory Failure: Patient developed progressive hypoxemia from volume overload eventually requiring CRRT with resolution of the same. However, on ___ she had an unexplained hypoxemic respiratory episode with persistent SpO2 measurements in the ___ despite NRB and NC; she was intubated with ___ of continued O2 saturations in the ___ before resolution not attributable to any particular intervention (nebs, suction, etc). This first hypoxemic episode was attributed to aspiration though subsequent CXR and bronchoscopy were not impressive for evidence of the same. She was extubated within 24hrs, but then reintubated in the setting of a break in her CRRT line that caused acute hypotension from blood loss (trapped in the CRRT circuit) and then hypoxemia. After restoration of hemodynamic stability and passing her RSBI, she was again extubated, but re-intubated for nearly the same exact sequence of events that evening(break in the CRRT circuit due to equipment failure; this has been reported and is being investigated). She was finally extubated on ___ and remains off supplemental O2 at time of MICU discharge. Antibiotics were empirically started in the setting of possible aspiration with leukocytosis (that could have been a stress reaction to aspiration pneumonitis or intubations/exbuations); these will finish on ___. She completed her course of antibiotics and remained afebrile and without respiratory distress the rest of her hospitalization. # Alcohol Abuse: Patient endorses heavy alcohol use. She was seen by social work who gave resources, though patient is not interested in counseling. # Severe Nutritional Deficiency: Nutritional deficiencies including zinc and selenium requiring significant repletion. Repeat testing of zinc showed continued need for repletion. Caloric needs and repletion addressed below. # Severe malnutrition: likely contributor to pancytopenia resulting from bone marrow suppression. Required tube feeding tube feed which was continued at discharge in order to meet her caloric needs. She was initially found to aspirate thin liquids by a speech and swallow evaluation, however on reevaluation after receiving tube feeds for some time, she was able to tolerate a regular diet and thin liquids. Her caloric intake by mouth was not sufficient to decrease tube feeds. # Hx Wernicke's Encephalopathy: Patient had waxing/waning mental status for much of her early hospital course which was initially attributed to delirium; however, for history of Wernicke's she was started on high-dose thiamine that seemed to improve her mental status. Nutrition was consulted, and nutrition labs were sent that were all markedly low. She was supplemented through her TFs and will need to remain on standing thiamine. # Deep Vein Thrombosis: Patient arrived to MICU with L femoral CVL; shortly thereafter, asymmetric R > L lower extremity swelling was noticed for which ___ was obtained - this showed extensive venous clot burden in the R lower extremity. IV heparin was started. Because of persistent thrombocytopenia, an IVC filter was placed, though because of her high clot risk IV heparin was continued. She should have interval follow-up of her DVTs after discharge, as well as scheduled follow-up with ___ for filter removal. She was maintained on a heparin drip and should be bridged to Coumadin to follow up with hematology/oncology as an outpatient. # Concern for Gastrointestinal Bleed: As described above, GI and Surgery were consulted early in her MICU stay for rising lactate and concern of gut ischemia in the setting of her hypotension; flexible sigmoidoscopy was unimpressive and lactate improved with pressors and IVF. Near the end of her FICU stay she had fresh blood coating a stool which raised concern for GIB; however, her Hct was stable, she was HD stable, and guaiacs of subsequent stools were negative prior to MICU discharge. She underwent evaluation by Hepatology and EGD which showed no varices, negative colonoscopy. Capsule study failed, but patient's H/H stabilized and hepatology felt the study could be done as an outpatient if necessary. **Transitional:** TRANSITIONAL ISSUES: -Patient will need daily assessment for hemodialysis needs, EPO with HD given renal failure -Reassess nutritional status and continued need for tube feeding, potential need for G-tube -Daily electrolytes and every other day CBC to evaluate need for blood transfusion -Patient on heparin gtt for DVT. Recommend bridge to coumadin -Needs appointment with OBGYN for Mirena IUD removal. Pt states this was places at least ___ years ago. -encourage smoking/alcohol cessation -f/u for potential IVC filter removal in the future -Outpatient hepatology f/u, consider outpatient capsule study -Outpatient Hematology f/u with Dr. ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath 4. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Cyanocobalamin 50 mcg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins W/minerals 1 TAB PO BID 4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Heparin IV per Weight-Based Dosing Guidelines Initial Bolus: 3900 units IVP Initial Infusion Rate: 850 units/hr Start: Today - ___, First Dose: 1600 Target PTT: 60 - 100 seconds 7. Nephrocaps 1 CAP PO DAILY 8. Warfarin 5 mg PO DAILY16 first dose ___ 9. sevelamer CARBONATE 800 mg PO TID W/MEALS 10. LOPERamide 2 mg PO QID:PRN diarrhea 11. Sarna Lotion 1 Appl TP PRN itching Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: acute oliguric renal failure, deep vein thrombosis, anemia, thrombocytopenia, hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at the ___ ___. You were hospitalized with low blood pressure and low blood counts. You were treated with blood transfusions, kidney replacement therapy, and antibiotics. You were found to have a blood clot in your leg and are being treated with blood thinning medications. Your platelets were low but these recovered. Your kidney function has not recovered prior to leaving the hospital and you will be discharged with a hemodialysis line. You were evaluated for GI bleeds, and these studies were reassuring. If you continue to bleed, you may benefit from a capsule study as an outpatient. Best wishes, Your ___ Care Team Followup Instructions: ___
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Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chief Complaint: Hypotension Reason for MICU transfer: Refractory hypotension, severe anemia Major Surgical or Invasive Procedure: Intubation: [MASKED] Sigmoidoscopy [MASKED] EGD [MASKED] Tunneled hemodialysis line placement [MASKED] Colonoscopy [MASKED] History of Present Illness: [MASKED] with a PMH of EtOH abuse, liver disease, hypothyroidism, and hypertension who presents with hypotension and severe anemia. The patient was seen at her PCPs office today for a a few days of fatigue and weakness. There she was found to be hypotensive to the 64/34, pulse 93. She was sent to [MASKED] by ambulance. She has also been having diarrhea for the past few days with normal stool color. She denies CP, SOB, Abd pain, N/V, dysuria. No hx of GIB. No previous EGDs or colonoscopies. Of note, the patient had a recent admission to [MASKED] [MASKED] for dizziness and hypotension that responded to IVF. At that time her H/H was 9.9/29, cr 1.3. In the ED, initial vitals: 97.8 90 70/42 18 100% RA. She was hypothermic in the ED to 34 degrees C after getting 3L IVF; was given a bear hugger. Labs were notable for: H/H 4.3/14.4 with MCV 107, PTT 140 with INR 1.1, transaminitis with AST 168 and ALT 89, Tbili 0.7, alb 2.3, creatinine 2.9->2.5 (baseline 0.9), bicarb 8->11, VBG 7.25/33/40/15, lactate 2.1-> 1.5, neg UA. Exam was significant for normal mentation and brown, guaiac negative stool. CXR was without acute findings, and CTA abd/pelvis was without source of bleed, but showed hepatic steatosis, colitis versus portal colopathy, and heterogenous kidneys. A cordis was placed in the R femoral vein for resuscitation. The patient was given: [MASKED] 13:12 IVF 1000 mL NS 1000 mL [MASKED] 13:53 IVF 1000 mL NS 1000 mL [MASKED] 15:23 IVF 1000 mL NS 1000 mL [MASKED] 15:34 IV Piperacillin-Tazobactam 4.5 g [MASKED] 15:34 PO Acetaminophen 1000 mg [MASKED] 15:34 IV BOLUS Pantoprazole 80 mg [MASKED] 16:16 IVF 1000 mL NS 1000 mL [MASKED] 16:16 IV Vancomycin 1000 mg [MASKED] 16:30 IV DRIP Pantoprazole Started 8 mg/hr 4 units pRBCs. On arrival to the MICU, the patient's vitals were 97.8 77 81/43 18 99% on RA. She was persistently hypotensive to [MASKED]. She was mentating well. She was given a total of 4L IVF and started on levophed without blood pressure response. A-line was placed. Past Medical History: [MASKED]'S ENCEPHELOPATHY ASTHMA TOBACCO DEPENDENCE ALCOHOL DEPENDENCE HYPOTHYROIDISM HYPERTENSION S/P BARIATRIC SURGERY H/O ALCOHOLIC HEPATITIS GOUT Social History: [MASKED] Family History: Family history significant for T2DM, HTN, hypothyroidism and asthma. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 97.8 90 70/42 18 100% RA. GENERAL: Alert, oriented, no acute distress. HEENT: PERRL, MMM NECK: supple, JVP not elevated LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, mildly distended, no tenderness to palpation. EXT: Warm, no edema LINES: right femoral CVL, right PIV, foley in place DISCHARGE PHYSICAL EXAM: ======================== VS 98.3 124/84 66 18 100%RA FSBG 67 (getting juice) GENERAL: NAD, ill appearing, awake and interactive HEENT: AT/NC, MMM, NGT in place Chest: R anterior chest wall improved tenderness at tunneled HD site. without erythema or fluctance. CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTA in anterior and axillary fields ABDOMEN: scaphoid. +BS, minimal tenderness diffusely EXTREMITIES: RLE edema present 1+ to around mid thigh asymmetrically w/ LLE with no edema. SKIN: warm, DP 2+ b/l Pertinent Results: ADMISSION LABS ============== [MASKED] 01:40PM BLOOD WBC-7.5# RBC-1.35*# Hgb-4.3*# Hct-14.4*# MCV-107*# MCH-31.9# MCHC-29.9* RDW-19.8* RDWSD-74.3* Plt [MASKED] [MASKED] 01:40PM BLOOD Neuts-60.3 [MASKED] Monos-11.2 Eos-0.8* Baso-0.0 Im [MASKED] AbsNeut-4.54 AbsLymp-1.99 AbsMono-0.84* AbsEos-0.06 AbsBaso-0.00* [MASKED] 01:40PM BLOOD [MASKED] PTT-140.0* [MASKED] [MASKED] 02:39PM BLOOD [MASKED] 01:40PM BLOOD Glucose-123* UreaN-62* Creat-2.9*# Na-140 K-5.4* Cl-123* HCO3-8* AnGap-14 [MASKED] 01:40PM BLOOD ALT-89* AST-168* AlkPhos-259* TotBili-0.7 [MASKED] 07:30PM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 02:39PM BLOOD Albumin-2.1* [MASKED] 07:14PM BLOOD Calcium-6.4* Phos-3.7# Mg-1.2* [MASKED] 11:51PM BLOOD calTIBC-90* VitB12-GREATER TH Folate-GREATER TH [MASKED] Ferritn-1085* TRF-69* [MASKED] 07:30PM BLOOD Cortsol-7.4 [MASKED] 07:30PM BLOOD ASA-NEG Acetmnp-9* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 01:43PM BLOOD [MASKED] pO2-40* pCO2-33* pH-7.25* calTCO2-15* Base XS--11 [MASKED] 01:43PM BLOOD Lactate-2.1* PERTINENT LABS: =============== Lactate trend: [MASKED] 02:44PM BLOOD Lactate-1.5 [MASKED] 07:48PM BLOOD Lactate-3.4* [MASKED] 12:10AM BLOOD Lactate-3.9* [MASKED] 12:49AM BLOOD Lactate-3.6* [MASKED] 12:15PM BLOOD Lactate-6.7* [MASKED] 05:30PM BLOOD Lactate-7.2* [MASKED] 09:55PM BLOOD Glucose-187* Lactate-5.8* Na-133 K-3.3 Cl-112* [MASKED] 01:49AM BLOOD Lactate-4.9* [MASKED] 11:35AM BLOOD Lactate-3.4* [MASKED] 03:54AM BLOOD Lactate-2.5* [MASKED] 06:27PM BLOOD Lactate-1.7 Troponin trend: [MASKED] 07:30PM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 05:51AM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 08:45AM BLOOD CK-MB-1 cTropnT-0.04* [MASKED] 06:41PM BLOOD CK-MB-2 cTropnT-0.07* [MASKED] 12:04AM BLOOD CK-MB-2 cTropnT-0.09* [MASKED] 03:38AM BLOOD cTropnT-0.05* [MASKED] 01:36AM BLOOD cTropnT-0.03* [MASKED] 07:19AM BLOOD CK-MB-3 cTropnT-0.02* BNP: [MASKED] 12:04AM BLOOD [MASKED] [MASKED] 05:32AM BLOOD Ret Aut-6.0* Abs Ret-0.16* [MASKED] 04:15AM BLOOD ALT-19 AST-32 LD(LDH)-201 AlkPhos-217* TotBili-1.0 [MASKED] 04:15AM BLOOD calTIBC-104* VitB12-GREATER TH Hapto-8* TRF-80* [MASKED] 03:06AM BLOOD Ferritn-2632* [MASKED] 11:10AM BLOOD %HbA1c-5.6 eAG-114 [MASKED] 02:30PM BLOOD Triglyc-59 [MASKED] 05:08PM BLOOD Osmolal-308 [MASKED] 07:30PM BLOOD TSH-0.82 [MASKED] 05:25AM BLOOD Cortsol-13.8 [MASKED] 05:44AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE [MASKED] 03:29PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [MASKED] 02:39PM BLOOD ANCA-NEGATIVE B [MASKED] 05:41AM BLOOD AMA-NEGATIVE [MASKED] 05:41AM BLOOD [MASKED] [MASKED] 05:45AM BLOOD C3-88* C4-27 [MASKED] 07:30PM BLOOD HIV Ab-Negative [MASKED] 05:27PM BLOOD ANTI-PLATELET ANTIBODY-Test Test Flag Result Unit Reference Value ---- ---- ------ ---- --------------- Platelet Ab, S Positive Not Applicable Comment Antibody reacts with glycoprotein to HLA Class I, probable alloimmunization due to pregnancy/transplant/transfusion. [MASKED] 12:00AM BLOOD COPPER (SERUM)-Test Test Result Reference Range/Units COPPER 91 70-175 mcg/dL [MASKED] 12:00AM BLOOD ZINC-Test Test Result Reference Range/Units ZINC 48 L 60-130 mcg/dL [MASKED] 11:55PM BLOOD VITAMIN B1-WHOLE BLOOD-Test Test Result Reference Range/Units VITAMIN B1 (THIAMINE), 