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10,039,917	23,863,775	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) / Ultram / environmental including cats and mold Attending: ___. Chief Complaint: Neck Pain Major Surgical or Invasive Procedure: ACDF C3-C5 History of Present Illness: Ms. ___ is a ___ year old female with a PMH of HTN and asthma and C5-6 fusion in ___ presenting with neck pain and left arm weakness . Past Medical History: HTN Asthma Seizures C5-C6 fusion in ___ Social History: ___ Family History: Mom: HTN, Right sided heart failure, 'a lot of autoimmune issues" diabetes, stroke, cancer in other relatives Physical ___ Well appearing, NAD, comfortable BUE: SILT C5-T1 dermatomal distributions BUE: ___ Del/Tri/Bic/WE/WF/FF/IO BUE: tone normal, negative ___, 2+ symmetric DTR bic/bra/tri All fingers WWP, brisk capillary refill, 2+ distal pulses BLE: SILT L1-S1 dermatomal distributions BLE: ___ ___ BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses 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: Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze DULoxetine ___ 60 mg PO DAILY Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY 2. Cyclobenzaprine 5 mg PO TID:PRN spasm RX cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day Disp #21 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX hydromorphone 2 mg ___ tablet(s) by mouth every ___ hours Disp #50 Tablet Refills:0 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 6. DULoxetine ___ 60 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Cervical Stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ACDF: You have undergone the following operation:Anterior Cervical Decompression and Fusion. Immediately after the operation: Activity:You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit in a car or chair for more than~45 minutes without getting up and walking around. Rehabilitation/ Physical ___ times a day you should go for a walk for ___ minutes as part of your recovery.You can walk as much as you can tolerate. Swallowing:Difficulty swallowing is not uncommon after this type of surgery.This should resolve over time.Please take small bites and eat slowly.Removing the collar while eating can be helpfulhowever,please limit your movement of your neck if you remove your collar while eating. Cervical Collar / Neck Brace:If you have been given a soft collar for comfort, you may remove the collar to take a shower or eat.Limit your motion of your neck while the collar is off.You should wear the collar when walking,especially in public. Wound Care:Remove the dressing in 2 days.If the incision is draining cover it with a new sterile dressing.If it is dry then you can leave the incision open to the air.Once the incision is completely dry (usually ___ days after the operation) you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery,do not get the incision wet.Call the office at that time. f you have an incision on your hip please follow the same instructions in terms of wound care. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so 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 narcotic (oxycontin,oxycodone,percocet) prescriptions to the pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: ___ Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. ___ At the 2-week visit we will check your incision,take baseline x rays and answer any questions. ___ We will then see you at 6 weeks from the day of the operation.At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound,or have any questions. Followup Instructions: ___	[ "M5031", "M4802", "M479", "F17210", "J45909" ]	Allergies: Sulfa (Sulfonamide Antibiotics) / Ultram / environmental including cats and mold Chief Complaint: Neck Pain Major Surgical or Invasive Procedure: ACDF C3-C5 History of Present Illness: Ms. [MASKED] is a [MASKED] year old female with a PMH of HTN and asthma and C5-6 fusion in [MASKED] presenting with neck pain and left arm weakness . Past Medical History: HTN Asthma Seizures C5-C6 fusion in [MASKED] Social History: [MASKED] Family History: Mom: HTN, Right sided heart failure, 'a lot of autoimmune issues" diabetes, stroke, cancer in other relatives Physical [MASKED] Well appearing, NAD, comfortable BUE: SILT C5-T1 dermatomal distributions BUE: [MASKED] Del/Tri/Bic/WE/WF/FF/IO BUE: tone normal, negative [MASKED], 2+ symmetric DTR bic/bra/tri All fingers WWP, brisk capillary refill, 2+ distal pulses BLE: SILT L1-S1 dermatomal distributions BLE: [MASKED] [MASKED] BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses 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: Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze DULoxetine [MASKED] 60 mg PO DAILY Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY 2. Cyclobenzaprine 5 mg PO TID:PRN spasm RX cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day Disp #21 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX hydromorphone 2 mg [MASKED] tablet(s) by mouth every [MASKED] hours Disp #50 Tablet Refills:0 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 6. DULoxetine [MASKED] 60 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Cervical Stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ACDF: You have undergone the following operation:Anterior Cervical Decompression and Fusion. Immediately after the operation: Activity:You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit in a car or chair for more than~45 minutes without getting up and walking around. Rehabilitation/ Physical [MASKED] times a day you should go for a walk for [MASKED] minutes as part of your recovery.You can walk as much as you can tolerate. Swallowing:Difficulty swallowing is not uncommon after this type of surgery.This should resolve over time.Please take small bites and eat slowly.Removing the collar while eating can be helpfulhowever,please limit your movement of your neck if you remove your collar while eating. Cervical Collar / Neck Brace:If you have been given a soft collar for comfort, you may remove the collar to take a shower or eat.Limit your motion of your neck while the collar is off.You should wear the collar when walking,especially in public. Wound Care:Remove the dressing in 2 days.If the incision is draining cover it with a new sterile dressing.If it is dry then you can leave the incision open to the air.Once the incision is completely dry (usually [MASKED] days after the operation) you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery,do not get the incision wet.Call the office at that time. f you have an incision on your hip please follow the same instructions in terms of wound care. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so 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 narcotic (oxycontin,oxycodone,percocet) prescriptions to the pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: [MASKED] Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. [MASKED] At the 2-week visit we will check your incision,take baseline x rays and answer any questions. [MASKED] We will then see you at 6 weeks from the day of the operation.At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound,or have any questions. Followup Instructions: [MASKED]	[]	[ "F17210", "J45909" ]	[ "M5031: Other cervical disc degeneration, high cervical region", "M4802: Spinal stenosis, cervical region", "M479: Spondylosis, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "J45909: Unspecified asthma, uncomplicated" ]
10,039,917	27,350,730	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Ultram Attending: ___. Chief Complaint: Neck pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old female with a PMH of HTN and asthma and C5-6 fusion in ___ presenting with neck pain and left arm weakness for 5 days being admitted to medicine for pain control. Patient reports that her pain started on ___ when she moved her neck very quickly to avoid a mosquito. Since then she has had posterior neck pain and weakness of her left arm. She presented to ___ ___ where she had a CT scan and was given pain medication. She initially felt better but then the next day her pain acutely worsened and was aggravated by any neck movement (flexion/extension/rotation). At this point represented to ___ and was transferred to ___ for neurosurgical evaluation. Of note she denies any lower extremity symptoms or any urinary/fecal incontinence. Past Medical History: HTN Asthma Seizures C5-C6 fusion in ___ Social History: ___ Family History: Mom: HTN, Right sided heart failure, 'a lot of autoimmune issues" diabetes, stroke, cancer in other relatives Physical ___: ADMISSION PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated ___ @ 2322) Temp: 97.4 (Tm 97.8), BP: 106/68 (106-126/68-71), HR: 80 (80-89), RR: 16, O2 sat: 95%, O2 delivery: RA, Wt: 138.67 lb/62.9 kg GENERAL: Sitting up in bed because pain worse when lying down. Holding/rubbing left side of neck. HEENT: PERRL, EOMI. MMM. CARDIAC: RRR no m/r/g LUNGS: CTAB, no r/r/w ABDOMEN: Soft, NT, ND, +BS EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Decreased strength in LUE. ___ in bilateral ___. DISCHARGE PHYSICAL EXAM: ======================== 97.8 140/92 73 18 98 ra GENERAL: Laying in bed pressing on L side of neck. HEENT: PERRL, EOMI. MMM. CARDIAC: RRR no m/r/g LUNGS: CTAB, no r/r/w ABDOMEN: Soft, NT, ND, +BS EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. ___ strength in both upper and lower extremities Pertinent Results: Admission Labs: =============== ___ 06:35PM ___ PTT-30.8 ___ ___ 03:40PM GLUCOSE-117* UREA N-4* CREAT-0.6 SODIUM-136 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-23 ANION GAP-16 ___ 03:40PM estGFR-Using this ___ 03:40PM WBC-7.8 RBC-4.04 HGB-13.8 HCT-40.3 MCV-100* MCH-34.2* MCHC-34.2 RDW-12.4 RDWSD-45.1 ___ 03:40PM NEUTS-89.4* LYMPHS-5.1* MONOS-4.2* EOS-0.6* BASOS-0.3 IM ___ AbsNeut-6.97* AbsLymp-0.40* AbsMono-0.33 AbsEos-0.05 AbsBaso-0.02 ___ 03:40PM PLT COUNT-157 Micro: None Imaging: MRI C-Spine ___: 1. Postsurgical changes related to anterior fusion at C5-6, similar in alignment compared to outside CT C-spine. 2. Examination is limited by motion with limited evaluation for spinal cord signal. 3. Moderate to severe spinal canal narrowing at C3-4 and moderate spinal canal narrowing at C4-5 level due to posterior osteophytes and ligamentous thickening. 4. Moderate-to-severe left foraminal narrowing at C3-4 and moderate left foraminal narrowing at C4-5 level due to uncovertebral degenerative changes. 5. No definite postcontrast enhancement, although sagittal T1 weighted precontrast images are moderate to severely motion degraded. CT C-Spine: 1. Status post anterior fusion of C5-C6 without evidence of hardware complication or fracture. 2. Cervical spondylosis, most prominent at C3-C4 and better assessed on MR cervical spine dated ___. Discharge Labs: =============== ___ 07:12AM BLOOD WBC-6.4 RBC-3.87* Hgb-13.2 Hct-38.7 MCV-100* MCH-34.1* MCHC-34.1 RDW-12.6 RDWSD-45.9 Plt ___ ___ 07:12AM BLOOD Glucose-110* UreaN-4* Creat-0.7 Na-137 K-3.6 Cl-97 HCO3-25 AnGap-15 ___ 07:12AM BLOOD Calcium-10.0 Phos-3.3 Mg-1.8 Brief Hospital Course: ================== SUMMARY STATEMENT: ================== Ms. ___ is a ___ year old female with a PMH of HTN and asthma and C5-6 fusion in ___ presenting with neck pain and left arm weakness for 5 days being admitted to medicine for pain control. ACUTE/ACTIVE ISSUES: ==================== #Acute neck pain with L arm symptoms #C4-5 bulge with spinal canal narrowing #Mild central stenosis C3-5 Patient with neck pain and LUE weakness since ___. MRI with severe canal narrowing at C3-4 and C4-5 due disc osteophyte complexes. There appears to be thickening of the anterior and posterior epidural space at C3-4 and C4-5, which may be due to prominent epidural fat or ligamental thickening. Evaluated by spine in the ED who recommended a Medrol dosepack and follow-up in clinic in one week as symptoms do not appear consistent with MRI findings. Ortho spine also recommended a CT scan which did not show evidence of hardware complication or fracture. Repeat neuro exam with intact strength in all extremities with improved radiation down arm. Patient was admitted due to intractable pain. Her pain was managed with APAP, hydromorphone, lidocaine patch, methocarbamol, and the steroid taper. Her pain improved from admission and ___ recommended out patient ___. She may benefit from revision decompression and fusion procedure with spinal surgery. CHRONIC/STABLE ISSUES: ====================== #Asthma: Continued home inhaler #Tobacco use disorder: Placed on nicotine patch ==================== TRANSITIONAL ISSUES: ==================== [ ] Given 1 week of opioids and muscle relaxer due to severe pain, should have re-evaluation of pain by PCP ___ 1 week [ ] Follow up orthopedic spine clinic visit as may benefit form a revision decompression and fusion procedure [ ] Has Medrol taper. Patient given written instructions. 