1118 H 78-185 nmol/L BLOOD, LC/MS/MS [MASKED] 11:55PM BLOOD VITAMIN C-Test Test Result Reference Range/Units VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL [MASKED] 09:10PM BLOOD SELENIUM-Test Test Result Reference Range/Units SELENIUM 29 L 63-160 mcg/L [MASKED] 09:10PM BLOOD COPPER (SERUM)-Test Test Result Reference Range/Units COPPER 34 L 70-175 mcg/dL [MASKED] 09:10PM BLOOD ZINC-Test Test Result Reference Range/Units ZINC 32 L 60-130 mcg/dL ZINC Test Result Reference Range/Units ZINC (repeat on [MASKED] 27 L 60-130 mcg/dL [MASKED] 09:10PM BLOOD VITAMIN C-Test Test Result Reference Range/Units VITAMIN C, LC/MS/MS 0.2 0.2-1.5 mg/dL [MASKED] 09:10PM BLOOD CERULOPLASMIN-Test Test Result Reference Range/Units CERULOPLASMIN 14 L [MASKED] mg/dL [MASKED] 06:35PM BLOOD VITAMIN B1-WHOLE BLOOD-Test Test Result Reference Range/Units VITAMIN B1 (THIAMINE), >1200 H 78-185 nmol/L BLOOD, LC/MS/MS [MASKED] 01:17PM BLOOD HEPARIN DEPENDENT ANTIBODIES-TEST TEST RESULTS REFERENCE RANGE UNITS [MASKED] [MASKED] [MASKED] [MASKED] PF4 Heparin Antibody .10 0.00 - 0.39 [MASKED] 01:17PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test Test Result Reference Range/Units SOURCE Whole Blood EBV DNA, QN PCR <200 <200 copies/mL [MASKED] 10:28AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-Test Test Result Reference Range/Units PARVOVIRUS B19 ANTIBODY 8.48 H (IGG) Reference Range <0.9 Negative 0.9-1.1 Equivocal >1.1 Positive IgG persists for years and provides life-long immunity. To diagnose current infection, consider Parvovirus B19 DNA, PCR. Test Result Reference Range/Units PARVOVIRUS B19 ANTIBODY <0.9 (IGM) Reference Range <0.9 Negative 0.9-1.1 Equivocal >1.1 Positive Results from any one IgM assay should not be used as a sole determinant of a current or recent infection. Because IgM tests can yield false positive results and low levels of IgM antibody may persist for months post infection, reliance on a single test result could be misleading. If an acute infection is suspected, consider obtaining a new specimen and submit for both IgG and IgM testing in two or more weeks. To diagnose current infection, consider parvovirus B19 DNA,PCR. [MASKED] 11:56AM BLOOD T4, FREE, DIRECT DIALYSIS-Test Test Result Reference Range/Units T4, FREE, DIRECT DIALYSIS 3.3 H 0.8-2.7 ng/dL Urine studies: [MASKED] 09:33AM URINE Color-Yellow Appear-Cloudy Sp [MASKED] [MASKED] 09:33AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [MASKED] 10:39PM URINE RBC-151* WBC->182* Bacteri-FEW Yeast-NONE Epi-2 TransE-1 [MASKED] 01:20PM URINE AmorphX-FEW [MASKED] 09:33AM URINE Hours-RANDOM UreaN-332 Creat-101 Na-41 K-43 Cl-12 TotProt-171 Prot/Cr-1.7* Albumin-36.1 Alb/Cre-357.4* DISCHARGE LABS: =============== [MASKED] 04:57AM BLOOD WBC-9.6 RBC-2.84* Hgb-9.0* Hct-27.5* MCV-97 MCH-31.7 MCHC-32.7 RDW-19.0* RDWSD-67.4* Plt [MASKED] [MASKED] 12:30PM BLOOD [MASKED] PTT-56.4* [MASKED] [MASKED] 04:57AM BLOOD Glucose-61* UreaN-33* Creat-2.9*# Na-137 K-4.6 Cl-100 HCO3-24 AnGap-18 [MASKED] 05:45AM BLOOD Glucose-75 UreaN-59* Creat-4.1* Na-138 K-5.4* Cl-106 HCO3-20* AnGap-17 [MASKED] 04:15AM BLOOD ALT-19 AST-32 LD(LDH)-201 AlkPhos-217* TotBili-1.0 [MASKED] 04:57AM BLOOD Calcium-8.7 Phos-5.8*# Mg-2.1 [MASKED] 04:15AM BLOOD calTIBC-104* VitB12-GREATER TH Hapto-8* TRF-80* [MASKED] 03:06AM BLOOD Ferritn-2632* [MASKED] 02:30PM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND [MASKED] 05:44AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE [MASKED] 03:29PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [MASKED] 07:30PM BLOOD HIV Ab-Negative [MASKED] 02:30PM BLOOD HCV Ab-PND [MASKED] 03:29PM BLOOD HCV Ab-NEGATIVE [MASKED] 06:27AM BLOOD freeCa-1.17 MICROBIOLOGY: ============= [MASKED] [MASKED] 11:53 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [MASKED] [MASKED] 1:29 pm URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] [MASKED] 9:07 am BLOOD CULTURE Source: Line-hd line. Blood Culture, Routine (Pending): [MASKED] [MASKED] 9:07 am BLOOD CULTURE Source: Line-aline 1 OF 2. Blood Culture, Routine (Pending): [MASKED] [MASKED] 3:39 pm Mini-BAL GRAM STAIN (Final [MASKED]: 3+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: YEAST. ~3000/ML. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [MASKED]: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): YEAST. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. [MASKED] [MASKED] 1:39 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final [MASKED]: 3+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. YEAST. ~3000/ML. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): Negative results: [MASKED] URINE URINE CULTURE-FINAL INPATIENT [MASKED] Immunology (CMV) CMV Viral Load-FINAL INPATIENT [MASKED] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT [MASKED] SWAB Chlamydia trachomatis, Nucleic Acid Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT [MASKED] URINE Chlamydia trachomatis, Nucleic Acid Probe, with Amplification-FINAL; NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION-FINAL INPATIENT [MASKED] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; FECAL CULTURE - R/O VIBRIO-FINAL; FECAL CULTURE - R/O YERSINIA-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] URINE URINE CULTURE-FINAL INPATIENT [MASKED] STOOL C. difficile DNA amplification assay-FINAL INPATIENT [MASKED] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [MASKED]- urine cultures x2 URINE CULTURE (Final [MASKED]: YEAST. 10,000-100,000 ORGANISMS/ML.. URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION [MASKED] - blood cultures x2 - no growth PERTINENT STUDIES: ================== [MASKED] CXR: FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. Chain sutures are noted in the left upper quadrant of the abdomen. IMPRESSION: No acute cardiopulmonary abnormality [MASKED] CT abd/pelvis: IMPRESSION: 1. No active extravasation of contrast to suggest active GI bleeding at this time. 2. Profound hepatic steatosis. Enlarged periportal lymph nodes with hazy mesentery and retroperitoneum likely reflect underlying liver disease. 3. Colonic and rectal wall thickening which may reflect colitis versus portal colopathy. 4. Heterogeneous appearance of the kidneys with possible striated nephrograms. Correlate with urinalysis to exclude pyelonephritis. [MASKED] TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 65%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are mildly myxomatous. Frank mitral valve prolapse is not seen but cannot be excluded with certainty. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. [MASKED] [MASKED] IMPRESSION: 1. Occlusive thrombus of all right lower extremity deep veins from the common femoral vein down to the calf veins. 2. Patent left lower extremity veins. [MASKED] ECHO The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. LV systolic function appears depressed (LVEF = 40%) secondary to hypokinesis of the basal two-thirds of the left ventricle. The apical one-third of the left ventricle is hyperdynamic. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. The pulmonary artery is not well visualized. There is no pericardial effusion. Compared with the prior study (images reviewed) of [MASKED], left ventricular systolic dysfunction is now present. Findings suggestive of stress cardiomyopathy with inverse Takotsubo pattern of left ventricular contractile dysfunction. [MASKED] CTH: IMPRESSION: 1. There is mild progression of global cerebral atrophy since the prior examination of [MASKED], greater than would be expected for the patient's age. 2. No intracranial hemorrhage or territorial infarct. [MASKED] LIVER US: IMPRESSION: 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. Trace ascites and small right pleural effusion. [MASKED] IVC filter placement: FINDINGS: 1. Patent normal sized, non-duplicated IVC with no evidence of a IVC thrombus. A small circumaortic renal vein originating from the IVC just above the bifurcation was noted however is very small in caliber and likely of no clinical significance. 2. Successful deployment of an infra-renal retrievable IVC filter. IMPRESSION: Successful deployment of an infra-renal removable IVC filter. [MASKED] ECHO: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve 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 trivial/physiologic pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved regional and low normal global biventricular systolic function. No valvular pathology or pathologic flow identified. Trivial pericardial effusion. [MASKED] Unilateral RLE veins IMPRESSION: Extensive deep venous thrombosis involving the wall of the right lower extremity veins, overall similar to [MASKED], but now with perhaps minimal flow in the distal right SFV. [MASKED] Video oropharyngeal swallow study Aspiration with thin liquid consistency. [MASKED] Portable abdomen x-ray Patient is post gastric bypass surgery. The Dobbhoff tube ends in the proximal jejunum. [MASKED] Renal ultrasound No evidence of hydronephrosis. Increased renal echogenicity consistent with diffuse parenchymal renal disease. Small bilateral effusions and small to moderate volume ascites. [MASKED] - EGD Duodenum was not examined. Small gastric pouch consistent with Roux en y anatomy the blind limb and jejunal limb were both visualized. No varices. Otherwise normal EGD to the jejunum. Brief Hospital Course: [MASKED] hx gastric bypass surgery, alcohol abuse complicated by Wernicke's encephalopathy, concern for autonomic insufficiency, presented originally with hypotension, anemia and academia. Her course in the MICU was complicated by severe nutritional deficiency, volume overload, renal failure, cardiomyopathy, hypoxemia and hypoxemic respiratory failure, and deep vein thrombosis. # Hypotension: # Cardiomyopathy: # Presumed alcoholic liver disease: Patient was given 4u PRBCs in the ED prior to FICU admission; her Hgb was stable for days afterward, and there was low suspicion for active GIB initially in her MICU course. She was empirically antiobiosed for concern of sepsis, but no source was found, and these antibiotics were held until a series of presumed aspiration events that will be discussed below. Morning cortisol was within normal limits twice; TSH was also within normal limits. She underwent several echocardiograms to explain her persistent hypotension with pressor requirement that showed in sequence: mitral regurgitation with eccentric jet; inverse Takutsubo's cardiomyopathy; and then resolution of these issues. Of note, the resolution occurred after initiation of high-dose thiamine repletion, which may suggest an element of wet beriberbi from severe nutritional deficiency in the setting of gastric bypass and alcoholism. There was also strong suspicion of cirrhosis given her imaging and alcohol abuse history, for which she was started on midodrine. With these measures, she was successfully weaned from pressors. Unresolved at the time of her MICU discharge was a question of autonomic insufficiency raised in her last Discharge Summary of [MASKED] where it was thought her alcohol abuse could be contributing to baseline systolic pressures in the [MASKED]. This in part resolved on the floor as the patient was weaned off midodrine and maintained systolic blood pressure in the 100s. # Anemia: -Unexplained, possible GI source with lack of erythropoietin in the setting of subacute renal failure . Patient had decreasing pRBC transfusion requirements over the course of her stay, ultimately needing 1U pRBC every 4 days. She was evaluated by Hem/Onc who felt there was no evidence of significant hemolysis or malignancy and felt that there was an element of anemia of chronic inflammation, as well as decreased erythropoietin in the setting of subacute renal failure. She was evaluated by GI who found no source of bleed on sigmoidoscopy early in her course and no varices or bleeding on EGD. She had an episode of guaiac positive stool but had no significant bleeding on colonoscopy. Patient may benefit from outpatient capsule study if bleeding is ongoing. # Thrombocytopenia: There was no evidence of active bleed on presentation (stool normal color, not tachycardic, no clinical or radiographic evidence of extravasation into a compartment). Surgery and GI were consulted early in her MICU course for concern of ischemic gut in the setting of rising lactate, but flexible sigmoidoscopy was negative for this and lactate resolved with fluid resuscitation. [MASKED] Hematology consulted, and believe her anemia and thrombocytopenia are likely a combination of alcoholic bone marrow suppression, malnutrition and critical illness. She may benefit from a bone marrow biopsy when more stable; additionally, given her renal failure, she may have a developing EPO deficiency. She was transfused by ED prior to MICU admission and did not require further blood products until [MASKED] (gradually dropping Hct attributed to anemia of chronic illness/inflammation/underproduction; she held her Hct each time after transfusion). # Diarrhea: Negative c. diff, improved over the course of the hospital stay. Possibly related to tube feeding formulas as this improved with changing to a higher fiber formula and with the addition of banana flakes. Recommend continued loperamide as needed and optimization of tube feeds in patient s/p gastric bypass. # Renal Failure (Addressed Separately Below): Presented with serum bicarbonate of 8 of unclear etiology. She manifested diarrhea in the early part of her ICU stay (C diff assay negative, thought related to either alcohol abuse or early course of antibiotics administered empirically for presumed sepsis, resolved); her renal function markers may also have been under-estimates of her true GFR given her nutritionally deficient state. Acidemia corrected with bicarbonate drip, but recurrence remains in a concern in the setting of her renal failure with poor UOP. CRRT was started in the setting of volume overload in the ICU as described above, though she was noted to have ATN by muddy brown casts in her urine as well as persistently poor UOP. At time of FICU discharge she is being trialed off CRRT, though with her poor UOP she may need to be initiated on standing dialysis. Upon transfer to the floor, her renal function did not improve and she remained oliguric. She was evaluated by nephrology who felt that ATN without renal recovery was the most likely diagnosis based on her urine sediment and history. A renal biopsy was considered, but nephrology felt that the risks of the biopsy on a patient already requiring heparin for DVT would outweigh the benefits with the suspicion of ATN being high already. Urine output remained low prior to discharge, and tunneled HD line was placed for longer-term access. # Respiratory Failure: Patient developed progressive hypoxemia from volume overload eventually requiring CRRT with resolution of the same. However, on [MASKED] she had an unexplained hypoxemic respiratory episode with persistent SpO2 measurements in the [MASKED] despite NRB and NC; she was intubated with [MASKED] of continued O2 saturations in the [MASKED] before resolution not attributable to any particular intervention (nebs, suction, etc). This first hypoxemic episode was attributed to aspiration though subsequent CXR and bronchoscopy were not impressive for evidence of the same. She was extubated within 24hrs, but then reintubated in the setting of a break in her CRRT line that caused acute hypotension from blood loss (trapped in the CRRT circuit) and then hypoxemia. After restoration of hemodynamic stability and passing her RSBI, she was again extubated, but re-intubated for nearly the same exact sequence of events that evening(break in the CRRT circuit due to equipment failure; this has been reported and is being investigated). She was finally extubated on [MASKED] and remains off supplemental O2 at time of MICU discharge. Antibiotics were empirically started in the setting of possible aspiration with leukocytosis (that could have been a stress reaction to aspiration pneumonitis or intubations/exbuations); these will finish on [MASKED]. She completed her course of antibiotics and remained afebrile and without respiratory distress the rest of her hospitalization. # Alcohol Abuse: Patient endorses heavy alcohol use. She was seen by social work who gave resources, though patient is not interested in counseling. # Severe Nutritional Deficiency: Nutritional deficiencies including zinc and selenium requiring significant repletion. Repeat testing of zinc showed continued need for repletion. Caloric needs and repletion addressed below. # Severe malnutrition: likely contributor to pancytopenia resulting from bone marrow suppression. Required tube feeding tube feed which was continued at discharge in order to meet her caloric needs. She was initially found to aspirate thin liquids by a speech and swallow evaluation, however on reevaluation after receiving tube feeds for some time, she was able to tolerate a regular diet and thin liquids. Her caloric intake by mouth was not sufficient to decrease tube feeds. # Hx Wernicke's Encephalopathy: Patient had waxing/waning mental status for much of her early hospital course which was initially attributed to delirium; however, for history of Wernicke's she was started on high-dose thiamine that seemed to improve her mental status. Nutrition was consulted, and nutrition labs were sent that were all markedly low. She was supplemented through her TFs and will need to remain on standing thiamine. # Deep Vein Thrombosis: Patient arrived to MICU with L femoral CVL; shortly thereafter, asymmetric R > L lower extremity swelling was noticed for which [MASKED] was obtained - this showed extensive venous clot burden in the R lower extremity. IV heparin was started. Because of persistent thrombocytopenia, an IVC filter was placed, though because of her high clot risk IV heparin was continued. She should have interval follow-up of her DVTs after discharge, as well as scheduled follow-up with [MASKED] for filter removal. She was maintained on a heparin drip and should be bridged to Coumadin to follow up with hematology/oncology as an outpatient. # Concern for Gastrointestinal Bleed: As described above, GI and Surgery were consulted early in her MICU stay for rising lactate and concern of gut ischemia in the setting of her hypotension; flexible sigmoidoscopy was unimpressive and lactate improved with pressors and IVF. Near the end of her FICU stay she had fresh blood coating a stool which raised concern for GIB; however, her Hct was stable, she was HD stable, and guaiacs of subsequent stools were negative prior to MICU discharge. She underwent evaluation by Hepatology and EGD which showed no varices, negative colonoscopy. Capsule study failed, but patient's H/H stabilized and hepatology felt the study could be done as an outpatient if necessary. **Transitional:** TRANSITIONAL ISSUES: -Patient will need daily assessment for hemodialysis needs, EPO with HD given renal failure -Reassess nutritional status and continued need for tube feeding, potential need for G-tube -Daily electrolytes and every other day CBC to evaluate need for blood transfusion -Patient on heparin gtt for DVT. Recommend bridge to coumadin -Needs appointment with OBGYN for Mirena IUD removal. Pt states this was places at least [MASKED] years ago. -encourage smoking/alcohol cessation -f/u for potential IVC filter removal in the future -Outpatient hepatology f/u, consider outpatient capsule study -Outpatient Hematology f/u with Dr. [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN shortness of breath 4. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Cyanocobalamin 50 mcg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins W/minerals 1 TAB PO BID 4. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN shortness of breath 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Heparin IV per Weight-Based Dosing Guidelines Initial Bolus: 3900 units IVP Initial Infusion Rate: 850 units/hr Start: Today - [MASKED], First Dose: 1600 Target PTT: 60 - 100 seconds 7. Nephrocaps 1 CAP PO DAILY 8. Warfarin 5 mg PO DAILY16 first dose [MASKED] 9. sevelamer CARBONATE 800 mg PO TID W/MEALS 10. LOPERamide 2 mg PO QID:PRN diarrhea 11. Sarna Lotion 1 Appl TP PRN itching Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY: acute oliguric renal failure, deep vein thrombosis, anemia, thrombocytopenia, hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at the [MASKED] [MASKED]. You were hospitalized with low blood pressure and low blood counts. You were treated with blood transfusions, kidney replacement therapy, and antibiotics. You were found to have a blood clot in your leg and are being treated with blood thinning medications. Your platelets were low but these recovered. Your kidney function has not recovered prior to leaving the hospital and you will be discharged with a hemodialysis line. You were evaluated for GI bleeds, and these studies were reassuring. If you continue to bleed, you may benefit from a capsule study as an outpatient. Best wishes, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "D649", "E872", "D696", "F17210", "E039", "I10", "J45909", "Y92230" ]
[ "D649: Anemia, unspecified", "N170: Acute kidney failure with tubular necrosis", "J9691: Respiratory failure, unspecified with hypoxia", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J690: Pneumonitis due to inhalation of food and vomit", "G9340: Encephalopathy, unspecified", "I5021: Acute systolic (congestive) heart failure", "J95851: Ventilator associated pneumonia", "E43: Unspecified severe protein-calorie malnutrition", "R64: Cachexia", "E872: Acidosis", "E5112: Wet beriberi", "I82401: Acute embolism and thrombosis of unspecified deep veins of right lower extremity", "Z681: Body mass index [BMI] 19.9 or less, adult", "E873: Alkalosis", "I5181: Takotsubo syndrome", "E870: Hyperosmolality and hypernatremia", "R34: Anuria and oliguria", "D61818: Other pancytopenia", "D696: Thrombocytopenia, unspecified", "R680: Hypothermia, not associated with low environmental temperature", "F1020: Alcohol dependence, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "I340: Nonrheumatic mitral (valve) insufficiency", "K7030: Alcoholic cirrhosis of liver without ascites", "K7010: Alcoholic hepatitis without ascites", "E59: Dietary selenium deficiency", "E60: Dietary zinc deficiency", "D124: Benign neoplasm of descending colon", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding", "E876: Hypokalemia", "R197: Diarrhea, unspecified", "J45909: Unspecified asthma, uncomplicated", "Z9884: Bariatric surgery status", "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" ]
10,039,708
29,488,258
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: cats, dogs, dust, pollen Attending: ___. Chief Complaint: confusion Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo F with hx of EtOH cirrhosis c/b esophageal varices s/p recent banding (___), stomach ulcer, ESRD on HD, HTN, asthma who presents with altered mental status from dialysis. She had a recent admission (___) with a similar presentation, and was treated for hepatic encephalopathy with lactulose, alcoholic hallucinosis with lorazepam, and uremic encephalopathy with resumption HD. In the ED initial vitals: 96.6, 55, 159/80, 16, 99% RA - Exam notable for: Lethargic but arousable, Ox2-3, +asterixis - Labs notable for: CBC: ___ Chem7: lytes OK LFTs: AST/ALT: 73/33, ALP 429, Tbili 1.8, lip 50 Coags: INR 1.1 EtOH level: negative - Imaging notable for: Clean CTH, non-con RUQUS: 1. There is cholelithiasis without evidence of cholecystitis. 2. Echogenic kidneys which can be seen with chronic medical renal disease. - Patient was given: Home meds Ceftriaxone for SBP(?) iso HE On arrival to the floor the patient states that her confusion is starting to improve. Her son is at bedside and agrees. She describes being at dialysis and feeling more confused along with whole body cramping, with a single episode of non-bloody non-bilious emesis. Of note, she denies abdominal pain despite eliciting pain on exam. She stopped taking lactulose several months ago due to the diarrhea. Last drink was yesterday and she drinks around 5 shots of vodka/brandy a day. Past Medical History: EtOh Cirrhosis Stage IV CKD Anemia Wernicke's Encephalopathy Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT ___ dt L patella fx s/p IVC filter (removed), w/ catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture S/P BARIATRIC SURGERY ___ - ___ w/ Dr. ___ ___ Seasonal allergies ascites esophageal varices malnutrition HEMORRHOIDS HEPATIC HYDROTHORAX COLONIC ADENOMA Social History: ___ Family History: Mother ASTHMA DIABETES ___ HYPERTENSION THYROID DISORDER OBESITY Father SUBSTANCE ABUSE CARDIAC HYPERTENSION Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: ___ ___ Temp: 97.8 PO BP: 133/80 R Lying HR: 61 RR: 16 O2 sat: 99% O2 delivery: ra Dyspnea: 0 RASS: -1 Pain Score: ___ GENERAL: NAD, tired appearing HEENT: Sclera icteric CARDIAC: Regular rhythm, normal rate. LUNGS: Bilateral crackles, No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, diffusely tender to palpation in all quadrants, greatest in RUQ. EXTREMITIES: mild non pitting edema to ankles SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. Large ecchymosis with mild erythema with no fluctuance on right AC. NEUROLOGIC: AOx3 to person place and time. asked to say days of week backward and she answered days of week forward. asterixis on exam DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 812) Temp: 98.5 (Tm 98.9), BP: 101/63 (94-121/52-75), HR: 80 (77-92), RR: 18 (___), O2 sat: 95% (94-100), O2 delivery: Ra, Wt: 166.7 lb/75.62 kg (163.3-166.7) GENERAL: NAD, tired appearing HEENT: Sclera icteric CARDIAC: Regular rhythm, normal rate. LUNGS: Bilateral crackles, No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, diffusely tender to palpation in all quadrants, greatest in RUQ. EXTREMITIES: mild non pitting edema to ankles SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. Large ecchymosis with mild erythema with no fluctuance on right AC. NEUROLOGIC: AOx3 to person place and time. asterixis on exam. Days of week backwards Pertinent Results: ADMSSION LABS: ======================= ___ 01:15PM BLOOD WBC-5.5 RBC-3.09* Hgb-10.4* Hct-32.9* MCV-107* MCH-33.7* MCHC-31.6* RDW-17.9* RDWSD-68.9* Plt Ct-73* ___ 01:45PM BLOOD ___ PTT-32.1 ___ ___ 01:15PM BLOOD Glucose-85 UreaN-35* Creat-7.9*# Na-136 K-4.2 Cl-98 HCO3-22 AnGap-16 ___ 01:15PM BLOOD ALT-33 AST-73* AlkPhos-429* TotBili-1.8* ___ 01:15PM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.4 Mg-2.3 ___ 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS: ======================== ___ 05:05AM BLOOD WBC-7.5 RBC-2.57* Hgb-8.5* Hct-28.0* MCV-109* MCH-33.1* MCHC-30.4* RDW-17.8* RDWSD-70.4* Plt Ct-92* ___ 05:05AM BLOOD ___ PTT-31.0 ___ ___ 05:05AM BLOOD Glucose-105* UreaN-18 Creat-5.3*# Na-138 K-3.6 Cl-98 HCO3-26 AnGap-14 ___ 05:05AM BLOOD ALT-26 AST-66* AlkPhos-365* TotBili-1.0 ___ 05:05AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.1 PERTINENT IMAGING: ======================= CT HEAD IMPRESSION: 1. No acute intracranial findings. LIVER OR GALLBLADDER US IMPRESSION: 1. ThEre is cholelithiasis without evidence of cholecystitis. 