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 in patient care and coordination of discharge on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 1 PUFF IH Frequency is Unknown Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate 3. Lidocaine 5% Patch 1 PTCH TD QAM 4. Methocarbamol 1000 mg PO QID 5. Methylprednisolone 4 mg PO DAILY 1tab PO with dinner and 2tabs QHS on ___ tab QID ___ TID ___ BID ___ 6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/wheeze 7.Outpatient Physical Therapy ICD: 10 ___.02 Patient would benefit from physical therapy for neck pain likely ___ muscle pain and cervical stenosis. Discharge Disposition: Home Discharge Diagnosis: Acute on chronic neck pain 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 admitted to the hospital for severe neck pain WHAT HAPPENED TO ME IN THE HOSPITAL? - You were evaluated by the orthopedic spinal team in the ED who recommended a Medrol (steroid) taper and pain management - You did not need urgent surgery based on your exam and MRI results - You were given pain medications to manage your pain and worked with physical therapy 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. - Please re-connect with a primary care doctor and start outpatient physical therapy. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "M4802", "M50221", "G8929", "J45909", "F17210", "Z981" ]	Allergies: Sulfa (Sulfonamide Antibiotics) / Ultram Chief Complaint: Neck pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old female with a PMH of HTN and asthma and C5-6 fusion in [MASKED] presenting with neck pain and left arm weakness for 5 days being admitted to medicine for pain control. Patient reports that her pain started on [MASKED] when she moved her neck very quickly to avoid a mosquito. Since then she has had posterior neck pain and weakness of her left arm. She presented to [MASKED] [MASKED] where she had a CT scan and was given pain medication. She initially felt better but then the next day her pain acutely worsened and was aggravated by any neck movement (flexion/extension/rotation). At this point represented to [MASKED] and was transferred to [MASKED] for neurosurgical evaluation. Of note she denies any lower extremity symptoms or any urinary/fecal incontinence. Past Medical History: HTN Asthma Seizures C5-C6 fusion in [MASKED] Social History: [MASKED] Family History: Mom: HTN, Right sided heart failure, 'a lot of autoimmune issues" diabetes, stroke, cancer in other relatives Physical [MASKED]: ADMISSION PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated [MASKED] @ 2322) Temp: 97.4 (Tm 97.8), BP: 106/68 (106-126/68-71), HR: 80 (80-89), RR: 16, O2 sat: 95%, O2 delivery: RA, Wt: 138.67 lb/62.9 kg GENERAL: Sitting up in bed because pain worse when lying down. Holding/rubbing left side of neck. HEENT: PERRL, EOMI. MMM. CARDIAC: RRR no m/r/g LUNGS: CTAB, no r/r/w ABDOMEN: Soft, NT, ND, +BS EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Decreased strength in LUE. [MASKED] in bilateral [MASKED]. DISCHARGE PHYSICAL EXAM: ======================== 97.8 140/92 73 18 98 ra GENERAL: Laying in bed pressing on L side of neck. HEENT: PERRL, EOMI. MMM. CARDIAC: RRR no m/r/g LUNGS: CTAB, no r/r/w ABDOMEN: Soft, NT, ND, +BS EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. [MASKED] strength in both upper and lower extremities Pertinent Results: Admission Labs: =============== [MASKED] 06:35PM [MASKED] PTT-30.8 [MASKED] [MASKED] 03:40PM GLUCOSE-117* UREA N-4* CREAT-0.6 SODIUM-136 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-23 ANION GAP-16 [MASKED] 03:40PM estGFR-Using this [MASKED] 03:40PM WBC-7.8 RBC-4.04 HGB-13.8 HCT-40.3 MCV-100* MCH-34.2* MCHC-34.2 RDW-12.4 RDWSD-45.1 [MASKED] 03:40PM NEUTS-89.4* LYMPHS-5.1* MONOS-4.2* EOS-0.6* BASOS-0.3 IM [MASKED] AbsNeut-6.97* AbsLymp-0.40* AbsMono-0.33 AbsEos-0.05 AbsBaso-0.02 [MASKED] 03:40PM PLT COUNT-157 Micro: None Imaging: MRI C-Spine [MASKED]: 1. Postsurgical changes related to anterior fusion at C5-6, similar in alignment compared to outside CT C-spine. 2. Examination is limited by motion with limited evaluation for spinal cord signal. 3. Moderate to severe spinal canal narrowing at C3-4 and moderate spinal canal narrowing at C4-5 level due to posterior osteophytes and ligamentous thickening. 4. Moderate-to-severe left foraminal narrowing at C3-4 and moderate left foraminal narrowing at C4-5 level due to uncovertebral degenerative changes. 5. No definite postcontrast enhancement, although sagittal T1 weighted precontrast images are moderate to severely motion degraded. CT C-Spine: 1. Status post anterior fusion of C5-C6 without evidence of hardware complication or fracture. 2. Cervical spondylosis, most prominent at C3-C4 and better assessed on MR cervical spine dated [MASKED]. Discharge Labs: =============== [MASKED] 07:12AM BLOOD WBC-6.4 RBC-3.87* Hgb-13.2 Hct-38.7 MCV-100* MCH-34.1* MCHC-34.1 RDW-12.6 RDWSD-45.9 Plt [MASKED] [MASKED] 07:12AM BLOOD Glucose-110* UreaN-4* Creat-0.7 Na-137 K-3.6 Cl-97 HCO3-25 AnGap-15 [MASKED] 07:12AM BLOOD Calcium-10.0 Phos-3.3 Mg-1.8 Brief Hospital Course: ================== SUMMARY STATEMENT: ================== Ms. [MASKED] is a [MASKED] year old female with a PMH of HTN and asthma and C5-6 fusion in [MASKED] presenting with neck pain and left arm weakness for 5 days being admitted to medicine for pain control. ACUTE/ACTIVE ISSUES: ==================== #Acute neck pain with L arm symptoms #C4-5 bulge with spinal canal narrowing #Mild central stenosis C3-5 Patient with neck pain and LUE weakness since [MASKED]. MRI with severe canal narrowing at C3-4 and C4-5 due disc osteophyte complexes. There appears to be thickening of the anterior and posterior epidural space at C3-4 and C4-5, which may be due to prominent epidural fat or ligamental thickening. Evaluated by spine in the ED who recommended a Medrol dosepack and follow-up in clinic in one week as symptoms do not appear consistent with MRI findings. Ortho spine also recommended a CT scan which did not show evidence of hardware complication or fracture. Repeat neuro exam with intact strength in all extremities with improved radiation down arm. Patient was admitted due to intractable pain. Her pain was managed with APAP, hydromorphone, lidocaine patch, methocarbamol, and the steroid taper. Her pain improved from admission and [MASKED] recommended out patient [MASKED]. She may benefit from revision decompression and fusion procedure with spinal surgery. CHRONIC/STABLE ISSUES: ====================== #Asthma: Continued home inhaler #Tobacco use disorder: Placed on nicotine patch ==================== TRANSITIONAL ISSUES: ==================== [ ] Given 1 week of opioids and muscle relaxer due to severe pain, should have re-evaluation of pain by PCP [MASKED] 1 week [ ] Follow up orthopedic spine clinic visit as may benefit form a revision decompression and fusion procedure [ ] Has Medrol taper. Patient given written instructions. 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 in patient care and coordination of discharge on [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 1 PUFF IH Frequency is Unknown Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate 3. Lidocaine 5% Patch 1 PTCH TD QAM 4. Methocarbamol 1000 mg PO QID 5. Methylprednisolone 4 mg PO DAILY 1tab PO with dinner and 2tabs QHS on [MASKED] tab QID [MASKED] TID [MASKED] BID [MASKED] 6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/wheeze 7.Outpatient Physical Therapy ICD: 10 [MASKED].02 Patient would benefit from physical therapy for neck pain likely [MASKED] muscle pain and cervical stenosis. Discharge Disposition: Home Discharge Diagnosis: Acute on chronic neck pain 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 admitted to the hospital for severe neck pain WHAT HAPPENED TO ME IN THE HOSPITAL? - You were evaluated by the orthopedic spinal team in the ED who recommended a Medrol (steroid) taper and pain management - You did not need urgent surgery based on your exam and MRI results - You were given pain medications to manage your pain and worked with physical therapy 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. - Please re-connect with a primary care doctor and start outpatient physical therapy. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "G8929", "J45909", "F17210" ]	[ "M4802: Spinal stenosis, cervical region", "M50221: Other cervical disc displacement at C4-C5 level", "G8929: Other chronic pain", "J45909: Unspecified asthma, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z981: Arthrodesis status" ]
10,039,990	29,933,748	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: lisinopril Attending: ___. Chief Complaint: transient vision loss and dizziness Major Surgical or Invasive Procedure: none History of Present Illness: NEUROLOGY STROKE ADMISSION/CONSULT NOTE NO CODE STROKE ___ Stroke Scale Score: 0 t-PA administered: [] Yes - Time given: __ [x] No - Reason t-PA was not given or considered: nihss 0 Thrombectomy performed: [] Yes [x] No - Reason not performed or considered: no LVO NIHSS performed within 6 hours of presentation at: ___ time/date ___ NIHSS Total: 0 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 REASON FOR CONSULTATION: transient vision loss and dizziness HPI: ___ is a ___ year old male with history of hypertension and hyperlipidemia who presents with 20 minutes of left upper outer quadrant vision loss and vertigo. He reports he has been in his usual state of health recently. He got up this morning and went on a 2 mile leisurely bike ride. He does bike in such a way that he has to hyperextend his neck. He then came out and ate some cheese sandwiches and then went about his day. He was working on fixing a door and was lifting and straining but felt fine with this activity. Then he went and sat on the cough and was talking with his wife. At 2:25, all of the sudden he noticed that in his upper outer left field of vision, he could not make things out (describes seeing light but everything was very blurry). He closed one eye at a time and the symptoms were still present with one eye closed. He also noticed that he felt like the room was spinning. He got up and walked into the kitchen and had to hold onto the kitchen counter. He googled his symptoms and looked up things to check for stroke. His wife checked his face, speech, weakness and sensation which were all normal. He specifically says he checked for drift of his arms and legs and there was none. After about 20 minutes the vision changes and dizziness resolved. He called his PCP who recommended he go to an eye doctor. He went to Mass Eye and Ear and had a normal dilated eye exam. He does report that there was a test in which the ophthalmologist held up a large red box and he had this transient vision change with that in which the very center (not left or right) of the box was fading from red to black, but then these symptoms stopped. He has not been sick recently. There are no new medications. He does report occasional palpitations. There is no headache or neck pain. ROS: On neurological review of systems, the patient denies headache, confusion, difficulties producing or comprehending speech, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the patient denies recent fever, chills, night sweats, or recent weight changes. Denies cough, shortness of breath, chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. Denies dysuria, or recent change in bowel or bladder habits. Denies arthralgias, myalgias, or rash. Past Medical History: hypertension hyperlipidemia GERD Social History: Full time ___, stopped smoking ___ years ago; had 10 pack year history, no drugs, no etoh, lives with wife - Modified Rankin Scale: [x] 0: No symptoms [] 1: No significant disability - able to carry out all usual activities despite some symptoms [] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [] 3: Moderate disability: requires some help but able to walk unassisted [] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead Family History: PGF had strokes in ___, father had strokes and MI in his ___, brother had MI at ___ Physical Exam: ADMISSION PHYSICAL EXAM: PHYSICAL EXAMINATION: Vitals: T: 98 BP: 150/85 HR: 73 RR: 18 SaO2: 97% on RA General: Awake, cooperative, HEENT: NC/AT, no scleral icterus noted Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x ___ or ___, ___, ___. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial ___: II, III, IV, VI: 8 mm NR (post dilation). EOMI without nystagmus. VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, or proprioception throughout. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was flexor bilaterally. -Coordination: Bilateral intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. ============================================== DISCHARGE PHYSICAL EXAM: General: Awake, cooperative HEENT: NC/AT, no scleral icterus noted Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, Able to relate history without difficulty. Attentive, Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial II, III, IV, VI: EOMI without nystagmus. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, or proprioception throughout. No extinction to DSS. Romberg absent. ============================================== Pertinent Results: ___ 07:15PM BLOOD WBC-8.1 RBC-4.76 Hgb-14.7 Hct-43.9 MCV-92 MCH-30.9 MCHC-33.5 RDW-12.3 RDWSD-41.5 Plt ___ ___ 07:15PM BLOOD Neuts-71.9* ___ Monos-6.8 Eos-1.9 Baso-0.2 Im ___ AbsNeut-5.81 AbsLymp-1.54 AbsMono-0.55 AbsEos-0.15 AbsBaso-0.02 ___ 07:15PM BLOOD ___ PTT-29.5 ___ ___ 07:15PM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-141 K-4.0 Cl-104 HCO3-25 AnGap-12 ___ 07:15PM BLOOD ALT-26 AST-18 AlkPhos-56 TotBili-0.4 ___ 07:15PM BLOOD Lipase-16 ___ 07:15PM BLOOD cTropnT-<0.01 ___ 05:30AM BLOOD Cholest-139 ___ 07:15PM BLOOD Albumin-4.5 Calcium-9.7 Phos-4.2 Mg-2.1 ___ 07:15PM BLOOD %HbA1c-5.6 eAG-114 ___ 05:30AM BLOOD Triglyc-95 HDL-42 CHOL/HD-3.3 LDLcalc-78 ___ 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Transthoracic ECHO : No evidence for right-to-left intracardiac shunt at rest or with maneuvers. The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 61 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal LV and RV size and systolic function. No significant valvular disease. ___: LENIs: No evidence of deep venous thrombosis in the right or left lower extremity veins. ___: MR head without contrast: No evidence of acute infarction, hemorrhage or intracranial mass. ___: 1. No evidence of acute infarction, hemorrhage or intracranial mass. 2. Patent intracranial and cervical vasculature without evidence of dissection, stenosis, vessel occlusion or aneurysm formation greater than 3 mm. 3. Paranasal sinus disease. CXR: No acute cardiopulmonary findings. Brief Hospital Course: BRIEF SUMMARY: ___ year old male with history of hypertension and hyperlipidemia who presented with 20 minutes of left upper outer quadrant vision loss and vertigo. Exam on presentation was normal s/p a long bike ride (likely dehydrated) and lifting heavy objects. History was concerning for a posterior circulation TIA, ?paradoxical embolism. He was admitted to stroke team, CT, CTA head and neck, and brain MRI did not show any acute infarct. Echo obtained and was reassuring (EF 61%), bubble study included and did not show a PFO on preliminary review, final results pending . ___ obtained and no DVT identified. Stroke labs showed reassuring CBC, HbA1c of 5.6, Cholesterol 139, Triglycerides 95, HDL 42, LDL 78. Etiology was presumed to be cardioembolic. Patient was started on aspirin 81 mg daily and discharged home with outpatient PCP follow up with plan for Neurology referral ___, At___ Neurologist). Exam at discharge was unremarkable, without any localizing signs. ================================================== TRANSITIONAL ISSUES: [ ] Follow up final read of TTE to confirm no PFO [ ] We have started patient on aspirin 81 mg daily (baby aspirin) [ ] We have placed a heart monitor (Ziopatch), the results of this will be communicated to your PCP / Dr. ___ ___. [ ] Please follow up with PCP, who will refer you to an Atrius Neurologist. =================================================== 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 = 78 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL >70, reason not given: [ ] Statin medication allergy [x ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist : LDL at 78, mechanism likely embolic, on discussion with pt it was decided that he will first try dietary modification to lower LDL from 78 to less than 70. [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? () Yes - (x) No. If no, why not? -- patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [x ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist : LDL at 78, mechanism likely embolic, on discussion with pt it was decided that he will first try dietary modification to lower LDL from 78 to less than 70. [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A ===================================================== CTA Head and neck: ___: 1. No evidence of acute infarction, hemorrhage or intracranial mass. 2. Patent intracranial and cervical vasculature without evidence of dissection, stenosis, vessel occlusion or aneurysm formation greater than 3 mm. 3. Paranasal sinus disease. MR head: ___: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. Major vascular flow voids are preserved. There is mild mucosal thickening along the ethmoid air cells. The remainder of the paranasal sinuses appear clear. There is trace opacification of the bilateral inferior mastoid air cells. The orbits appear unremarkable. IMPRESSION: 1. No evidence of acute infarction, hemorrhage or intracranial mass. ECHO ___: The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 61 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal LV and RV size and systolic function. No significant valvular disease. =============================================== Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Omeprazole 40 mg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Atorvastatin 20 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Omeprazole 20 mg PO DAILY Patient take 20 mg Omeprazole alternating with 40 mg every other day. 3. Atorvastatin 20 mg PO QPM 4. Losartan Potassium 50 mg PO DAILY 5. Omeprazole 40 mg PO DAILY Patient take 20 mg Omeprazole alternating with 40 mg every other day. Discharge Disposition: Home Discharge Diagnosis: TRANSIENT ISCHEMIC ATTACK 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 "20 minutes of left upper outer quadrant vision loss and vertigo" resulting from a TRANSIENT ISCHEMIC ATTACK (TIA), a condition where a blood vessel providing oxygen and nutrients to the brain is blocked transiently 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. We obtained brain imaging and heart echo, which were both reassuring. TIA can have many different causes, so we assessed you for medical conditions that might raise your risk of having TIA/stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: [ ] high blood pressure [ ] high cholesterol We are changing your medications as follows: [ ] We have started you on aspirin 81 mg daily (baby aspirin) [ ] We have placed a heart monitor (Ziopatch), the results of this will be communicated to your PCP and Dr. ___ ___. [ ] Please follow up with your PCP, who will refer you to an Atrius Neurologist. An appointment with your PCP has been set for ___ at 3:20 ___. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___	[ "G459", "I10", "E785", "K219", "Z87891", "H53462" ]	Allergies: lisinopril Chief Complaint: transient vision loss and dizziness Major Surgical or Invasive Procedure: none History of Present Illness: NEUROLOGY STROKE ADMISSION/CONSULT NOTE NO CODE STROKE [MASKED] Stroke Scale Score: 0 t-PA administered: [] Yes - Time given: [x] No - Reason t-PA was not given or considered: nihss 0 Thrombectomy performed: [] Yes [x] No - Reason not performed or considered: no LVO NIHSS performed within 6 hours of presentation at: [MASKED] time/date [MASKED] NIHSS Total: 0 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 REASON FOR CONSULTATION: transient vision loss and dizziness HPI: [MASKED] is a [MASKED] year old male with history of hypertension and hyperlipidemia who presents with 20 minutes of left upper outer quadrant vision loss and vertigo. He reports he has been in his usual state of health recently. He got up this morning and went on a 2 mile leisurely bike ride. He does bike in such a way that he has to hyperextend his neck. He then came out and ate some cheese sandwiches and then went about his day. He was working on fixing a door and was lifting and straining but felt fine with this activity. Then he went and sat on the cough and was talking with his wife. At 2:25, all of the sudden he noticed that in his upper outer left field of vision, he could not make things out (describes seeing light but everything was very blurry). He closed one eye at a time and the symptoms were still present with one eye closed. He also noticed that he felt like the room was spinning. He got up and walked into the kitchen and had to hold onto the kitchen counter. He googled his symptoms and looked up things to check for stroke. His wife checked his face, speech, weakness and sensation which were all normal. He specifically says he checked for drift of his arms and legs and there was none. After about 20 minutes the vision changes and dizziness resolved. He called his PCP who recommended he go to an eye doctor. He went to Mass Eye and Ear and had a normal dilated eye exam. He does report that there was a test in which the ophthalmologist held up a large red box and he had this transient vision change with that in which the very center (not left or right) of the box was fading from red to black, but then these symptoms stopped. He has not been sick recently. There are no new medications. He does report occasional palpitations. There is no headache or neck pain. ROS: On neurological review of systems, the patient denies headache, confusion, difficulties producing or comprehending speech, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the patient denies recent fever, chills, night sweats, or recent weight changes. Denies cough, shortness of breath, chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. Denies dysuria, or recent change in bowel or bladder habits. Denies arthralgias, myalgias, or rash. Past Medical History: hypertension hyperlipidemia GERD Social History: Full time [MASKED], stopped smoking [MASKED] years ago; had 10 pack year history, no drugs, no etoh, lives with wife - Modified Rankin Scale: [x] 0: No symptoms [] 1: No significant disability - able to carry out all usual activities despite some symptoms [] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [] 3: Moderate disability: requires some help but able to walk unassisted [] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead Family History: PGF had strokes in [MASKED], father had strokes and MI in his [MASKED], brother had MI at [MASKED] Physical Exam: ADMISSION PHYSICAL EXAM: PHYSICAL EXAMINATION: Vitals: T: 98 BP: 150/85 HR: 73 RR: 18 SaO2: 97% on RA General: Awake, cooperative, HEENT: NC/AT, no scleral icterus noted Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No [MASKED] edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x [MASKED] or [MASKED], [MASKED], [MASKED]. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial [MASKED]: II, III, IV, VI: 8 mm NR (post dilation). EOMI without nystagmus. VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, or proprioception throughout. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [[MASKED]] [Pat] [Ach] L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was flexor bilaterally. -Coordination: Bilateral intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. ============================================== DISCHARGE PHYSICAL EXAM: General: Awake, cooperative HEENT: NC/AT, no scleral icterus noted Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No [MASKED] edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, Able to relate history without difficulty. Attentive, Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial II, III, IV, VI: EOMI without nystagmus. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, or proprioception throughout. No extinction to DSS. Romberg absent. ============================================== Pertinent Results: [MASKED] 07:15PM BLOOD WBC-8.1 RBC-4.76 Hgb-14.7 Hct-43.9 MCV-92 MCH-30.9 MCHC-33.5 RDW-12.3 RDWSD-41.5 Plt [MASKED] [MASKED] 07:15PM BLOOD Neuts-71.9* [MASKED] Monos-6.8 Eos-1.9 Baso-0.2 Im [MASKED] AbsNeut-5.81 AbsLymp-1.54 AbsMono-0.55 AbsEos-0.15 AbsBaso-0.02 [MASKED] 07:15PM BLOOD [MASKED] PTT-29.5 [MASKED] [MASKED] 07:15PM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-141 K-4.0 Cl-104 HCO3-25 AnGap-12 [MASKED] 07:15PM BLOOD ALT-26 AST-18 AlkPhos-56 TotBili-0.4 [MASKED] 07:15PM BLOOD Lipase-16 [MASKED] 07:15PM BLOOD cTropnT-<0.01 [MASKED] 05:30AM BLOOD Cholest-139 [MASKED] 07:15PM BLOOD Albumin-4.5 Calcium-9.7 Phos-4.2 Mg-2.1 [MASKED] 07:15PM BLOOD %HbA1c-5.6 eAG-114 [MASKED] 05:30AM BLOOD Triglyc-95 HDL-42 CHOL/HD-3.3 LDLcalc-78 [MASKED] 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED]:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Transthoracic ECHO : No evidence for right-to-left intracardiac shunt at rest or with maneuvers. The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 61 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal LV and RV size and systolic function. No significant valvular disease. [MASKED]: LENIs: No evidence of deep venous thrombosis in the right or left lower extremity veins. [MASKED]: MR head without contrast: No evidence of acute infarction, hemorrhage or intracranial mass. [MASKED]: 1. No evidence of acute infarction, hemorrhage or intracranial mass. 2. Patent intracranial and cervical vasculature without evidence of dissection, stenosis, vessel occlusion or aneurysm formation greater than 3 mm. 3. Paranasal sinus disease. CXR: No acute cardiopulmonary findings. Brief Hospital Course: BRIEF SUMMARY: [MASKED] year old male with history of hypertension and hyperlipidemia who presented with 20 minutes of left upper outer quadrant vision loss and vertigo. Exam on presentation was normal s/p a long bike ride (likely dehydrated) and lifting heavy objects. History was concerning for a posterior circulation TIA, ?paradoxical embolism. He was admitted to stroke team, CT, CTA head and neck, and brain MRI did not show any acute infarct. Echo obtained and was reassuring (EF 61%), bubble study included and did not show a PFO on preliminary review, final results pending . [MASKED] obtained and no DVT identified. Stroke labs showed reassuring CBC, HbA1c of 5.6, Cholesterol 139, Triglycerides 95, HDL 42, LDL 78. Etiology was presumed to be cardioembolic. Patient was started on aspirin 81 mg daily and discharged home with outpatient PCP follow up with plan for Neurology referral [MASKED], At Neurologist). Exam at discharge was unremarkable, without any localizing signs. ================================================== TRANSITIONAL ISSUES: [ ] Follow up final read of TTE to confirm no PFO [ ] We have started patient on aspirin 81 mg daily (baby aspirin) [ ] We have placed a heart monitor (Ziopatch), the results of this will be communicated to your PCP / Dr. [MASKED] [MASKED]. [ ] Please follow up with PCP, who will refer you to an Atrius Neurologist. =================================================== 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 = 78 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL >70, reason not given: [ ] Statin medication allergy [x ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist : LDL at 78, mechanism likely embolic, on discussion with pt it was decided that he will first try dietary modification to lower LDL from 78 to less than 70. [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? () Yes - (x) No. If no, why not? -- patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [x ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist : LDL at 78, mechanism likely embolic, on discussion with pt it was decided that he will first try dietary modification to lower LDL from 78 to less than 70. [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A ===================================================== CTA Head and neck: [MASKED]: 1. No evidence of acute infarction, hemorrhage or intracranial mass. 2. Patent intracranial and cervical vasculature without evidence of dissection, stenosis, vessel occlusion or aneurysm formation greater than 3 mm. 3. Paranasal sinus disease. MR head: [MASKED]: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. Major vascular flow voids are preserved. There is mild mucosal thickening along the ethmoid air cells. The remainder of the paranasal sinuses appear clear. There is trace opacification of the bilateral inferior mastoid air cells. The orbits appear unremarkable. IMPRESSION: 1. No evidence of acute infarction, hemorrhage or intracranial mass. ECHO [MASKED]: The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 61 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal LV and RV size and systolic function. No significant valvular disease. =============================================== Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Omeprazole 40 mg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Atorvastatin 20 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Omeprazole 20 mg PO DAILY Patient take 20 mg Omeprazole alternating with 40 mg every other day. 3. Atorvastatin 20 mg PO QPM 4. Losartan Potassium 50 mg PO DAILY 5. Omeprazole 40 mg PO DAILY Patient take 20 mg Omeprazole alternating with 40 mg every other day. Discharge Disposition: Home Discharge Diagnosis: TRANSIENT ISCHEMIC ATTACK 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 "20 minutes of left upper outer quadrant vision loss and vertigo" resulting from a TRANSIENT ISCHEMIC ATTACK (TIA), a condition where a blood vessel providing oxygen and nutrients to the brain is blocked transiently 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. We obtained brain imaging and heart echo, which were both reassuring. TIA can have many different causes, so we assessed you for medical conditions that might raise your risk of having TIA/stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: [ ] high blood pressure [ ] high cholesterol We are changing your medications as follows: [ ] We have started you on aspirin 81 mg daily (baby aspirin) [ ] We have placed a heart monitor (Ziopatch), the results of this will be communicated to your PCP and Dr. [MASKED] [MASKED]. [ ] Please follow up with your PCP, who will refer you to an Atrius Neurologist. An appointment with your PCP has been set for [MASKED] at 3:20 [MASKED]. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]	[]	[ "I10", "E785", "K219", "Z87891" ]	[ "G459: Transient cerebral ischemic attack, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "H53462: Homonymous bilateral field defects, left side" ]
10,039,997	22,484,749	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Right arm weakness and unsteadiness with walking. Major Surgical or Invasive Procedure: None. History of Present Illness: ___ is a ___ year old woman with past medical history significant for stroke ___ (thought to be ___ hypercoaguable state from OCPs and smoking), right pericallosal aneurysm s/p clipping in ___, hypertension, hyperlipidemia who presents with left-sided weakness and gait unsteadiness worsening since ___. She reports that sometime on ___ she noticed that her left leg which is always weak seemed weaker than normal as well as her left arm. She has noticed that her right leg seemed a little bit weak which was new for her and she knows that she was having trouble writing. Over the next few days she has had more trouble with her right hand and she has been dropping things. She has also had multiple falls. Yesterday she fell at home and her sister had to help her out because she could not get up on her own. She says that she thinks the weakness might feel a little bit better when she is walking around, but she feels off balance so she has not been able to walk much. She has a hard time describing this feeling of off balance; she does not report any room spinning or lightheadedness she just feels like she might fall. She has not had any illnesses recently and she has not had any medication changes. 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 numbness, parasthesia. Denies loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Hyperlipidemia Gout CVA, minimal left hemiparesis History of alcohol dependence Fracture femur in ___ Social History: ___ FAMILY HISTORY: Her mother had a stroke hypertension and myocardial infarction. Family History: Her mother had a stroke hypertension and myocardial infarction. Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== PHYSICAL EXAMINATION Vitals: T: 97.2 HR 71 BP 165/79 RR 18 SaO2 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: Irregular rhymthm. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Patient was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. Cranial Nerves: II, III, IV, VI: PERRL 2 to 1mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity ___ bilaterally with correction. V: Facial sensation intact to light touch. VII: Slight left facial droop, which activates symmetrically. Left orbital fissure slightly wider compared to the right with strong eye closure 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, 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 4+ 4+ 5 4+ 5 4+ 5 4+ 5 5 5 R 5 ___ ___ 4+ 5 5 5 5 5 Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. DTRs: Bi Tri ___ Pat Ach L 2 2 2 1 1 R 2 2 2 1 1 Plantar response was flexor on right, mute on left. Coordination: Dysmetria present on finger-nose-finger left greater than right. Slight dysmetria present on heel to shin bilaterally. Patient had dysmetria when reaching for her phone and trying to unlock it when I asked her about it she seemed like she had not noticed it before but seemed to think it was new. Gait: Upon sitting up in bed patient with very prominent truncal ataxia, but able to sit up straight. On standing, patient with sway. Upon taking one step she lost balance and fell onto examiner. She said this is how her standing and walking has been at home for the past few days and that she has been using an assistive device to help her but it has not been enough that she has been falling. Unable to test Romberg. ======================== DISCHARGE PHYSICAL EXAM: ======================== Objective: 24 HR Data (last updated ___ @ 757) Temp: 97.6 (Tm 98.4) BP: 134/73 (124-162/70-97) HR: 67 (51-74), RR: 16 (___) O2 sat: 98% (94-100) O2 delivery: Ra Physical exam: General: Comfortable and in no distress Head: No irritation/exudate from eyes, nose, throat Neck: Supple with no pain to flexion or extension Cardio: Regular rate and rhythm, warm, no peripheral edema Lungs: Unlabored breathing Abdomen: Soft, non tender, non distended Skin: No rashes or lesions Neurologic exam: Mental status: Alert and oriented x3, attentive. Speech is fluent without dysarthria. Able to carry out extensive conversations with good comprehension of hospital course and plan. CN: II, III, IV, VI: Pupils constrict 3 to 2mm on right and 3.5-2.5 on left. Visual fields full. R ptosis (may be chronic). V: Facial sensation intact to light touch bilaterally (L side feels 50% of R side chronically). VII: Slight lower L facial droop (chronic) VIII: Hearing intact to finger rub bilaterally IX, X: Palate elevates symmetrically XI: ___ strength in R, L trapezii and SCM XII: Tongue protrudes midline Motor: normal bulk and tone, no extraneous movements Delt Tri Bic WrE FE FF IP Ham TA Gas L 4+ 4+ 5 5 4+ ___ 5 5 R 5 5 5 5 ___ 5 5 5 Pronator drift (downwards) on L Sensory: Deferred Coordination: Significant dysmetria with to FTN L worse than R. Reflexes: Deferred. Gait: Very unsteady, falling backwards and towards the left. Left leg drags. Pertinent Results: ___ 08:30AM BLOOD WBC-3.5* RBC-4.58 Hgb-13.3 Hct-40.8 MCV-89 MCH-29.0 MCHC-32.6 RDW-13.7 RDWSD-44.4 Plt ___ ___ 08:30AM BLOOD Glucose-100 UreaN-19 Creat-1.1 (baseline) Na-142 K-4.3 Cl-105 HCO3-24 AnGap-13 MRI brain ___: 1. Few small foci of slow diffusion involving the left corona radiata and left frontal lobe. 2. Old right frontal parietal infarction where there is associated volume loss. 3. A few small old right cerebellar infarcts. 