2. Echogenic kidneys which can be seen with chronic medical renal disease. Brief Hospital Course: PATIENT SUMMARY =================== Ms. ___ is a ___ yo F with hx of EtOH cirrhosis complicated by esophageal varices s/p recent banding (___), stomach ulcer, ESRD on HD, HTN, asthma who presented with altered mental status from dialysis. The AMS is likely multi-factorial including lethargy from dialysis, recent excessive etoh intake, and non-compliance with lactulose. Specifically, she reports not taking lactulose for several months due to it causing diarrhea, therefore, she may only need 1x dosing a day. Her mental status completely improved the day after admission. The patient was encouraged to stop drinking and educated on the importance of taking lactulose and rifaximin. The patient is unaware of the medications she is taking and would benefit from close follow up. We discharged her with some medications to bedside. Please see below for more information TRANSITIONAL ISSUES: ==================== MED CHANGES [] Gave the patient four tiny bottles of lactulose and instructed her to use it if she or her son was concerned about confusion. Also filled rifaximin [] Filled Advair prescription for asthma. Unclear if she is using inhaler and would likely benefit from getting a rescue inhaler as well [] Filled baclofen that she takes for back pain (tiny dose) but this may be a deliriogenic that should be avoid in the future if she has recurrent confusion [] Gave the patient folic acid and thiamine given concern for malnutrition and Wernickes during previous hospitalization [] It was too soon to fill her levothyroxine. She states she has it at home. [] It was too soon to fill midodrine and dialysis vitamins [] Continued Alcohol Cessation Counseling [] Encourage cessation of tobacco --Discharge Hgb 8.5 --Discharge weight 166 lbs ACTIVE ISSUES ============= # Encephalopathy Multifactorial with most important factor likely hepatic encephalopathy. Patient and son confirm that she has not taken her lactulose for ~ 1 month, had drank a marked amount of alcohol the night prior. Has hx of concern for wernicke's encephalopathy and prior admissions for alcoholic hallucinosis but no signs of withdrawal this admission. Treated predominantly with lactulose with recovery of mental status and folate and thiamine by mouth. #Alcohol use disorder Patient met with social work on last hospitalization but stated she does not wish to stop drinking at this time. Was given resources for relapse prevention. This admission she states that she has a social worker already and not interested in another consultation. Patient received thiamine, MV, and folate. She was monitored for signs of withdrawal but did not require treatment. #Etoh Cirrhosis History of etoh cirrhosis with continued etoh intake. MELD score 21 Childs Class 6 on admission. Not a transplant candidate given continued etoh intake. Volume: no ascites on RUQUS, not discharged on diuretics and denies taking at home Infection: see above Bleed: Hgb 10.4 on admit and last was 7.3. history of anemia requiring transfusions, last EGD in ___ s/p banding of varices. Encephalopathy: on home rifaximin, but was not taking lactulose, discharged with lactulose PRN confusion CHRONIC ISSUES: ====================== #ESRD on iHD (___) Missed ___ dialysis as she was sent to ED. She received dialysis while in patient #asthma patient is taking advair at home twice a day. #hypothyroidism continued home levothyroxine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Baclofen 2.5 mg PO BID 3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 4. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 5. FoLIC Acid 1 mg PO DAILY 6. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 7. Levothyroxine Sodium 62.5 mcg PO DAILY 8. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 9. Midodrine 20 mg PO TID 10. Multivitamins 1 TAB PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. rifAXIMin 550 mg PO BID 13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID Discharge Medications: 1. Lactulose 30 mL PO Q6H:PRN encephalopathy RX *lactulose 20 gram/30 mL 30 ml by mouth every six (6) hours Disp #*1 Bottle Refills:*1 2. Thiamine 100 mg PO DAILY Duration: 5 Days RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Allopurinol ___ mg PO EVERY OTHER DAY RX *allopurinol ___ mg 1 tablet(s) by mouth every other day Disp #*30 Tablet Refills:*1 4. Baclofen 2.5 mg PO BID RX *baclofen 5 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*1 5. Dialyvite (B complex ___ complex-vitamin C-folic acid) ___ mg-mg-mcg-mg oral DAILY RX *B complex ___ [Dialyvite] 1 mg-100 mg-300 mcg-50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing RX *fluticasone propionate 50 mcg/actuation 1 spray intranasally each nostril, once a day Disp #*1 Spray Refills:*0 7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID RX *fluticasone propion-salmeterol 100 mcg-50 mcg/dose 1 inhaled twice a day Disp #*1 Disk Refills:*1 8. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet by mouth once a day Disp #*30 Tablet Refills:*1 9. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 10. Levothyroxine Sodium 62.5 mcg PO DAILY RX *levothyroxine 125 mcg 0.5 (One half) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 11. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 12. Midodrine 20 mg PO TID RX *midodrine 10 mg 2 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 15. rifAXIMin 550 mg PO BID RX *rifaximin [___] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Primary: Hepatic Encephalopathy Secondary: Alcohol Intoxication ESRD on Dialysis Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at the ___ ___. You came to the hospital because you were confused and sleepy at dialysis. You were given lactulose to help with your confusion. This medicine works by helping you stool frequently. Please remember that if you do not take lactulose the confusion will return. We also encourage you to stop drinking alcohol. Your liver disease is worsening and you may die if you do not stop drinking. We wish you all the best, and once again it was a pleasure caring for you. Sincerely, Your ___ Team Followup Instructions: ___
[ "K7290", "N186", "F1019", "I8510", "K7030", "J45909", "T473X6A", "E039", "F17210", "D649", "Z992", "Z86718", "Z91128" ]
Allergies: cats, dogs, dust, pollen Chief Complaint: confusion Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] yo F with hx of EtOH cirrhosis c/b esophageal varices s/p recent banding ([MASKED]), stomach ulcer, ESRD on HD, HTN, asthma who presents with altered mental status from dialysis. She had a recent admission ([MASKED]) with a similar presentation, and was treated for hepatic encephalopathy with lactulose, alcoholic hallucinosis with lorazepam, and uremic encephalopathy with resumption HD. In the ED initial vitals: 96.6, 55, 159/80, 16, 99% RA - Exam notable for: Lethargic but arousable, Ox2-3, +asterixis - Labs notable for: CBC: [MASKED] Chem7: lytes OK LFTs: AST/ALT: 73/33, ALP 429, Tbili 1.8, lip 50 Coags: INR 1.1 EtOH level: negative - Imaging notable for: Clean CTH, non-con RUQUS: 1. There is cholelithiasis without evidence of cholecystitis. 2. Echogenic kidneys which can be seen with chronic medical renal disease. - Patient was given: Home meds Ceftriaxone for SBP(?) iso HE On arrival to the floor the patient states that her confusion is starting to improve. Her son is at bedside and agrees. She describes being at dialysis and feeling more confused along with whole body cramping, with a single episode of non-bloody non-bilious emesis. Of note, she denies abdominal pain despite eliciting pain on exam. She stopped taking lactulose several months ago due to the diarrhea. Last drink was yesterday and she drinks around 5 shots of vodka/brandy a day. Past Medical History: EtOh Cirrhosis Stage IV CKD Anemia Wernicke's Encephalopathy Asthma Tobacco Use HTN Hypothyroidism CIN II (cervical intraepithelial neoplasia II) RLE DVT [MASKED] dt L patella fx s/p IVC filter (removed), w/ catheter directed thrombolysis c/b ?extravasation into right thigh. DVT in setting of immobility from left patella fracture S/P BARIATRIC SURGERY [MASKED] - [MASKED] w/ Dr. [MASKED] [MASKED] Seasonal allergies ascites esophageal varices malnutrition HEMORRHOIDS HEPATIC HYDROTHORAX COLONIC ADENOMA Social History: [MASKED] Family History: Mother ASTHMA DIABETES [MASKED] HYPERTENSION THYROID DISORDER OBESITY Father SUBSTANCE ABUSE CARDIAC HYPERTENSION Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: [MASKED] [MASKED] Temp: 97.8 PO BP: 133/80 R Lying HR: 61 RR: 16 O2 sat: 99% O2 delivery: ra Dyspnea: 0 RASS: -1 Pain Score: [MASKED] GENERAL: NAD, tired appearing HEENT: Sclera icteric CARDIAC: Regular rhythm, normal rate. LUNGS: Bilateral crackles, No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, diffusely tender to palpation in all quadrants, greatest in RUQ. EXTREMITIES: mild non pitting edema to ankles SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. Large ecchymosis with mild erythema with no fluctuance on right AC. NEUROLOGIC: AOx3 to person place and time. asked to say days of week backward and she answered days of week forward. asterixis on exam DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated [MASKED] @ 812) Temp: 98.5 (Tm 98.9), BP: 101/63 (94-121/52-75), HR: 80 (77-92), RR: 18 ([MASKED]), O2 sat: 95% (94-100), O2 delivery: Ra, Wt: 166.7 lb/75.62 kg (163.3-166.7) GENERAL: NAD, tired appearing HEENT: Sclera icteric CARDIAC: Regular rhythm, normal rate. LUNGS: Bilateral crackles, No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, diffusely tender to palpation in all quadrants, greatest in RUQ. EXTREMITIES: mild non pitting edema to ankles SKIN: Warm. Cap refill <2s. Multiple ecchymoses on bilateral forearms, shoulder/flank. Large ecchymosis with mild erythema with no fluctuance on right AC. NEUROLOGIC: AOx3 to person place and time. asterixis on exam. Days of week backwards Pertinent Results: ADMSSION LABS: ======================= [MASKED] 01:15PM BLOOD WBC-5.5 RBC-3.09* Hgb-10.4* Hct-32.9* MCV-107* MCH-33.7* MCHC-31.6* RDW-17.9* RDWSD-68.9* Plt Ct-73* [MASKED] 01:45PM BLOOD [MASKED] PTT-32.1 [MASKED] [MASKED] 01:15PM BLOOD Glucose-85 UreaN-35* Creat-7.9*# Na-136 K-4.2 Cl-98 HCO3-22 AnGap-16 [MASKED] 01:15PM BLOOD ALT-33 AST-73* AlkPhos-429* TotBili-1.8* [MASKED] 01:15PM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.4 Mg-2.3 [MASKED] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS: ======================== [MASKED] 05:05AM BLOOD WBC-7.5 RBC-2.57* Hgb-8.5* Hct-28.0* MCV-109* MCH-33.1* MCHC-30.4* RDW-17.8* RDWSD-70.4* Plt Ct-92* [MASKED] 05:05AM BLOOD [MASKED] PTT-31.0 [MASKED] [MASKED] 05:05AM BLOOD Glucose-105* UreaN-18 Creat-5.3*# Na-138 K-3.6 Cl-98 HCO3-26 AnGap-14 [MASKED] 05:05AM BLOOD ALT-26 AST-66* AlkPhos-365* TotBili-1.0 [MASKED] 05:05AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.1 PERTINENT IMAGING: ======================= CT HEAD IMPRESSION: 1. No acute intracranial findings. LIVER OR GALLBLADDER US IMPRESSION: 1. ThEre is cholelithiasis without evidence of cholecystitis. 