4. Moderate white matter chronic small vessel ischemic disease. 5. Status post right frontal craniotomy and clipping of a right pericallosal artery aneurysm. Echo ___: IMPRESSION: Mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No definite structural cardiac source of embolism identified. Brief Hospital Course: Patient is a ___ year old female with past medical history most remarkable for remote right sided parietal and cerebellar strokes with residual left sided weakness, right pericallosal aneurysm status post clipping in ___, hypertension, and hyperlipidemia whom presented ___ with right sided weakness found to have left corona radiata infarction. Etiology of patient's stroke uncertain, but suspect paroxysmal atrial fibrillation given large vessel occlusion and now history of bilateral strokes in different vascular territories. No atrial fibrillation on telemetry, but have arranged for patient to be monitored with outpatient holter (scheduled ___. Patient has been taking aspirin 325 mg daily for stroke risk reduction, but this admission we have switched her to clopidogrel 75 mg daily. Patient's LDL found to be 95 and we have increased her rosuvastatin to 30 mg daily (from 20 mg daily) with hopes to get her to goal of less than 70. Patient by the time of discharge had full motor strength on the right and her exam remained remarkable for chronic left sided weakness. Patient was having difficulty with ambulating and was at high risk of falling. Therefore, she was discharged to acute rehabilitation to work on improved and safe ambulation. Patient was told to follow up with her primary care physician to obtain ___ neurology referral. Patient should be neurologist in 3 months from discharge. Transitional issues: Left corona radiate/motor cortex stroke: Please ensure that patient makes Holter placement appointment ___. Please ensure patient has scheduled appointment with PCP ___ days post discharge from acute rehabilitation to follow up on this hospitalization and to obtain referral to see neurologist 3 months post discharge. Leukopenia and thrombocytopenia: Patient needs to have levels followed up with PCP. If chronically low, might need hematology work up to rule out hematologic disorder. Patient also with mild chronic kidney disease and mildly elevated alkaline phosphatase. Would recommend starting with outpatient SPEP/UPEP to rule out multiple myeloma. Hyperlipidemia: Patient's LDL 98 this admission, increased rosuvastatin to 30 mg daily to work towards goal of less than 70. Will need to follow up with PCP. Hypertension: There were no changes in her hypertension medications this admission, would follow up with PCP to ensure blood pressure adequately managed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LamoTRIgine 200 mg PO DAILY 2. Metoprolol Succinate XL 350 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. OLANZapine 10 mg PO DAILY 5. amLODIPine 10 mg PO DAILY 6. Rosuvastatin Calcium 20 mg PO QPM 7. Aspirin 325 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Rosuvastatin Calcium 30 mg PO QPM 3. amLODIPine 10 mg PO DAILY 4. LamoTRIgine 200 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. Metoprolol Succinate XL 350 mg PO DAILY 7. OLANZapine 10 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left corona radiata stroke 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: You presented to the hospital with right sided weakness and walking unsteadiness and were found to have had a stroke on the left side of your brain. Thankfully, it looks like you are recovering well from this stroke and we have transferred you to acute rehabilitation to maximize your recovery potential. We want to help prevent you from having another stroke and have therefore changed some of your current medications. We have started you on clopidogrel 75 mg daily and you will discontinue taking aspirin 325 mg daily. We have increased your rosuvastatin to 30 mg daily (from 20 mg daily) to help tighten control of your blood lipid levels. Ultimately, we are uncertain why you had a stroke, but we suspect that you have an abnormal rhythm in your heart that is increasing your risks of having strokes. Therefore, will have scheduled for you to come to pick up a monitor to wear to possibly detect this abnormal rhythm. Please have your primary care physician send ___ referral for you to follow up with a neurologist in three months so that your stroke management can be reviewed. Thank you for allowing us to care for you, ___ Stroke Team Followup Instructions: ___	[ "I6340", "I69354", "D696", "I480", "G8191", "I129", "I69392", "N189", "I69893", "E785", "D72819", "R2681", "F17210", "F329", "Z9181" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right arm weakness and unsteadiness with walking. Major Surgical or Invasive Procedure: None. History of Present Illness: [MASKED] is a [MASKED] year old woman with past medical history significant for stroke [MASKED] (thought to be [MASKED] hypercoaguable state from OCPs and smoking), right pericallosal aneurysm s/p clipping in [MASKED], hypertension, hyperlipidemia who presents with left-sided weakness and gait unsteadiness worsening since [MASKED]. She reports that sometime on [MASKED] she noticed that her left leg which is always weak seemed weaker than normal as well as her left arm. She has noticed that her right leg seemed a little bit weak which was new for her and she knows that she was having trouble writing. Over the next few days she has had more trouble with her right hand and she has been dropping things. She has also had multiple falls. Yesterday she fell at home and her sister had to help her out because she could not get up on her own. She says that she thinks the weakness might feel a little bit better when she is walking around, but she feels off balance so she has not been able to walk much. She has a hard time describing this feeling of off balance; she does not report any room spinning or lightheadedness she just feels like she might fall. She has not had any illnesses recently and she has not had any medication changes. 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 numbness, parasthesia. Denies loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Hyperlipidemia Gout CVA, minimal left hemiparesis History of alcohol dependence Fracture femur in [MASKED] Social History: [MASKED] FAMILY HISTORY: Her mother had a stroke hypertension and myocardial infarction. Family History: Her mother had a stroke hypertension and myocardial infarction. Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== PHYSICAL EXAMINATION Vitals: T: 97.2 HR 71 BP 165/79 RR 18 SaO2 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: Irregular rhymthm. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No [MASKED] edema. Skin: no rashes or lesions noted. Neurologic: Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Patient was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. Cranial Nerves: II, III, IV, VI: PERRL 2 to 1mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity [MASKED] bilaterally with correction. V: Facial sensation intact to light touch. VII: Slight left facial droop, which activates symmetrically. Left orbital fissure slightly wider compared to the right with strong eye closure 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, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 5 4+ 4+ 5 4+ 5 4+ 5 4+ 5 5 5 R 5 [MASKED] [MASKED] 4+ 5 5 5 5 5 Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 1 1 R 2 2 2 1 1 Plantar response was flexor on right, mute on left. Coordination: Dysmetria present on finger-nose-finger left greater than right. Slight dysmetria present on heel to shin bilaterally. Patient had dysmetria when reaching for her phone and trying to unlock it when I asked her about it she seemed like she had not noticed it before but seemed to think it was new. Gait: Upon sitting up in bed patient with very prominent truncal ataxia, but able to sit up straight. On standing, patient with sway. Upon taking one step she lost balance and fell onto examiner. She said this is how her standing and walking has been at home for the past few days and that she has been using an assistive device to help her but it has not been enough that she has been falling. Unable to test Romberg. ======================== DISCHARGE PHYSICAL EXAM: ======================== Objective: 24 HR Data (last updated [MASKED] @ 757) Temp: 97.6 (Tm 98.4) BP: 134/73 (124-162/70-97) HR: 67 (51-74), RR: 16 ([MASKED]) O2 sat: 98% (94-100) O2 delivery: Ra Physical exam: General: Comfortable and in no distress Head: No irritation/exudate from eyes, nose, throat Neck: Supple with no pain to flexion or extension Cardio: Regular rate and rhythm, warm, no peripheral edema Lungs: Unlabored breathing Abdomen: Soft, non tender, non distended Skin: No rashes or lesions Neurologic exam: Mental status: Alert and oriented x3, attentive. Speech is fluent without dysarthria. Able to carry out extensive conversations with good comprehension of hospital course and plan. CN: II, III, IV, VI: Pupils constrict 3 to 2mm on right and 3.5-2.5 on left. Visual fields full. R ptosis (may be chronic). V: Facial sensation intact to light touch bilaterally (L side feels 50% of R side chronically). VII: Slight lower L facial droop (chronic) VIII: Hearing intact to finger rub bilaterally IX, X: Palate elevates symmetrically XI: [MASKED] strength in R, L trapezii and SCM XII: Tongue protrudes midline Motor: normal bulk and tone, no extraneous movements Delt Tri Bic WrE FE FF IP Ham TA Gas L 4+ 4+ 5 5 4+ [MASKED] 5 5 R 5 5 5 5 [MASKED] 5 5 5 Pronator drift (downwards) on L Sensory: Deferred Coordination: Significant dysmetria with to FTN L worse than R. Reflexes: Deferred. Gait: Very unsteady, falling backwards and towards the left. Left leg drags. Pertinent Results: [MASKED] 08:30AM BLOOD WBC-3.5* RBC-4.58 Hgb-13.3 Hct-40.8 MCV-89 MCH-29.0 MCHC-32.6 RDW-13.7 RDWSD-44.4 Plt [MASKED] [MASKED] 08:30AM BLOOD Glucose-100 UreaN-19 Creat-1.1 (baseline) Na-142 K-4.3 Cl-105 HCO3-24 AnGap-13 MRI brain [MASKED]: 1. Few small foci of slow diffusion involving the left corona radiata and left frontal lobe. 2. Old right frontal parietal infarction where there is associated volume loss. 3. A few small old right cerebellar infarcts. 4. Moderate white matter chronic small vessel ischemic disease. 