2. Echogenic kidneys which can be seen with chronic medical renal disease. Brief Hospital Course: PATIENT SUMMARY =================== Ms. [MASKED] is a [MASKED] yo F with hx of EtOH cirrhosis complicated by esophageal varices s/p recent banding ([MASKED]), stomach ulcer, ESRD on HD, HTN, asthma who presented with altered mental status from dialysis. The AMS is likely multi-factorial including lethargy from dialysis, recent excessive etoh intake, and non-compliance with lactulose. Specifically, she reports not taking lactulose for several months due to it causing diarrhea, therefore, she may only need 1x dosing a day. Her mental status completely improved the day after admission. The patient was encouraged to stop drinking and educated on the importance of taking lactulose and rifaximin. The patient is unaware of the medications she is taking and would benefit from close follow up. We discharged her with some medications to bedside. Please see below for more information TRANSITIONAL ISSUES: ==================== MED CHANGES [] Gave the patient four tiny bottles of lactulose and instructed her to use it if she or her son was concerned about confusion. Also filled rifaximin [] Filled Advair prescription for asthma. Unclear if she is using inhaler and would likely benefit from getting a rescue inhaler as well [] Filled baclofen that she takes for back pain (tiny dose) but this may be a deliriogenic that should be avoid in the future if she has recurrent confusion [] Gave the patient folic acid and thiamine given concern for malnutrition and Wernickes during previous hospitalization [] It was too soon to fill her levothyroxine. She states she has it at home. [] It was too soon to fill midodrine and dialysis vitamins [] Continued Alcohol Cessation Counseling [] Encourage cessation of tobacco --Discharge Hgb 8.5 --Discharge weight 166 lbs ACTIVE ISSUES ============= # Encephalopathy Multifactorial with most important factor likely hepatic encephalopathy. Patient and son confirm that she has not taken her lactulose for ~ 1 month, had drank a marked amount of alcohol the night prior. Has hx of concern for wernicke's encephalopathy and prior admissions for alcoholic hallucinosis but no signs of withdrawal this admission. Treated predominantly with lactulose with recovery of mental status and folate and thiamine by mouth. #Alcohol use disorder Patient met with social work on last hospitalization but stated she does not wish to stop drinking at this time. Was given resources for relapse prevention. This admission she states that she has a social worker already and not interested in another consultation. Patient received thiamine, MV, and folate. She was monitored for signs of withdrawal but did not require treatment. #Etoh Cirrhosis History of etoh cirrhosis with continued etoh intake. MELD score 21 Childs Class 6 on admission. Not a transplant candidate given continued etoh intake. Volume: no ascites on RUQUS, not discharged on diuretics and denies taking at home Infection: see above Bleed: Hgb 10.4 on admit and last was 7.3. history of anemia requiring transfusions, last EGD in [MASKED] s/p banding of varices. Encephalopathy: on home rifaximin, but was not taking lactulose, discharged with lactulose PRN confusion CHRONIC ISSUES: ====================== #ESRD on iHD ([MASKED]) Missed [MASKED] dialysis as she was sent to ED. She received dialysis while in patient #asthma patient is taking advair at home twice a day. #hypothyroidism continued home levothyroxine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO EVERY OTHER DAY 2. Baclofen 2.5 mg PO BID 3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID 4. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing 5. FoLIC Acid 1 mg PO DAILY 6. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 7. Levothyroxine Sodium 62.5 mcg PO DAILY 8. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 9. Midodrine 20 mg PO TID 10. Multivitamins 1 TAB PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. rifAXIMin 550 mg PO BID 13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID Discharge Medications: 1. Lactulose 30 mL PO Q6H:PRN encephalopathy RX *lactulose 20 gram/30 mL 30 ml by mouth every six (6) hours Disp #*1 Bottle Refills:*1 2. Thiamine 100 mg PO DAILY Duration: 5 Days RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Allopurinol [MASKED] mg PO EVERY OTHER DAY RX *allopurinol [MASKED] mg 1 tablet(s) by mouth every other day Disp #*30 Tablet Refills:*1 4. Baclofen 2.5 mg PO BID RX *baclofen 5 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*1 5. Dialyvite (B complex [MASKED] complex-vitamin C-folic acid) [MASKED] mg-mg-mcg-mg oral DAILY RX *B complex [MASKED] [Dialyvite] 1 mg-100 mg-300 mcg-50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN wheezing RX *fluticasone propionate 50 mcg/actuation 1 spray intranasally each nostril, once a day Disp #*1 Spray Refills:*0 7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID RX *fluticasone propion-salmeterol 100 mcg-50 mcg/dose 1 inhaled twice a day Disp #*1 Disk Refills:*1 8. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet by mouth once a day Disp #*30 Tablet Refills:*1 9. Ipratropium Bromide Neb 1 NEB IH BID:PRN wheezing 10. Levothyroxine Sodium 62.5 mcg PO DAILY RX *levothyroxine 125 mcg 0.5 (One half) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 11. Lidocaine 0.5% 2 mL TT DAILY:PRN during dialysis 12. Midodrine 20 mg PO TID RX *midodrine 10 mg 2 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 15. rifAXIMin 550 mg PO BID RX *rifaximin [[MASKED]] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Primary: Hepatic Encephalopathy Secondary: Alcohol Intoxication ESRD on Dialysis Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at the [MASKED] [MASKED]. You came to the hospital because you were confused and sleepy at dialysis. You were given lactulose to help with your confusion. This medicine works by helping you stool frequently. Please remember that if you do not take lactulose the confusion will return. We also encourage you to stop drinking alcohol. Your liver disease is worsening and you may die if you do not stop drinking. We wish you all the best, and once again it was a pleasure caring for you. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "J45909", "E039", "F17210", "D649", "Z86718" ]
[ "K7290: Hepatic failure, unspecified without coma", "N186: End stage renal disease", "F1019: Alcohol abuse with unspecified alcohol-induced disorder", "I8510: Secondary esophageal varices without bleeding", "K7030: Alcoholic cirrhosis of liver without ascites", "J45909: Unspecified asthma, uncomplicated", "T473X6A: Underdosing of saline and osmotic laxatives, initial encounter", "E039: Hypothyroidism, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "D649: Anemia, unspecified", "Z992: Dependence on renal dialysis", "Z86718: Personal history of other venous thrombosis and embolism", "Z91128: Patient's intentional underdosing of medication regimen for other reason" ]
10,039,709
21,965,984
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Pneumococcal Vaccine / nuts / treenuts Attending: ___. Chief Complaint: severe left thoracic pain Major Surgical or Invasive Procedure: T5-6 DISCECTOMY AND T5-7 POSTERIOR INSTRUMENTED ARTHRODESIS History of Present Illness: Mr. ___ is a pleasant gentleman who presented with severe left thoracic radiculopathy.He did not have any response to conservative management.A decision for surgical treatment was taken Past Medical History: - Asthma - Seasonal allergies - History of pulmonar embolus (thought to be provoked by flight from ___ ___, now s/p 6 months of warfarin - Hypertension - Previous knee surgery - Negative stress test several years ago Social History: ___ Family History: Father had CABG at age ___. No other family history of heart disease. Physical Exam: PE: VS ___ 0636 Temp: 98.2 PO BP: 130/85 L Lying HR: 78 RR: 18 O2 sat: 95% O2 delivery: Ra NAD, A&Ox4 nl resp effort RRR dressing c/d/I hemovac output 20 cc Sensory: ___ L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___ R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Pertinent Results: ___ 03:58AM BLOOD WBC-12.8* RBC-4.13* Hgb-12.6* Hct-37.4* MCV-91 MCH-30.5 MCHC-33.7 RDW-12.1 RDWSD-39.8 Plt ___ ___ 12:00PM BLOOD WBC-7.5 RBC-4.57* Hgb-14.0 Hct-40.8 MCV-89 MCH-30.6 MCHC-34.3 RDW-12.1 RDWSD-39.7 Plt ___ ___ 03:58AM BLOOD Plt ___ ___ 12:00PM BLOOD Plt ___ ___ 03:58AM BLOOD Glucose-126* UreaN-14 Creat-0.8 Na-141 K-4.0 Cl-102 HCO3-26 AnGap-13 ___ 03:58AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.9 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.Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation DAILY:PRN 2. Atenolol 50 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Gabapentin 100 mg PO TID 5. Valsartan 160 mg PO DAILY 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H may take over the counter 2. Cyclobenzaprine 10 mg PO TID:PRN spasms may cause drowsiness RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #*25 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID please take while taking narcotics RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*25 Tablet Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate please do not operate heavy machinery, drink alcohol or drive RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 5. Aspirin 81 mg PO DAILY 6. Atenolol 50 mg PO DAILY 7. Chlorthalidone 25 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation DAILY:PRN 10. Valsartan 160 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: 1. T5-6 disc herniation. 2. T5-6 spinal stenosis. 3. Thoracic radiculopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 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 incision covered with a dry dressing on until your follow up appointment. Once the incision is completely dry (usually ___ days after the operation) you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery,do not get the incision wet.Cover it with a sterile dressing and call the office. • You should resume taking your normal home medications. • You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on ___.We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. • Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision, take baseline X-rays and answer any questions.We may at that time start physical therapy. We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Followup Instructions: ___
[ "M5114", "M4804", "I10", "Z86718", "Z86711" ]
Allergies: Pneumococcal Vaccine / nuts / treenuts Chief Complaint: severe left thoracic pain Major Surgical or Invasive Procedure: T5-6 DISCECTOMY AND T5-7 POSTERIOR INSTRUMENTED ARTHRODESIS History of Present Illness: Mr. [MASKED] is a pleasant gentleman who presented with severe left thoracic radiculopathy.He did not have any response to conservative management.A decision for surgical treatment was taken Past Medical History: - Asthma - Seasonal allergies - History of pulmonar embolus (thought to be provoked by flight from [MASKED] [MASKED], now s/p 6 months of warfarin - Hypertension - Previous knee surgery - Negative stress test several years ago Social History: [MASKED] Family History: Father had CABG at age [MASKED]. No other family history of heart disease. Physical Exam: PE: VS [MASKED] 0636 Temp: 98.2 PO BP: 130/85 L Lying HR: 78 RR: 18 O2 sat: 95% O2 delivery: Ra NAD, A&Ox4 nl resp effort RRR dressing c/d/I hemovac output 20 cc Sensory: [MASKED] L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: [MASKED] Flex(L1) Add(L2) Quad(L3) TA(L4) [MASKED] [MASKED] R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Pertinent Results: [MASKED] 03:58AM BLOOD WBC-12.8* RBC-4.13* Hgb-12.6* Hct-37.4* MCV-91 MCH-30.5 MCHC-33.7 RDW-12.1 RDWSD-39.8 Plt [MASKED] [MASKED] 12:00PM BLOOD WBC-7.5 RBC-4.57* Hgb-14.0 Hct-40.8 MCV-89 MCH-30.6 MCHC-34.3 RDW-12.1 RDWSD-39.7 Plt [MASKED] [MASKED] 03:58AM BLOOD Plt [MASKED] [MASKED] 12:00PM BLOOD Plt [MASKED] [MASKED] 03:58AM BLOOD Glucose-126* UreaN-14 Creat-0.8 Na-141 K-4.0 Cl-102 HCO3-26 AnGap-13 [MASKED] 03:58AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.9 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.Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation DAILY:PRN 2. Atenolol 50 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Gabapentin 100 mg PO TID 5. Valsartan 160 mg PO DAILY 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H may take over the counter 2. Cyclobenzaprine 10 mg PO TID:PRN spasms may cause drowsiness RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #*25 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID please take while taking narcotics RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*25 Tablet Refills:*0 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate please do not operate heavy machinery, drink alcohol or drive RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 5. Aspirin 81 mg PO DAILY 6. Atenolol 50 mg PO DAILY 7. Chlorthalidone 25 mg PO DAILY 8. Gabapentin 100 mg PO TID 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation DAILY:PRN 10. Valsartan 160 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: 1. T5-6 disc herniation. 2. T5-6 spinal stenosis. 3. Thoracic radiculopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 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 incision covered with a dry dressing on until your follow up appointment. Once the incision is completely dry (usually [MASKED] days after the operation) you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery,do not get the incision wet.Cover it with a sterile dressing and call the office. • You should resume taking your normal home medications. • You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on [MASKED].We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. • Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision, take baseline X-rays and answer any questions.We may at that time start physical therapy. We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Followup Instructions: [MASKED]
[]
[ "I10", "Z86718" ]
[ "M5114: Intervertebral disc disorders with radiculopathy, thoracic region", "M4804: Spinal stenosis, thoracic region", "I10: Essential (primary) hypertension", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism" ]
10,039,870
22,600,344
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Diagnostic laparoscopy and open appendectomy History of Present Illness: ___ woman with 3-day history of abdominal pain which was generalized, and ultimately today had started to localize to the right lower quadrant. She was anorexic but had no nausea, vomiting, fever, or chills. She had focal tenderness to palpation in the right lower quadrant on examination, and on CT scan, had a 15 mm appendix in the right lower quadrant with significant surrounding inflammation and secondary inflammation of the terminal ileum. Past Medical History: none Social History: ___ Family History: NC Physical Exam: On Discharge 98.5 81 121/66 18 94% RA General: comfortable ___: regular rate and rhythm Pulm: no respiratory distress Abdomen: soft nontender, midline staples in tact Extremities: warm and well perfused. Pertinent Results: ___ 04:58AM BLOOD WBC-10.6* RBC-3.08* Hgb-9.7* Hct-30.2* MCV-98 MCH-31.5 MCHC-32.1 RDW-12.4 RDWSD-44.3 Plt ___ ___ 09:15PM BLOOD WBC-14.2* RBC-3.70* Hgb-11.6 Hct-36.4 MCV-98 MCH-31.4 MCHC-31.9* RDW-12.5 RDWSD-44.9 Plt ___ ___ 05:38PM BLOOD WBC-11.9* RBC-3.51* Hgb-10.9* Hct-34.1 MCV-97 MCH-31.1 MCHC-32.0 RDW-12.8 RDWSD-45.2 Plt ___ ___ 04:58AM BLOOD Glucose-134* UreaN-6 Creat-0.5 Na-136 K-3.9 Cl-99 HCO3-25 AnGap-16 ___ 09:15PM BLOOD Glucose-106* UreaN-6 Creat-0.6 Na-137 K-4.2 Cl-100 HCO3-25 AnGap-16 ___ 04:58AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9 ___ 09:15PM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1 Brief Hospital Course: Ms. ___ was admitted to the acute surgery service for her abdominal pain and CT scan concerning for appendicitis. She was taken to the operating room for a diagnostic laparoscopy and open appendectomy. She tolerated the procedure well and was extubated in the OR. She was monitored in the PACU and then transferred to the floor. She was kept NPO initially her diet was slowly advanced. The patient was retaining urine post operatively requiring straight cathx1. Early morning POD1 the patient was found to be unresponsive on the floor and was thought to be given too much pain medication. She responded to narcan and her pain meds were then held. The following day she was started on tramadol for pain control which she tolerated well. Additionally on POD1 the patient was febrile to 101.9. Her fever curve was trended throughout her hospital stay and she remained afebrile. Her leukocytosis was also monitored and came down postoperatively from 14 to 10. Her vitals were monitored and remained stable. Prior to discharge she was voiding spontaneously, ambulating independently, passing flatus, tolerating a diet and her pain was controlled. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q4H RX *acetaminophen 650 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*6 Tablet Refills:*0 RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*6 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every 12 hours Disp #*30 Capsule Refills:*0 4. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*9 Tablet Refills:*0 5. TraMADol 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*28 Tablet Refills:*0 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 were admitted to ___ with acute appendicitis. You underwent an appendectomy and are now ready to go home. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. Followup Instructions: ___
[ "K353", "K660", "R338", "R400", "T402X5A", "Y92230" ]
Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Diagnostic laparoscopy and open appendectomy History of Present Illness: [MASKED] woman with 3-day history of abdominal pain which was generalized, and ultimately today had started to localize to the right lower quadrant. She was anorexic but had no nausea, vomiting, fever, or chills. She had focal tenderness to palpation in the right lower quadrant on examination, and on CT scan, had a 15 mm appendix in the right lower quadrant with significant surrounding inflammation and secondary inflammation of the terminal ileum. Past Medical History: none Social History: [MASKED] Family History: NC Physical Exam: On Discharge 98.5 81 121/66 18 94% RA General: comfortable [MASKED]: regular rate and rhythm Pulm: no respiratory distress Abdomen: soft nontender, midline staples in tact Extremities: warm and well perfused. Pertinent Results: [MASKED] 04:58AM BLOOD WBC-10.6* RBC-3.08* Hgb-9.7* Hct-30.2* MCV-98 MCH-31.5 MCHC-32.1 RDW-12.4 RDWSD-44.3 Plt [MASKED] [MASKED] 09:15PM BLOOD WBC-14.2* RBC-3.70* Hgb-11.6 Hct-36.4 MCV-98 MCH-31.4 MCHC-31.9* RDW-12.5 RDWSD-44.9 Plt [MASKED] [MASKED] 05:38PM BLOOD WBC-11.9* RBC-3.51* Hgb-10.9* Hct-34.1 MCV-97 MCH-31.1 MCHC-32.0 RDW-12.8 RDWSD-45.2 Plt [MASKED] [MASKED] 04:58AM BLOOD Glucose-134* UreaN-6 Creat-0.5 Na-136 K-3.9 Cl-99 HCO3-25 AnGap-16 [MASKED] 09:15PM BLOOD Glucose-106* UreaN-6 Creat-0.6 Na-137 K-4.2 Cl-100 HCO3-25 AnGap-16 [MASKED] 04:58AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9 [MASKED] 09:15PM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1 Brief Hospital Course: Ms. [MASKED] was admitted to the acute surgery service for her abdominal pain and CT scan concerning for appendicitis. She was taken to the operating room for a diagnostic laparoscopy and open appendectomy. She tolerated the procedure well and was extubated in the OR. She was monitored in the PACU and then transferred to the floor. She was kept NPO initially her diet was slowly advanced. The patient was retaining urine post operatively requiring straight cathx1. Early morning POD1 the patient was found to be unresponsive on the floor and was thought to be given too much pain medication. She responded to narcan and her pain meds were then held. The following day she was started on tramadol for pain control which she tolerated well. Additionally on POD1 the patient was febrile to 101.9. Her fever curve was trended throughout her hospital stay and she remained afebrile. Her leukocytosis was also monitored and came down postoperatively from 14 to 10. Her vitals were monitored and remained stable. Prior to discharge she was voiding spontaneously, ambulating independently, passing flatus, tolerating a diet and her pain was controlled. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q4H RX *acetaminophen 650 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*6 Tablet Refills:*0 RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours Disp #*6 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every 12 hours Disp #*30 Capsule Refills:*0 4. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp #*9 Tablet Refills:*0 5. TraMADol 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*28 Tablet Refills:*0 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 were admitted to [MASKED] with acute appendicitis. You underwent an appendectomy and are now ready to go home. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. Followup Instructions: [MASKED]
[]
[ "Y92230" ]
[ "K353: Acute appendicitis with localized peritonitis", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "R338: Other retention of urine", "R400: Somnolence", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,039,913
24,711,716
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: shortness of breath and cough Major Surgical or Invasive Procedure: None History of Present Illness: CC: cough HISTORY OF THE PRESENTING ILLNESS: This is a ___ gentleman with a history of HIV currently on active retroviral therapy, hepatitis C who was recently completed treatment who presents with cough. Patient first noticed a fever and cough 7 days ago. He notes that his cough is productive of green-yellow sputum as well as some blood-tinged sputum intermittently. He notes a subjective fever as well as sweating and chills but did not take his temperature at home. Patient notes that she had some pleuritic right flank pain that has been persistent for the last 5 days and is worse with deep inspiration and with movement. It is somewhat tender to palpation. The patient denies any diarrhea or constipation or abdominal pain other than the flank pain noted above. He has been intermittently taking n.p.o. but notes significant decrease over the last week. Patient notes that his last CD4 count was just over 200 and that he has recently completed a course of treatment for his hepatitis C with Harvoni. He has a previous history of IV drug use but has not used IV drugs since ___. In the ED, initial vitals were: Temp: 102.8 HR 94 BP 111/72 RR 22 SpO2 95% RA - Exam: Con: Ill-appearing, in no acute distress HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Resp: Decreased breath sounds in the right middle and lung base CV: Regular rate and rhythm, normal ___ and ___ heart sounds, no ___ heart sound, no JVD, no pedal edema, 2+ distal upper extremity and lower extremity pulses. Capillary refill less than 2 seconds. Abd: Soft, tender to palpation in the right upper quadrant, Nondistended GU: costovertebral angle tenderness worse in the right MSK: No cyanosis, clubbing or edema Skin: No rash, Warm and dry, No petechiae Neuro: Alert and following commands, moving all extremities spontaneously, sensation intact to light touch, speech fluent Psych: Normal mood/mentation - Labs: WBC: 11.9 Hgb: 11.1 CR: 1.8 Na: 134 Lactate: 1.4 - Imaging: CXR: Bibasilar opacities on the right would be compatible with pneumonia in the proper clinical setting and suspected right pleural effusion. Linear left basilar opacity is likely atelectasis. Consider PA and lateral views. CTA CHEST: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Dense consolidation in a significant portion of the right lower lobe suspicious for pneumonia. Streaky left basilar opacities likely atelectasis though additional region of infection would be possible. 3. Trace right pleural effusion. - ECG: ___: ECG: sinus rhythm at 87 - Consults: NONE - Patient was given: ___ 17:58 PO Acetaminophen 1000 mg ___ 17:58 IV CefePIME ___ 17:58 IVF LR ___ 18:31 IV Vancomycin ___ 18:31 IV CefePIME 2 g ___ 19:42 IV Vancomycin 1000 mg ___ 19:42 IVF LR 1000 mL ___ 20:06 IV MethylPREDNISolone Sodium Succ 40 mg ___ 20:06 IV Sulfamethoxazole-Trimethoprim 350 mg ___ 23:24 PO Dolutegravir 50 mg ___ 23:24 PO Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History: NARCOTIC ABUSE HIV INFECTION HEPATITIS C Social History: ___ Family History: Non contributory Physical Exam: ADMISSOIN PHYSICAL EXAM ====================== VITALS: 24 HR Data (last updated ___ @ 352) Temp: 97.6 (Tm 98.3), BP: 114/72 (114-122/72-77), HR: 61 (61-72), RR: 20, O2 sat: 93%, O2 delivery: 2L NC, Wt: 142.64 lb/64.7 kg GEN: Alert, cooperative, no distress, appears stated age, diaphoretic HENT: NC/AT, MMM. Nares patent, no drainage or sinus tenderness. Teeth and gums normal. EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus. Right NECK: No cervical lymphadenopathy. No JVD, no carotid bruit. Neck supple, symmetrical, trachea midline. LUNG: poor air movement with ronchi at right base and crackles at left base, no accessory muscle use HEART: RRR, Normal S1/S2, No M/R/G BACK: Symmetric, no curvature. ROM normal. No CVA tenderness. ABD: Soft, non-tender, non-distended; nl bowel sounds; no rebound or guarding, no organomegaly GU: Not examined EXTRM: Extremities warm, no edema, no cyanosis, positive ___ pulses bilaterally SKIN: Skin color and temperature, appropriate. No rashes or lesions NEUR: CN II-XII intact grossly. Moving all extremities, strength, sensation and reflexes equal and intact throughout. PSYC: Mood and affect appropriate he did not do DISCHARGE PHYSICAL EXAM ========================= 24 HR Data (last updated ___ @ 429) Temp: 98.9 (Tm 99.5), BP: 117/72 (108-148/70-96), HR: 67 (65-76), RR: 20 (___), O2 sat: 94% (92-97), O2 delivery: RA HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Resp: Decreased breath sounds in the right middle and lung base. Pain to palpation of R flank and CVA. CV: Regular rate and rhythm, normal ___ and ___ heart sounds, no ___ heart sound, no JVD, no pedal edema, 2+ distal upper extremity and lower extremity pulses. Abd: Soft, NTND MSK: No cyanosis, clubbing or edema Skin: No rash, Warm and dry, No petechiae Neuro: A and O x 3 Pertinent Results: ======================== ADMISSION LABS ======================== ___ 11:23PM URINE HOURS-RANDOM ___ 11:23PM URINE UHOLD-HOLD ___ 11:23PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 11:23PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 11:23PM URINE RBC-1 WBC-7* BACTERIA-FEW* YEAST-NONE EPI-0 ___ 05:49PM ___ PO2-22* PCO2-45 PH-7.40 TOTAL CO2-29 BASE XS-0 ___ 05:49PM LACTATE-1.4 ___ 05:49PM O2 SAT-34 ___ 05:43PM GLUCOSE-112* UREA N-23* CREAT-1.8* SODIUM-134* POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-26 ANION GAP-13 ___ 05:43PM estGFR-Using this ___ 05:43PM ALT(SGPT)-44* AST(SGOT)-88* LD(LDH)-288* ALK PHOS-83 TOT BILI-0.5 ___ 05:43PM LIPASE-9 ___ 05:43PM ALBUMIN-3.6 ___ 05:43PM WBC-11.9* RBC-3.44* HGB-11.1* HCT-33.7* MCV-98 MCH-32.3* MCHC-32.9 RDW-13.2 RDWSD-47.5* ___ 05:43PM NEUTS-61 BANDS-27* LYMPHS-8* MONOS-4* EOS-0* BASOS-0 AbsNeut-10.47* AbsLymp-0.95* AbsMono-0.48 AbsEos-0.00* AbsBaso-0.00* ___ 05:43PM RBCM-WITHIN NOR ___ 05:43PM PLT SMR-NORMAL PLT COUNT-152 ___ 05:43PM ___ PTT-32.3 ___ ====================== DISCHARGE LABS ====================== ___ 08:50AM BLOOD WBC-6.5 RBC-3.44* Hgb-11.1* Hct-33.7* MCV-98 MCH-32.3* MCHC-32.9 RDW-13.5 RDWSD-48.5* Plt ___ ___ 08:50AM BLOOD Glucose-87 UreaN-16 Creat-1.1 Na-139 K-5.1 Cl-99 HCO3-26 AnGap-14 ====================== IMAGING ====================== CTA CHEST ___ IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Dense consolidation in a significant portion of the right lower lobe suspicious for pneumonia. Streaky left basilar opacities likely atelectasis though additional region of infection would be possible. 3. Trace right pleural effusion. ================== OTHER IMPORTANT LABS ================= ___ 06:45AM BLOOD WBC-10.0# Lymph-3.0* Abs ___ CD3%-55 Abs CD3-165* CD4%-6 Abs CD4-18* CD8%-46 Abs CD8-139* CD4/CD8-0.13* =================== MICROBIOLOGY ===================== ___ 1:22 pm SPUTUM Source: Expectorated. GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. ___ 4:55 am URINE Source: ___. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. Clinical correlation and additional testing suggested including culture and detection of serum antibody. ___ 12:17 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. Brief Hospital Course: ==================== PATIENT SUMMARY: ==================== Mr. ___ is a ___ man with a history of HIV on AVRT, hepatitis C (status post treatment), who presented with cough x7 days. On admission he endorsed having a productive cough with blood-tinged sputum for 7 days, fevers at home, shortness of breath. He denied any chest pain or palpitations. He endorsed right flank pain which started around the time of his cough and was made worse with coughing. On arrival his temperature was 102.8 and he was breathing 22 times per minute. He was started on nasal cannula oxygen. CT chest showed right lower lobe pneumonia with some streaking in left lower lobe. He was initially treated with vancomycin, cefepime, and Bactrim. Also started on prednisone given concern for PCP. On the floor Legionella urine antigen was positive. He was started on azithromycin x7 days and other antibiotics were stopped. On ___ he reported more right-sided pain secondary to cough and he was concerned about worsening cough. Since sputum had not resulted he was started on ceftriaxone for strep pneumo coverage. He will transition to Cefpodoxime on discharge for total 5-day course. His CD4 count was found to be 18. He was started on double strength Bactrim 1 tab ___ for PCP ___. While on antibiotics his symptoms improved, he had diminished O2 requirements and transition to room air, and on day of discharge had an ambulatory O2 sat of 93%. ==================== TRANSITIONAL ISSUES: ==================== [ ] He had elevated transaminases this admission thought to be secondary to Legionella. Please repeat AST and ALT in 1 week (week of ___. [ ] He had a transaminitis this admission thought to be secondary to Legionella. However given history of hepatitis C, hep C viral load was sent and still pending on discharge. Please follow-up viral load. [ ] CD4 18 this admission. Patient adamantly expressed compliance with HIV medications. Will need follow-up with primary care provider regarding adherence with HIV medications. VL was pending on discharge, please follow up when it results. [ ] Started on PCP prophylaxis with ___ 1 double strength tab ___. Already receiving azithromycin for treatment of Legionella pneumonia through ___. Would likely be indicated for MAC prophylaxis going forward as well. Please continue to follow-up as outpatient and determine need for prophylaxis. [ ] Please follow-up regarding dose of Suboxone. Per our pharmacy records he last filled prescription on ___. [ ] He was started on azithromycin 500 mg twice a day for 7 days (end date ___. He was also given a total of 5 days treatment for strep pneumo PNA (ceftriaxone ___, should start Cefpodoxime ___. Please confirm he was able to take full antibiotic course as prescribed. Please ensure PNA is resolving. [] Sputum culture, strep pneumo still pending on discharge. Please follow up once resulted. ==================== ACUTE ISSUES: ==================== #Legionella PNA #Acute Hypoxemic respiratory failure, improving Patient presented with 1 week of fevers, productive cough, pleuritic chest pain, chest x-ray on admission consistent with PNA. Given the patient's most recent CD4 count of 200 he represented a mildly suppressed host and was at higher risk for infections. He had an elevated LDH to 288 and bilaterality to his opacities on CXR concerning for PCP. CT chest showed right lower lobe pneumonia with some streaking in left lower lobe. He was initially treated with vancomycin, cefepime, and Bactrim. Also started on prednisone given concern for PCP. Given the fevers to 103, hyponatremia, blood tinged sputum and pneumonia urine Legionella was obtained. Legionella urine antigen was positive on ___ with consistent findings of hyponatremia and transaminitis although no GI sx. He was started on a course of azithromycin 500 mg twice a day for 7 days (end date ___. His other antibiotics were stopped on ___ and his prednisone was stopped. Beta-D-glucan was mildly positive but not felt to be reflective of acute fungal infection. On ___ given concern for ongoing right-sided pain and continued productive cough he was started on ceftriaxone for strep pneumo coverage. Sputum culture and strep pneumo was still pending on day of discharge. Plan for transition to Cefpodoxime on discharge for total 5-day course (end date ___. His symptoms improved with antibiotics and on day of discharge he was satting well on room air, had easy work of breathing, ambulatory oxygen of 93%. Sputum culture and strep still pending, will need follow-up. #h/o Hep C #Elevated Transaminitis - resolved He had mild elevated transaminases on admission as well as an elevated LDH. He was recently treated for Hep C and has previously normal LFTs. Medication effect would be a likely culprit however the patient has been on antiretroviral medications for some time without notable LFT abnormalities. He had a positive legionella UA; thus transaminitis likely explained in part by legionella which can cause transaminitis. Levels were normal by the time of discharge. ___, improved Patient has a baseline creatinine of 1.0 with admission creatinine of 1.8. Likely represented a prerenal etiology given the patient's poor p.o. intake, high fevers and diaphoresis. He received 1 L of IV to the emergency department and Cr down trended to 1.2. Creatinine on day of discharge was 1.1 #Anemia He has a history of anemia with baseline hemoglobin around 12. He presented with a hemoglobin of 11.1. He had a small amount of hemoptysis in the form of blood tinged sputum during his admission but no other evidence of bleeding. B12, folate WNL. #Hyponatremia, resolved Patient was found to be hyponatremic to 134 on admission. This was thought to be secondary to Legionella pneumonia. His sodium improved during his stay and on day of discharge was 141. ==================== CHRONIC ISSUES: ==================== #HIV Patient has a history of HIV with a most recent CD4 count of 215. He takes Descovy and Dolutegravir at home. The patient believes he is taking his medications however he is not able to recall the names of them when asked. Given his pneumonia with hypoxemia repeat CD4 counts and HIV viral loads were obtained and CD4 was found to be 18. Viral load was still pending on discharge. Will need to be followed up once resulted. Patient started on Bactrim for PCP ___. Was given azithromycin for legionella PNA, and azithromycin for MAC prophylaxis will need to be addressed in outpatient follow-up. #H.o IVDU (___) and other opioid use Patient reports last used in ___. However prior notes in ___ state patient was still using various opioids. Pharmacy checked his most recent Suboxone filled at outside hospital and he was continued on this dose of ___ mg twice daily. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dolutegravir 50 mg PO DAILY 2. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB PO DAILY 3. Buprenorphine-Naloxone Film (12mg-3mg) 1 FILM SL BID Discharge Medications: 1. Azithromycin 500 mg PO DAILY Duration: 7 Days RX *azithromycin 500 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 2. Cefpodoxime Proxetil 200 mg PO BID RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 3. Sulfameth/Trimethoprim DS 1 TAB PO ___ 4. Buprenorphine-Naloxone Film (12mg-3mg) 1 FILM SL BID 5. Dolutegravir 50 mg PO DAILY 6. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis ================ -Legionella pneumonia Secondary diagnosis ====================== -Hyponatremia -___ -Transaminitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had a lung infection called pneumonia WHAT HAPPENED IN THE HOSPITAL? ============================== -You had a chest x-ray and chest CT scan that showed an infection in the bottom part of your right lung. -You are given antibiotics to treat your infection. You were also given oxygen to help with your breathing. -You were given your medications for HIV. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and 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: ___
[ "A481", "B20", "E871", "N179", "D649", "Z8619", "F1911", "Z87891", "R0902" ]
Allergies: Penicillins Chief Complaint: shortness of breath and cough Major Surgical or Invasive Procedure: None History of Present Illness: CC: cough HISTORY OF THE PRESENTING ILLNESS: This is a [MASKED] gentleman with a history of HIV currently on active retroviral therapy, hepatitis C who was recently completed treatment who presents with cough. Patient first noticed a fever and cough 7 days ago. He notes that his cough is productive of green-yellow sputum as well as some blood-tinged sputum intermittently. He notes a subjective fever as well as sweating and chills but did not take his temperature at home. Patient notes that she had some pleuritic right flank pain that has been persistent for the last 5 days and is worse with deep inspiration and with movement. It is somewhat tender to palpation. The patient denies any diarrhea or constipation or abdominal pain other than the flank pain noted above. He has been intermittently taking n.p.o. but notes significant decrease over the last week. Patient notes that his last CD4 count was just over 200 and that he has recently completed a course of treatment for his hepatitis C with Harvoni. He has a previous history of IV drug use but has not used IV drugs since [MASKED]. In the ED, initial vitals were: Temp: 102.8 HR 94 BP 111/72 RR 22 SpO2 95% RA - Exam: Con: Ill-appearing, in no acute distress HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Resp: Decreased breath sounds in the right middle and lung base CV: Regular rate and rhythm, normal [MASKED] and [MASKED] heart sounds, no [MASKED] heart sound, no JVD, no pedal edema, 2+ distal upper extremity and lower extremity pulses. Capillary refill less than 2 seconds. Abd: Soft, tender to palpation in the right upper quadrant, Nondistended GU: costovertebral angle tenderness worse in the right MSK: No cyanosis, clubbing or edema Skin: No rash, Warm and dry, No petechiae Neuro: Alert and following commands, moving all extremities spontaneously, sensation intact to light touch, speech fluent Psych: Normal mood/mentation - Labs: WBC: 11.9 Hgb: 11.1 CR: 1.8 Na: 134 Lactate: 1.4 - Imaging: CXR: Bibasilar opacities on the right would be compatible with pneumonia in the proper clinical setting and suspected right pleural effusion. Linear left basilar opacity is likely atelectasis. Consider PA and lateral views. CTA CHEST: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Dense consolidation in a significant portion of the right lower lobe suspicious for pneumonia. Streaky left basilar opacities likely atelectasis though additional region of infection would be possible. 3. Trace right pleural effusion. - ECG: [MASKED]: ECG: sinus rhythm at 87 - Consults: NONE - Patient was given: [MASKED] 17:58 PO Acetaminophen 1000 mg [MASKED] 17:58 IV CefePIME [MASKED] 17:58 IVF LR [MASKED] 18:31 IV Vancomycin [MASKED] 18:31 IV CefePIME 2 g [MASKED] 19:42 IV Vancomycin 1000 mg [MASKED] 19:42 IVF LR 1000 mL [MASKED] 20:06 IV MethylPREDNISolone Sodium Succ 40 mg [MASKED] 20:06 IV Sulfamethoxazole-Trimethoprim 350 mg [MASKED] 23:24 PO Dolutegravir 50 mg [MASKED] 23:24 PO Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History: NARCOTIC ABUSE HIV INFECTION HEPATITIS C Social History: [MASKED] Family History: Non contributory Physical Exam: ADMISSOIN PHYSICAL EXAM ====================== VITALS: 24 HR Data (last updated [MASKED] @ 352) Temp: 97.6 (Tm 98.3), BP: 114/72 (114-122/72-77), HR: 61 (61-72), RR: 20, O2 sat: 93%, O2 delivery: 2L NC, Wt: 142.64 lb/64.7 kg GEN: Alert, cooperative, no distress, appears stated age, diaphoretic HENT: NC/AT, MMM. Nares patent, no drainage or sinus tenderness. Teeth and gums normal. EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus. Right NECK: No cervical lymphadenopathy. No JVD, no carotid bruit. Neck supple, symmetrical, trachea midline. LUNG: poor air movement with ronchi at right base and crackles at left base, no accessory muscle use HEART: RRR, Normal S1/S2, No M/R/G BACK: Symmetric, no curvature. ROM normal. No CVA tenderness. ABD: Soft, non-tender, non-distended; nl bowel sounds; no rebound or guarding, no organomegaly GU: Not examined EXTRM: Extremities warm, no edema, no cyanosis, positive [MASKED] pulses bilaterally SKIN: Skin color and temperature, appropriate. No rashes or lesions NEUR: CN II-XII intact grossly. Moving all extremities, strength, sensation and reflexes equal and intact throughout. PSYC: Mood and affect appropriate he did not do DISCHARGE PHYSICAL EXAM ========================= 24 HR Data (last updated [MASKED] @ 429) Temp: 98.9 (Tm 99.5), BP: 117/72 (108-148/70-96), HR: 67 (65-76), RR: 20 ([MASKED]), O2 sat: 94% (92-97), O2 delivery: RA HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Resp: Decreased breath sounds in the right middle and lung base. Pain to palpation of R flank and CVA. CV: Regular rate and rhythm, normal [MASKED] and [MASKED] heart sounds, no [MASKED] heart sound, no JVD, no pedal edema, 2+ distal upper extremity and lower extremity pulses. Abd: Soft, NTND MSK: No cyanosis, clubbing or edema Skin: No rash, Warm and dry, No petechiae Neuro: A and O x 3 Pertinent Results: ======================== ADMISSION LABS ======================== [MASKED] 11:23PM URINE HOURS-RANDOM [MASKED] 11:23PM URINE UHOLD-HOLD [MASKED] 11:23PM URINE COLOR-Yellow APPEAR-Hazy* SP [MASKED] [MASKED] 11:23PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 11:23PM URINE RBC-1 WBC-7* BACTERIA-FEW* YEAST-NONE EPI-0 [MASKED] 05:49PM [MASKED] PO2-22* PCO2-45 PH-7.40 TOTAL CO2-29 BASE XS-0 [MASKED] 05:49PM LACTATE-1.4 [MASKED] 05:49PM O2 SAT-34 [MASKED] 05:43PM GLUCOSE-112* UREA N-23* CREAT-1.8* SODIUM-134* POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-26 ANION GAP-13 [MASKED] 05:43PM estGFR-Using this [MASKED] 05:43PM ALT(SGPT)-44* AST(SGOT)-88* LD(LDH)-288* ALK PHOS-83 TOT BILI-0.5 [MASKED] 05:43PM LIPASE-9 [MASKED] 05:43PM ALBUMIN-3.6 [MASKED] 05:43PM WBC-11.9* RBC-3.44* HGB-11.1* HCT-33.7* MCV-98 MCH-32.3* MCHC-32.9 RDW-13.2 RDWSD-47.5* [MASKED] 05:43PM NEUTS-61 BANDS-27* LYMPHS-8* MONOS-4* EOS-0* BASOS-0 AbsNeut-10.47* AbsLymp-0.95* AbsMono-0.48 AbsEos-0.00* AbsBaso-0.00* [MASKED] 05:43PM RBCM-WITHIN NOR [MASKED] 05:43PM PLT SMR-NORMAL PLT COUNT-152 [MASKED] 05:43PM [MASKED] PTT-32.3 [MASKED] ====================== DISCHARGE LABS ====================== [MASKED] 08:50AM BLOOD WBC-6.5 RBC-3.44* Hgb-11.1* Hct-33.7* MCV-98 MCH-32.3* MCHC-32.9 RDW-13.5 RDWSD-48.5* Plt [MASKED] [MASKED] 08:50AM BLOOD Glucose-87 UreaN-16 Creat-1.1 Na-139 K-5.1 Cl-99 HCO3-26 AnGap-14 ====================== IMAGING ====================== CTA CHEST [MASKED] IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Dense consolidation in a significant portion of the right lower lobe suspicious for pneumonia. Streaky left basilar opacities likely atelectasis though additional region of infection would be possible. 3. Trace right pleural effusion. ================== OTHER IMPORTANT LABS ================= [MASKED] 06:45AM BLOOD WBC-10.0# Lymph-3.0* Abs [MASKED] CD3%-55 Abs CD3-165* CD4%-6 Abs CD4-18* CD8%-46 Abs CD8-139* CD4/CD8-0.13* =================== MICROBIOLOGY ===================== [MASKED] 1:22 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [MASKED]: <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. [MASKED] 4:55 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] Legionella Urinary Antigen (Final [MASKED]: PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. Clinical correlation and additional testing suggested including culture and detection of serum antibody. [MASKED] 12:17 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. Brief Hospital Course: ==================== PATIENT SUMMARY: ==================== Mr. [MASKED] is a [MASKED] man with a history of HIV on AVRT, hepatitis C (status post treatment), who presented with cough x7 days. On admission he endorsed having a productive cough with blood-tinged sputum for 7 days, fevers at home, shortness of breath. He denied any chest pain or palpitations. He endorsed right flank pain which started around the time of his cough and was made worse with coughing. On arrival his temperature was 102.8 and he was breathing 22 times per minute. He was started on nasal cannula oxygen. CT chest showed right lower lobe pneumonia with some streaking in left lower lobe. He was initially treated with vancomycin, cefepime, and Bactrim. Also started on prednisone given concern for PCP. On the floor Legionella urine antigen was positive. He was started on azithromycin x7 days and other antibiotics were stopped. On [MASKED] he reported more right-sided pain secondary to cough and he was concerned about worsening cough. Since sputum had not resulted he was started on ceftriaxone for strep pneumo coverage. He will transition to Cefpodoxime on discharge for total 5-day course. His CD4 count was found to be 18. He was started on double strength Bactrim 1 tab [MASKED] for PCP [MASKED]. While on antibiotics his symptoms improved, he had diminished O2 requirements and transition to room air, and on day of discharge had an ambulatory O2 sat of 93%. ==================== TRANSITIONAL ISSUES: ==================== [ ] He had elevated transaminases this admission thought to be secondary to Legionella. Please repeat AST and ALT in 1 week (week of [MASKED]. [ ] He had a transaminitis this admission thought to be secondary to Legionella. However given history of hepatitis C, hep C viral load was sent and still pending on discharge. Please follow-up viral load. [ ] CD4 18 this admission. Patient adamantly expressed compliance with HIV medications. Will need follow-up with primary care provider regarding adherence with HIV medications. VL was pending on discharge, please follow up when it results. [ ] Started on PCP prophylaxis with [MASKED] 1 double strength tab [MASKED]. Already receiving azithromycin for treatment of Legionella pneumonia through [MASKED]. Would likely be indicated for MAC prophylaxis going forward as well. Please continue to follow-up as outpatient and determine need for prophylaxis. [ ] Please follow-up regarding dose of Suboxone. Per our pharmacy records he last filled prescription on [MASKED]. [ ] He was started on azithromycin 500 mg twice a day for 7 days (end date [MASKED]. He was also given a total of 5 days treatment for strep pneumo PNA (ceftriaxone [MASKED], should start Cefpodoxime [MASKED]. Please confirm he was able to take full antibiotic course as prescribed. Please ensure PNA is resolving. [] Sputum culture, strep pneumo still pending on discharge. Please follow up once resulted. ==================== ACUTE ISSUES: ==================== #Legionella PNA #Acute Hypoxemic respiratory failure, improving Patient presented with 1 week of fevers, productive cough, pleuritic chest pain, chest x-ray on admission consistent with PNA. Given the patient's most recent CD4 count of 200 he represented a mildly suppressed host and was at higher risk for infections. He had an elevated LDH to 288 and bilaterality to his opacities on CXR concerning for PCP. CT chest showed right lower lobe pneumonia with some streaking in left lower lobe. He was initially treated with vancomycin, cefepime, and Bactrim. Also started on prednisone given concern for PCP. Given the fevers to 103, hyponatremia, blood tinged sputum and pneumonia urine Legionella was obtained. Legionella urine antigen was positive on [MASKED] with consistent findings of hyponatremia and transaminitis although no GI sx. He was started on a course of azithromycin 500 mg twice a day for 7 days (end date [MASKED]. His other antibiotics were stopped on [MASKED] and his prednisone was stopped. Beta-D-glucan was mildly positive but not felt to be reflective of acute fungal infection. On [MASKED] given concern for ongoing right-sided pain and continued productive cough he was started on ceftriaxone for strep pneumo coverage. Sputum culture and strep pneumo was still pending on day of discharge. Plan for transition to Cefpodoxime on discharge for total 5-day course (end date [MASKED]. His symptoms improved with antibiotics and on day of discharge he was satting well on room air, had easy work of breathing, ambulatory oxygen of 93%. Sputum culture and strep still pending, will need follow-up. #h/o Hep C #Elevated Transaminitis - resolved He had mild elevated transaminases on admission as well as an elevated LDH. He was recently treated for Hep C and has previously normal LFTs. Medication effect would be a likely culprit however the patient has been on antiretroviral medications for some time without notable LFT abnormalities. He had a positive legionella UA; thus transaminitis likely explained in part by legionella which can cause transaminitis. Levels were normal by the time of discharge. [MASKED], improved Patient has a baseline creatinine of 1.0 with admission creatinine of 1.8. Likely represented a prerenal etiology given the patient's poor p.o. intake, high fevers and diaphoresis. He received 1 L of IV to the emergency department and Cr down trended to 1.2. Creatinine on day of discharge was 1.1 #Anemia He has a history of anemia with baseline hemoglobin around 12. He presented with a hemoglobin of 11.1. He had a small amount of hemoptysis in the form of blood tinged sputum during his admission but no other evidence of bleeding. B12, folate WNL. #Hyponatremia, resolved Patient was found to be hyponatremic to 134 on admission. This was thought to be secondary to Legionella pneumonia. His sodium improved during his stay and on day of discharge was 141. ==================== CHRONIC ISSUES: ==================== #HIV Patient has a history of HIV with a most recent CD4 count of 215. He takes Descovy and Dolutegravir at home. The patient believes he is taking his medications however he is not able to recall the names of them when asked. Given his pneumonia with hypoxemia repeat CD4 counts and HIV viral loads were obtained and CD4 was found to be 18. Viral load was still pending on discharge. Will need to be followed up once resulted. Patient started on Bactrim for PCP [MASKED]. Was given azithromycin for legionella PNA, and azithromycin for MAC prophylaxis will need to be addressed in outpatient follow-up. #H.o IVDU ([MASKED]) and other opioid use Patient reports last used in [MASKED]. However prior notes in [MASKED] state patient was still using various opioids. Pharmacy checked his most recent Suboxone filled at outside hospital and he was continued on this dose of [MASKED] mg twice daily. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dolutegravir 50 mg PO DAILY 2. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB PO DAILY 3. Buprenorphine-Naloxone Film (12mg-3mg) 1 FILM SL BID Discharge Medications: 1. Azithromycin 500 mg PO DAILY Duration: 7 Days RX *azithromycin 500 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 2. Cefpodoxime Proxetil 200 mg PO BID RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 3. Sulfameth/Trimethoprim DS 1 TAB PO [MASKED] 4. Buprenorphine-Naloxone Film (12mg-3mg) 1 FILM SL BID 5. Dolutegravir 50 mg PO DAILY 6. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis ================ -Legionella pneumonia Secondary diagnosis ====================== -Hyponatremia -[MASKED] -Transaminitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had a lung infection called pneumonia WHAT HAPPENED IN THE HOSPITAL? ============================== -You had a chest x-ray and chest CT scan that showed an infection in the bottom part of your right lung. -You are given antibiotics to treat your infection. You were also given oxygen to help with your breathing. -You were given your medications for HIV. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and 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]
[]
[ "E871", "N179", "D649", "Z87891" ]
[ "A481: Legionnaires' disease", "B20: Human immunodeficiency virus [HIV] disease", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "D649: Anemia, unspecified", "Z8619: Personal history of other infectious and parasitic diseases", "F1911: Other psychoactive substance abuse, in remission", "Z87891: Personal history of nicotine dependence", "R0902: Hypoxemia" ]