5. Status post right frontal craniotomy and clipping of a right pericallosal artery aneurysm. Echo [MASKED]: IMPRESSION: Mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No definite structural cardiac source of embolism identified. Brief Hospital Course: Patient is a [MASKED] year old female with past medical history most remarkable for remote right sided parietal and cerebellar strokes with residual left sided weakness, right pericallosal aneurysm status post clipping in [MASKED], hypertension, and hyperlipidemia whom presented [MASKED] with right sided weakness found to have left corona radiata infarction. Etiology of patient's stroke uncertain, but suspect paroxysmal atrial fibrillation given large vessel occlusion and now history of bilateral strokes in different vascular territories. No atrial fibrillation on telemetry, but have arranged for patient to be monitored with outpatient holter (scheduled [MASKED]. Patient has been taking aspirin 325 mg daily for stroke risk reduction, but this admission we have switched her to clopidogrel 75 mg daily. Patient's LDL found to be 95 and we have increased her rosuvastatin to 30 mg daily (from 20 mg daily) with hopes to get her to goal of less than 70. Patient by the time of discharge had full motor strength on the right and her exam remained remarkable for chronic left sided weakness. Patient was having difficulty with ambulating and was at high risk of falling. Therefore, she was discharged to acute rehabilitation to work on improved and safe ambulation. Patient was told to follow up with her primary care physician to obtain [MASKED] neurology referral. Patient should be neurologist in 3 months from discharge. Transitional issues: Left corona radiate/motor cortex stroke: Please ensure that patient makes Holter placement appointment [MASKED]. Please ensure patient has scheduled appointment with PCP [MASKED] days post discharge from acute rehabilitation to follow up on this hospitalization and to obtain referral to see neurologist 3 months post discharge. Leukopenia and thrombocytopenia: Patient needs to have levels followed up with PCP. If chronically low, might need hematology work up to rule out hematologic disorder. Patient also with mild chronic kidney disease and mildly elevated alkaline phosphatase. Would recommend starting with outpatient SPEP/UPEP to rule out multiple myeloma. Hyperlipidemia: Patient's LDL 98 this admission, increased rosuvastatin to 30 mg daily to work towards goal of less than 70. Will need to follow up with PCP. Hypertension: There were no changes in her hypertension medications this admission, would follow up with PCP to ensure blood pressure adequately managed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LamoTRIgine 200 mg PO DAILY 2. Metoprolol Succinate XL 350 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. OLANZapine 10 mg PO DAILY 5. amLODIPine 10 mg PO DAILY 6. Rosuvastatin Calcium 20 mg PO QPM 7. Aspirin 325 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Rosuvastatin Calcium 30 mg PO QPM 3. amLODIPine 10 mg PO DAILY 4. LamoTRIgine 200 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. Metoprolol Succinate XL 350 mg PO DAILY 7. OLANZapine 10 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Left corona radiata stroke 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: You presented to the hospital with right sided weakness and walking unsteadiness and were found to have had a stroke on the left side of your brain. Thankfully, it looks like you are recovering well from this stroke and we have transferred you to acute rehabilitation to maximize your recovery potential. We want to help prevent you from having another stroke and have therefore changed some of your current medications. We have started you on clopidogrel 75 mg daily and you will discontinue taking aspirin 325 mg daily. We have increased your rosuvastatin to 30 mg daily (from 20 mg daily) to help tighten control of your blood lipid levels. Ultimately, we are uncertain why you had a stroke, but we suspect that you have an abnormal rhythm in your heart that is increasing your risks of having strokes. Therefore, will have scheduled for you to come to pick up a monitor to wear to possibly detect this abnormal rhythm. Please have your primary care physician send [MASKED] referral for you to follow up with a neurologist in three months so that your stroke management can be reviewed. Thank you for allowing us to care for you, [MASKED] Stroke Team Followup Instructions: [MASKED]	[]	[ "D696", "I480", "I129", "N189", "E785", "F17210", "F329" ]	[ "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "D696: Thrombocytopenia, unspecified", "I480: Paroxysmal atrial fibrillation", "G8191: Hemiplegia, unspecified affecting right dominant side", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I69392: Facial weakness following cerebral infarction", "N189: Chronic kidney disease, unspecified", "I69893: Ataxia following other cerebrovascular disease", "E785: Hyperlipidemia, unspecified", "D72819: Decreased white blood cell count, unspecified", "R2681: Unsteadiness on feet", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "Z9181: History of falling" ]
10,040,025	21,791,856	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Attending: ___ Chief Complaint: Dyspnea and cough Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo with h/o CAD s/p DES, CKD, HFpEF (EF>60%) on torsemide, AF on coumadin, presented to ED w/3 days of productive cough and gradual onset dyspnea. Patient reports she developed URI symptoms soon after ___, including nasal congestion and cough. Over the past few days cough has worsened, productive of white/yellow sputum. She has also noted some SOB when lying flat and worsening dyspnea on exertion. She denies fevers, chest pain, abdominal pain, nausea, vomiting, diarrhea or urinary symptoms. She has been compliant with all of her medications, including her diuretics and denies worsening leg swelling or PND. Weight is down to 199lbs, from 210 in the past (intentional weight loss). No increase in her weight since she has been feeling unwell. Patient has been hospitalized in past w/HF exacerbation and states that her symptoms are not similar to those episodes. No history of asthma or COPD. In the ED, initial vitals were: 98.1, 71, 168/80, 16, 93% NC (improved to 95% on RA w/nebs). Exam notable for diffuse wheezes, no crackles. Labs revealed WBC 8.7, Hb 10.4 (baseline), BUN/CR 110/3.5 (unclear baseline-last measured ___ 93/2.41), trop 0.03, BNP ___. EKG NSR rate 70, no ischemic changes. UA negative, CXR showed "possible minimal pulmonary vascular congestion, no focal consolidation". Patient given duonebs with improvement in her respiratory status and transferred to medicine for further management. On the floor, patient complains of persistent productive cough. She is also requesting oxygen to be worn while she sleeps, for comfort (on no O2 at home). No additional acute complaints. Review of systems: (+) Per HPI (-) Otherwise 10 point ROS negative. Past Medical History: - HTN, labile - HLD - HYPOTHYROIDISM - RETINAL ARTERY OCCLUSION - BRANCH - MIGRAINE EQUIVALENT - CAD/MI (MIs in ___ and ___: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) - CHF (EF 60-65% in ___ - OBESITY, - insulin-dependent DMII - Gout - Renal artery stenosis - CKDIII - Anemia - a-fib on anticoagulation - Depression Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION ========== Vital Signs: 97.9 PO 152 / 72 L Sitting 63 20 90 RA Weight: 90.58kg (199.7lbs) General: sitting up in bed, appears comfortable, NAD HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple, JVP difficult to appreciate, given obese neck, but does not appear grossly elevated. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Poor air movement throught, diffuse expiratory wheezes. No crackles. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding Ext: Warm, well perfused, trace edema midway up calves b/l Neuro: no focal deficits LABS: Reviewed, see below. DISCHARGE ========= Vitals: 98.4, HR 78, 93% RA, RR 20, BP ___ GENERAL: Alert, NAD, sitting up in bed HEENT: Sclera anicteric, MMM, oropharynx clear NECK: JVP difficult to appreciate due to habitus RESP: Kyphotic chest. Poor air movement but no wheezing or crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs ABD: +BS, soft, obese, nontender, nondistended. EXT: warm, well perfused. Trace edema bilaterally of medial ankles. NEURO: Grossly intact motor and sensory function. Pertinent Results: ADMISSION LABS ============== ___ 08:20PM BLOOD WBC-8.7 RBC-3.43* Hgb-10.4* Hct-33.6* MCV-98 MCH-30.3 MCHC-31.0* RDW-13.6 RDWSD-48.1* Plt ___ ___ 08:20PM BLOOD Neuts-72.5* Lymphs-18.4* Monos-6.7 Eos-1.2 Baso-0.2 Im ___ AbsNeut-6.27* AbsLymp-1.59 AbsMono-0.58 AbsEos-0.10 AbsBaso-0.02 ___ 08:20PM BLOOD ___ PTT-52.3* ___ ___ 08:20PM BLOOD Glucose-192* UreaN-110* Creat-3.5# Na-135 K-4.4 Cl-91 HCO3-29 AnGap-19 ___ 08:20PM BLOOD ___ 08:20PM BLOOD cTropnT-0.03* ___ 08:20PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.7* ___ 08:20PM BLOOD Digoxin-0.9 ___ 08:20PM URINE Color-Straw Appear-Clear Sp ___ ___ 08:20PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 08:20PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 ___ 10:11AM URINE Hours-RANDOM UreaN-359 Creat-36 Na-87 TotProt-81 Prot/Cr-2.3* ___ 10:11AM URINE Osmolal-339 DISCHARGE LABS ============== ___ 07:35AM BLOOD WBC-12.4* RBC-3.66* Hgb-11.4 Hct-36.3 MCV-99* MCH-31.1 MCHC-31.4* RDW-13.6 RDWSD-49.7* Plt ___ ___ 07:35AM BLOOD ___ ___ 07:35AM BLOOD Glucose-168* UreaN-112* Creat-2.3* Na-141 K-4.0 Cl-95* HCO3-29 AnGap-21* ___ 07:35AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0 REPORTS ======== CT Chest ___. Bronchial wall thickening, endobronchial secretions, and peribronchial ground-glass and nodular opacities in the middle lobe and bilateral lower lobes, suspicious for aspiration pneumonia. 2. At least one pulmonary nodule measuring 10 mm in the middle lobe, possibly with a second 10 mm nodule in the right lower lobe. Recommend follow-up chest CT in 6 weeks, after appropriate treatment. 3. Probably reactive mediastinal and hilar lymphadenopathy. 4. Mild dilation of the ascending aorta, measuring 41 mm. Mild aortic valve calcifications. 5. Coronary calcifications. 6. Indeterminate 12 x 12 mm left adrenal nodule. Recommend further characterization with adrenal protocol CT or MRI. CXR PA-Lateral ___ COPD. Increasing left lower lobe opacities could be atelectasis or pneumonia in the appropriate clinical setting Renal US ___: Normal renal ultrasound. CXR ___ Possible minimal pulmonary vascular congestion. No focal consolidation. MICROBIOLOGY ============ Blood cultures - negative Urine culture - negative Brief Hospital Course: ___ y/o F with a h/o CAD, diastolic CHF, AFib, DM, CKD 4, Gout, who presented with hypoxic respiratory failure most consistent with a COPD exacerbation, and ___ on CKD. ACTIVE PROBLEMS =============== # Hypoxic Respiratory Failure # COPD Exacerbation # Aspiration PNA Her presenting symptoms included a preceding URI, which led to wheezing, cough, and dyspnea, in a patient with longstanding smoking history. She had a low peak flow. Thus, her diagnosis was most consistent with a COPD exacerbation, although there was no diagnosis of COPD prior to admission. She remained hypoxic when ambulatory on room air throughout her admission despite several days of high dose PO steroid (Methylpred 32mg daily - this chosen as opposed to Prednisone for simplicity's sake as she is chronically on low dose Methylpred), and scheduled/PRN nebulizers. Thus, due to continued hypoxia, repeat CXR was done on ___, which showed only radiographic evidence of COPD, as well as atelectasis. She was thus given Incentive Spirometry for atelectasis. As she remained hypoxic, CT chest was then done ___, showing likely consolidation due to aspiration in both lower lobes. She was thus started on Augmentin, and will complete ___s outpatient. There was no evidence of CHF exacerbation based on bedside eval or imaging. PE unlikely given she is chronically on Warfarin. Home O2 was arranged, but the patient declined this on day of discharge. Started inhaled fluticasone BID given clinical certainty of COPD. Outpatient PFT's recommended on discharge. # ___ on Stage 4 CKD: Presented with Cr 3.5, but quickly downtrended back to baseline mid-2's without any intervention. She appeared euvolemic, although volume status is certainly complex given CHF history. It is unclear what the acute insult was to cause worsening Cr of admission. FE-Urea was 28%, which is consistent with pre-renal azotemia, but not a fully reliable test. Renal US was unremarkable. Her home Torsemide was continued. Her home ___ (irbesartan) was replaced with Losartan while in house, as irbesartan is not formulary. CHRONIC PROBLEMS ================ # Chronic Diastolic CHF: No e/o exacerbation. She is below prior dry weight and had minimal edema and no significant rales. Continued home Torsemide, Carvedilol. Continued ___. Monitored volume status. Low salt diet # CAD: Stable. - Continue home ASA 81mg, Ezetimibe, Carvedilol - ___ as above # A-Fib on Warfarin: INR was supratherapeutic on admission, held Warfarin, and resumed once INR was therapeutic. There were no further INR issues. - Continued Warfarin - Daily INR, should recheck as outpatient with ___ Anticoag Team per their routine - Continue home digoxin (level checked, was 0.9) # Diabetes - Continue home Glargine/Humalog regimen, along with sliding scale # Gout - Continue home Febuxostat - Continue home Methylprednisolone 4mg (initially was on higher dose of 32mg daily to treat COPD exacerbation) # Hypothyroidism - Continue home Levothyroxine # Anxiety - Continue home Bupropion, Lorazepam # Incidental findings - Pulm nodules need f/u CT in 6 weeks - Adrenal nodule needs f/u CT or MRI with adrenal protocol as outpatient TRANSITIONAL ISSUES =================== - Augmentin 500mg BID x7 days for aspiration pneumonia, ___ - Started inhaled fluticasone BID given likely COPD - Arranged for home O2 and offered to the patient, but she declined it - Outpatient PFT's recommended - Needs f/u CT chest in 6 weeks to assess for resolution of x2 10mm pulmonary nodules seen on CT chest - Adrenal nodule noted on CT chest. Needs outpatient adrenal protocol CT or MRI for further characterization of left adrenal nodule Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Ezetimibe 10 mg PO DAILY 3. Methylprednisolone 4 mg PO DAILY 4. LORazepam 0.5 mg PO BID:PRN anxiety 5. Avapro (irbesartan) 150 mg oral DAILY 6. Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Vitamin D ___ UNIT PO DAILY 8. Warfarin 6.25 mg PO 3X/WEEK (___) 9. Metolazone 2.5 mg PO DAILY 10. Febuxostat 40 mg PO DAILY 11. Torsemide 60 mg PO BID 12. nystatin 100,000 unit/gram topical ___ daily 13. BuPROPion (Sustained Release) 150 mg PO QAM 14. Digoxin 0.125 mg PO 4X/WEEK (___) 15. Carvedilol 37.5 mg PO BID 16. Levothyroxine Sodium 112 mcg PO DAILY 17. Miconazole Powder 2% 1 Appl TP BID 18. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 19. Ferrous Sulfate 325 mg PO BID 20. Aspirin 81 mg PO DAILY 21. Warfarin 5 mg PO 4X/WEEK (___) 22. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX amoxicillin-pot clavulanate [Augmentin] 500 mg-125 mg 1 tablet(s) by mouth twice daily Disp #14 Tablet Refills:0 2. Fluticasone Propionate 110mcg 2 PUFF IH BID RX fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs inhaled twice daily Disp #1 Inhaler Refills:2 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 4. Aspirin 81 mg PO DAILY 5. Avapro (irbesartan) 150 mg oral DAILY 6. BuPROPion (Sustained Release) 150 mg PO QAM 7. Carvedilol 37.5 mg PO BID 8. Digoxin 0.125 mg PO 3X/WEEK (___) 9. Ezetimibe 10 mg PO DAILY 10. Febuxostat 40 mg PO DAILY 11. Ferrous Sulfate 325 mg PO BID 12. Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 13. Levothyroxine Sodium 112 mcg PO DAILY 14. LORazepam 0.5 mg PO BID:PRN anxiety 15. Methylprednisolone 4 mg PO DAILY 16. Metolazone 2.5 mg PO DAILY as directed 17. Miconazole Powder 2% 1 Appl TP BID 18. nystatin 100,000 unit/gram topical ___ daily 19. Ondansetron 4 mg PO Q8H:PRN nausea 20. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN 21. Torsemide 60 mg PO BID 22. Vitamin D ___ UNIT PO DAILY 23. Warfarin 6.25 mg PO 3X/WEEK (___) 24. Warfarin 5 mg PO 4X/WEEK (___) 25.Home Oxygen ICD-10: J44.9, COPD 2 liters/minute flow rate Discharge Disposition: Home Discharge Diagnosis: Primary: COPD exacerbation ___ on CKD Aspiration pneumonia Secondary: CAD, diastolic CHF, AFib, DM, 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 caring for you at ___. You were admitted to our hospital because of trouble breathing. It was discovered that the most likely cause of this was an exacerbation/crisis of "COPD." You were treated with high dose steroids and nebulizers. The CT scan of your chest also showed evidence of a small pneumonia. We will prescribe you an antibiotic for this, to take twice per day for 1 week. You were also found to have worsening of your kidney function on arrival. However, this fortunately improved back to baseline during your stay. It was a pleasure caring for you, and we wish you the best. Please contact your PCP to get ___ follow up appointment. - ___ team Followup Instructions: ___	[ "J441", "J9691", "J690", "N179", "I4891", "E1122", "I130", "N184", "I5032", "E278", "G43109", "H34239", "Z87891", "Z794", "I2510", "Z955", "I252", "Z7901", "E785", "E039", "E669", "Z6832", "M109", "I701", "D649", "F329", "F419", "R918" ]	Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: Dyspnea and cough Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] yo with h/o CAD s/p DES, CKD, HFpEF (EF>60%) on torsemide, AF on coumadin, presented to ED w/3 days of productive cough and gradual onset dyspnea. Patient reports she developed URI symptoms soon after [MASKED], including nasal congestion and cough. Over the past few days cough has worsened, productive of white/yellow sputum. She has also noted some SOB when lying flat and worsening dyspnea on exertion. She denies fevers, chest pain, abdominal pain, nausea, vomiting, diarrhea or urinary symptoms. She has been compliant with all of her medications, including her diuretics and denies worsening leg swelling or PND. Weight is down to 199lbs, from 210 in the past (intentional weight loss). No increase in her weight since she has been feeling unwell. Patient has been hospitalized in past w/HF exacerbation and states that her symptoms are not similar to those episodes. No history of asthma or COPD. In the ED, initial vitals were: 98.1, 71, 168/80, 16, 93% NC (improved to 95% on RA w/nebs). Exam notable for diffuse wheezes, no crackles. Labs revealed WBC 8.7, Hb 10.4 (baseline), BUN/CR 110/3.5 (unclear baseline-last measured [MASKED] 93/2.41), trop 0.03, BNP [MASKED]. EKG NSR rate 70, no ischemic changes. UA negative, CXR showed "possible minimal pulmonary vascular congestion, no focal consolidation". Patient given duonebs with improvement in her respiratory status and transferred to medicine for further management. On the floor, patient complains of persistent productive cough. She is also requesting oxygen to be worn while she sleeps, for comfort (on no O2 at home). No additional acute complaints. Review of systems: (+) Per HPI (-) Otherwise 10 point ROS negative. Past Medical History: - HTN, labile - HLD - HYPOTHYROIDISM - RETINAL ARTERY OCCLUSION - BRANCH - MIGRAINE EQUIVALENT - CAD/MI (MIs in [MASKED] and [MASKED]: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) - CHF (EF 60-65% in [MASKED] - OBESITY, - insulin-dependent DMII - Gout - Renal artery stenosis - CKDIII - Anemia - a-fib on anticoagulation - Depression Social History: [MASKED] Family History: Non-contributory Physical Exam: ADMISSION ========== Vital Signs: 97.9 PO 152 / 72 L Sitting 63 20 90 RA Weight: 90.58kg (199.7lbs) General: sitting up in bed, appears comfortable, NAD HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple, JVP difficult to appreciate, given obese neck, but does not appear grossly elevated. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Poor air movement throught, diffuse expiratory wheezes. No crackles. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding Ext: Warm, well perfused, trace edema midway up calves b/l Neuro: no focal deficits LABS: Reviewed, see below. DISCHARGE ========= Vitals: 98.4, HR 78, 93% RA, RR 20, BP [MASKED] GENERAL: Alert, NAD, sitting up in bed HEENT: Sclera anicteric, MMM, oropharynx clear NECK: JVP difficult to appreciate due to habitus RESP: Kyphotic chest. Poor air movement but no wheezing or crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs ABD: +BS, soft, obese, nontender, nondistended. EXT: warm, well perfused. Trace edema bilaterally of medial ankles. NEURO: Grossly intact motor and sensory function. Pertinent Results: ADMISSION LABS ============== [MASKED] 08:20PM BLOOD WBC-8.7 RBC-3.43* Hgb-10.4* Hct-33.6* MCV-98 MCH-30.3 MCHC-31.0* RDW-13.6 RDWSD-48.1* Plt [MASKED] [MASKED] 08:20PM BLOOD Neuts-72.5* Lymphs-18.4* Monos-6.7 Eos-1.2 Baso-0.2 Im [MASKED] AbsNeut-6.27* AbsLymp-1.59 AbsMono-0.58 AbsEos-0.10 AbsBaso-0.02 [MASKED] 08:20PM BLOOD [MASKED] PTT-52.3* [MASKED] [MASKED] 08:20PM BLOOD Glucose-192* UreaN-110* Creat-3.5# Na-135 K-4.4 Cl-91 HCO3-29 AnGap-19 [MASKED] 08:20PM BLOOD [MASKED] 08:20PM BLOOD cTropnT-0.03* [MASKED] 08:20PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.7* [MASKED] 08:20PM BLOOD Digoxin-0.9 [MASKED] 08:20PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 08:20PM URINE Blood-TR Nitrite-NEG Protein-100 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 08:20PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 [MASKED] 10:11AM URINE Hours-RANDOM UreaN-359 Creat-36 Na-87 TotProt-81 Prot/Cr-2.3* [MASKED] 10:11AM URINE Osmolal-339 DISCHARGE LABS ============== [MASKED] 07:35AM BLOOD WBC-12.4* RBC-3.66* Hgb-11.4 Hct-36.3 MCV-99* MCH-31.1 MCHC-31.4* RDW-13.6 RDWSD-49.7* Plt [MASKED] [MASKED] 07:35AM BLOOD [MASKED] [MASKED] 07:35AM BLOOD Glucose-168* UreaN-112* Creat-2.3* Na-141 K-4.0 Cl-95* HCO3-29 AnGap-21* [MASKED] 07:35AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0 REPORTS ======== CT Chest [MASKED]. Bronchial wall thickening, endobronchial secretions, and peribronchial ground-glass and nodular opacities in the middle lobe and bilateral lower lobes, suspicious for aspiration pneumonia. 2. At least one pulmonary nodule measuring 10 mm in the middle lobe, possibly with a second 10 mm nodule in the right lower lobe. Recommend follow-up chest CT in 6 weeks, after appropriate treatment. 3. Probably reactive mediastinal and hilar lymphadenopathy. 4. Mild dilation of the ascending aorta, measuring 41 mm. Mild aortic valve calcifications. 5. Coronary calcifications. 6. Indeterminate 12 x 12 mm left adrenal nodule. Recommend further characterization with adrenal protocol CT or MRI. CXR PA-Lateral [MASKED] COPD. Increasing left lower lobe opacities could be atelectasis or pneumonia in the appropriate clinical setting Renal US [MASKED]: Normal renal ultrasound. CXR [MASKED] Possible minimal pulmonary vascular congestion. No focal consolidation. MICROBIOLOGY ============ Blood cultures - negative Urine culture - negative Brief Hospital Course: [MASKED] y/o F with a h/o CAD, diastolic CHF, AFib, DM, CKD 4, Gout, who presented with hypoxic respiratory failure most consistent with a COPD exacerbation, and [MASKED] on CKD. ACTIVE PROBLEMS =============== # Hypoxic Respiratory Failure # COPD Exacerbation # Aspiration PNA Her presenting symptoms included a preceding URI, which led to wheezing, cough, and dyspnea, in a patient with longstanding smoking history. She had a low peak flow. Thus, her diagnosis was most consistent with a COPD exacerbation, although there was no diagnosis of COPD prior to admission. She remained hypoxic when ambulatory on room air throughout her admission despite several days of high dose PO steroid (Methylpred 32mg daily - this chosen as opposed to Prednisone for simplicity's sake as she is chronically on low dose Methylpred), and scheduled/PRN nebulizers. Thus, due to continued hypoxia, repeat CXR was done on [MASKED], which showed only radiographic evidence of COPD, as well as atelectasis. She was thus given Incentive Spirometry for atelectasis. As she remained hypoxic, CT chest was then done [MASKED], showing likely consolidation due to aspiration in both lower lobes. She was thus started on Augmentin, and will complete s outpatient. There was no evidence of CHF exacerbation based on bedside eval or imaging. PE unlikely given she is chronically on Warfarin. Home O2 was arranged, but the patient declined this on day of discharge. Started inhaled fluticasone BID given clinical certainty of COPD. Outpatient PFT's recommended on discharge. # [MASKED] on Stage 4 CKD: Presented with Cr 3.5, but quickly downtrended back to baseline mid-2's without any intervention. She appeared euvolemic, although volume status is certainly complex given CHF history. It is unclear what the acute insult was to cause worsening Cr of admission. FE-Urea was 28%, which is consistent with pre-renal azotemia, but not a fully reliable test. Renal US was unremarkable. Her home Torsemide was continued. Her home [MASKED] (irbesartan) was replaced with Losartan while in house, as irbesartan is not formulary. CHRONIC PROBLEMS ================ # Chronic Diastolic CHF: No e/o exacerbation. She is below prior dry weight and had minimal edema and no significant rales. Continued home Torsemide, Carvedilol. Continued [MASKED]. Monitored volume status. Low salt diet # CAD: Stable. - Continue home ASA 81mg, Ezetimibe, Carvedilol - [MASKED] as above # A-Fib on Warfarin: INR was supratherapeutic on admission, held Warfarin, and resumed once INR was therapeutic. There were no further INR issues. - Continued Warfarin - Daily INR, should recheck as outpatient with [MASKED] Anticoag Team per their routine - Continue home digoxin (level checked, was 0.9) # Diabetes - Continue home Glargine/Humalog regimen, along with sliding scale # Gout - Continue home Febuxostat - Continue home Methylprednisolone 4mg (initially was on higher dose of 32mg daily to treat COPD exacerbation) # Hypothyroidism - Continue home Levothyroxine # Anxiety - Continue home Bupropion, Lorazepam # Incidental findings - Pulm nodules need f/u CT in 6 weeks - Adrenal nodule needs f/u CT or MRI with adrenal protocol as outpatient TRANSITIONAL ISSUES =================== - Augmentin 500mg BID x7 days for aspiration pneumonia, [MASKED] - Started inhaled fluticasone BID given likely COPD - Arranged for home O2 and offered to the patient, but she declined it - Outpatient PFT's recommended - Needs f/u CT chest in 6 weeks to assess for resolution of x2 10mm pulmonary nodules seen on CT chest - Adrenal nodule noted on CT chest. Needs outpatient adrenal protocol CT or MRI for further characterization of left adrenal nodule Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Ezetimibe 10 mg PO DAILY 3. Methylprednisolone 4 mg PO DAILY 4. LORazepam 0.5 mg PO BID:PRN anxiety 5. Avapro (irbesartan) 150 mg oral DAILY 6. Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Vitamin D [MASKED] UNIT PO DAILY 8. Warfarin 6.25 mg PO 3X/WEEK ([MASKED]) 9. Metolazone 2.5 mg PO DAILY 10. Febuxostat 40 mg PO DAILY 11. Torsemide 60 mg PO BID 12. nystatin 100,000 unit/gram topical [MASKED] daily 13. BuPROPion (Sustained Release) 150 mg PO QAM 14. Digoxin 0.125 mg PO 4X/WEEK ([MASKED]) 15. Carvedilol 37.5 mg PO BID 16. Levothyroxine Sodium 112 mcg PO DAILY 17. Miconazole Powder 2% 1 Appl TP BID 18. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 19. Ferrous Sulfate 325 mg PO BID 20. Aspirin 81 mg PO DAILY 21. Warfarin 5 mg PO 4X/WEEK ([MASKED]) 22. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H RX amoxicillin-pot clavulanate [Augmentin] 500 mg-125 mg 1 tablet(s) by mouth twice daily Disp #14 Tablet Refills:0 2. Fluticasone Propionate 110mcg 2 PUFF IH BID RX fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs inhaled twice daily Disp #1 Inhaler Refills:2 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 4. Aspirin 81 mg PO DAILY 5. Avapro (irbesartan) 150 mg oral DAILY 6. BuPROPion (Sustained Release) 150 mg PO QAM 7. Carvedilol 37.5 mg PO BID 8. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 9. Ezetimibe 10 mg PO DAILY 10. Febuxostat 40 mg PO DAILY 11. Ferrous Sulfate 325 mg PO BID 12. Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 13. Levothyroxine Sodium 112 mcg PO DAILY 14. LORazepam 0.5 mg PO BID:PRN anxiety 15. Methylprednisolone 4 mg PO DAILY 16. Metolazone 2.5 mg PO DAILY as directed 17. Miconazole Powder 2% 1 Appl TP BID 18. nystatin 100,000 unit/gram topical [MASKED] daily 19. Ondansetron 4 mg PO Q8H:PRN nausea 20. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN 21. Torsemide 60 mg PO BID 22. Vitamin D [MASKED] UNIT PO DAILY 23. Warfarin 6.25 mg PO 3X/WEEK ([MASKED]) 24. Warfarin 5 mg PO 4X/WEEK ([MASKED]) 25.Home Oxygen ICD-10: J44.9, COPD 2 liters/minute flow rate Discharge Disposition: Home Discharge Diagnosis: Primary: COPD exacerbation [MASKED] on CKD Aspiration pneumonia Secondary: CAD, diastolic CHF, AFib, DM, 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 caring for you at [MASKED]. You were admitted to our hospital because of trouble breathing. It was discovered that the most likely cause of this was an exacerbation/crisis of "COPD." You were treated with high dose steroids and nebulizers. The CT scan of your chest also showed evidence of a small pneumonia. We will prescribe you an antibiotic for this, to take twice per day for 1 week. You were also found to have worsening of your kidney function on arrival. However, this fortunately improved back to baseline during your stay. It was a pleasure caring for you, and we wish you the best. Please contact your PCP to get [MASKED] follow up appointment. - [MASKED] team Followup Instructions: [MASKED]	[]	[ "N179", "I4891", "E1122", "I130", "I5032", "Z87891", "Z794", "I2510", "Z955", "I252", "Z7901", "E785", "E039", "E669", "M109", "D649", "F329", "F419" ]	[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "J9691: Respiratory failure, unspecified with hypoxia", "J690: Pneumonitis due to inhalation of food and vomit", "N179: Acute kidney failure, unspecified", "I4891: Unspecified atrial fibrillation", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N184: Chronic kidney disease, stage 4 (severe)", "I5032: Chronic diastolic (congestive) heart failure", "E278: Other specified disorders of adrenal gland", "G43109: Migraine with aura, not intractable, without status migrainosus", "H34239: Retinal artery branch occlusion, unspecified eye", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction", "Z7901: Long term (current) use of anticoagulants", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "M109: Gout, unspecified", "I701: Atherosclerosis of renal artery", "D649: Anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "R918: Other nonspecific abnormal finding of lung field" ]
10,040,025	22,251,969	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: low urine output Major Surgical or Invasive Procedure: none History of Present Illness: ___ female with a history of insulin-dependent diabetes and chronic renal failure who has been evaluated for possible transplant for dialysis but has not yet proceed with same, CAD s/p DES, CKD, HFpEF (EF>60%) on torsemide, AF on coumadin, recently hospitalized in ___ for pneumonia and concurrent AoCKD improved with treatment of pneumonia, presenting for evaluation of decreased urine output over the last 12 hours. Unfortunately I was only able to briefly speak with her in the emergency department until I was called away. Upon my return, she stated "son of a bitch. It's 4 o clok in the morning, leave me a alone!" removed my hands from examining her. Per ED history: patient states that she has been unable to pee since morning, with the exception of a small amount of dribbling. She has not had any pain or other associated symptoms. She drinks several juice boxes and was still unable to pee. She does not feel like she has a sense of bladder distention at this time. To me she stated denied PND, orthopnea, worsened leg swelling, worsened weight. Per RN: denied changed urine color, foul smelling urine, dysuria. In ED: Initial VS: 97.1 77 107/58 18 96% RA Examination soft obese abdomen with no tenderness or discomfort in the suprapubic region. No CVA tenderness. No edema of legs Pt voided 20 ml yellow urine - post void residule on bladder scanner approx. 5 Labs notable for: hyponatremia (129), elevated BUN/Cr to 140/3.9 from 67/1.7 on discharge in ___. WBC 1.3, anemia stable from prir 8.3/26.1; Urine Na <20, Cl <20, Prot/Cr 2.0 Renal u/s: Normal sonographic appearance of bilateral kidneys. No hydronephrosis Renal c/s: Please wait for bicarb level, use d5w-150meq bicarb drip if bicarb<20, otherwise use normal saline. Check urine protein/CT ratio also. Following 1L NS administration, patient voided unknown amount in ED. Patient voided 175cc on the floor. Per RN patient stated that she felt better after IVF, didn't realize she was dehydrated. Past Medical History: HTN, labile HLD HYPOTHYROIDISM RETINAL ARTERY OCCLUSION - BRANCH MIGRAINE EQUIVALENT CAD/MI (MIs in ___ and ___: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) CHF (EF 60-65% in ___ OBESITY, insulin-dependent DMII Gout Renal artery stenosis CKDIII Anemia afib on anticoagulation Depression Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: ======================== Vital Signs: 98.1 PO 100 / 53 Sitting 81 18 93 RA Weight: 93 kg General: sitting up in bed, appears comfortable, NAD CV: Irreg irreg no murmurs, rubs, gallops Lungs: Poor inspiratory effort. Poor air movement throught, diffuse crackles Patient declined further exam . Discharge Physical Exam: ======================== Vital Signs: 97.9 134/82 65 18 95% RA Weight: 94.89kg <- 94.94kg General: Lying in bed comfortably, in NAD HEENT: NA/AT, EOMI Neck: supple CV: RRR, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally anteriorly Extremities: varicose veins, some mild lower extremity edema around ankles b/l, appears improved from yesterday Pertinent Results: Admission Labs: =============== ___ 07:00PM BLOOD WBC-11.3* RBC-2.63* Hgb-8.3* Hct-26.1* MCV-99* MCH-31.6 MCHC-31.8* RDW-14.6 RDWSD-53.1* Plt ___ ___ 07:00PM BLOOD Neuts-80.1* Lymphs-9.5* Monos-8.1 Eos-1.0 Baso-0.1 Im ___ AbsNeut-9.08* AbsLymp-1.08* AbsMono-0.92* AbsEos-0.11 AbsBaso-0.01 ___ 06:35AM BLOOD ___ PTT-47.9* ___ ___ 07:00PM BLOOD Glucose-256* UreaN-140* Creat-3.9# Na-129 K-4.4 Cl-85* HCO3-23 AnGap-25* ___ 06:35AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.2 ___ 06:35AM BLOOD Digoxin-1.0 . Imaging: ======== ___ Renal US: Normal sonographic appearance of bilateral kidneys. No hydronephrosis. . ___ CXR: In comparison with the study of ___, there again is hyperexpansion of the lungs consistent with chronic pulmonary disease and substantial enlargement of the cardiac silhouette. Mild indistinctness of pulmonary vessels could reflect minimal vascular congestion. Blunting of the costophrenic angles is again seen. No evidence of acute focal pneumonia. . Discharge Labs: =============== ___ 07:00AM BLOOD WBC-9.0 RBC-2.68* Hgb-7.9* Hct-26.0* MCV-97 MCH-29.5 MCHC-30.4* RDW-14.6 RDWSD-51.5* Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD ___ PTT-41.1* ___ ___ 07:00AM BLOOD Glucose-186* UreaN-137* Creat-3.2* Na-136 K-4.2 Cl-93* HCO3-19* AnGap-28* ___ 07:00AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.___ with PMH CAD s/p DES, CKD, HFpEF (EF>60%) on torsemide, AF on coumadin, who presented with low UOP and was found to have ___. She received 3L of IV fluids without initial improvement in creatinine. Home irbesartan was held. The renal team was consulted and recommended holding torsemide and irbesartan, and monitoring Cr, which improved by time of discharge. Thought to ___ secondary to ATN. TRANSITIONAL ISSUES: -- Weight at discharge: 94.9 kg -- Cr at discharge: 3.2 (in setting of ___, recent baseline of 1.7-2.3) -- INR at discharge was 2.7. Please check. Initially patient was supratherapeutic and Coumadin was held. Restarted prior to discharge. -- HELD Irbesartan (SBPs during admission 100s-140s) -- HELD Torsemide in setting ___ -- Please recheck electrolytes at next appointment on ___, restart torsemide if improving kidney function, consider lower dose Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Carvedilol 50 mg PO BID 4. Digoxin 0.125 mg PO 3X/WEEK (___) 5. Ezetimibe 10 mg PO DAILY 6. Febuxostat 40 mg PO DAILY 7. Levothyroxine Sodium 112 mcg PO DAILY 8. LORazepam 0.5 mg PO BID:PRN anxiety 9. Methylprednisolone 4 mg PO DAILY 10. Ondansetron 4 mg PO Q8H:PRN nausea 11. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN 12. Torsemide 60 mg PO BID 13. Vitamin D ___ UNIT PO DAILY 14. Warfarin 3.75 mg PO 5X/WEEK (___) 15. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 16. Ferrous Sulfate 325 mg PO BID 17. Metolazone 2.5 mg PO DAILY 18. Miconazole Powder 2% 1 Appl TP BID 19. nystatin 100,000 unit/gram topical ___ daily 20. Fluticasone Propionate 110mcg 2 PUFF IH BID 21. Warfarin 5 mg PO 2X/WEEK (___) 22. irbesartan 150 mg oral DAILY 23. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Simethicone 40-80 mg PO QID:PRN bloating 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 3. Aspirin 81 mg PO DAILY 4. BuPROPion (Sustained Release) 150 mg PO QAM 5. Carvedilol 50 mg PO BID 6. Digoxin 0.125 mg PO 3X/WEEK (___) 7. Ezetimibe 10 mg PO DAILY 8. Febuxostat 40 mg PO DAILY 9. Ferrous Sulfate 325 mg PO BID 10. Fluticasone Propionate 110mcg 2 PUFF IH BID 11. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Levothyroxine Sodium 112 mcg PO DAILY 13. LORazepam 0.5 mg PO BID:PRN anxiety 14. Methylprednisolone 4 mg PO DAILY 15. Miconazole Powder 2% 1 Appl TP BID 16. nystatin 100,000 unit/gram topical ___ daily 17. Ondansetron 4 mg PO Q8H:PRN nausea 18. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN 19. Vitamin D ___ UNIT PO DAILY 20. Warfarin 3.75 mg PO 5X/WEEK (___) 21. Warfarin 5 mg PO 2X/WEEK (___) 22. HELD- irbesartan 150 mg oral DAILY This medication was held. Do not restart irbesartan until discussing restarting this medication with your doctor on ___. HELD- Metolazone 2.5 mg PO DAILY This medication was held. Do not restart Metolazone until discussing restarting this medication with your doctor on ___. HELD- Torsemide 60 mg PO BID This medication was held. Do not restart Torsemide until after you see your doctor on ___ Discharge Disposition: Home Discharge Diagnosis: Primary: Acute on chronic kidney injury Secondary: Type 2 DM on insulin Hypertension Gout Chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came to the hospital because you noticed that your urine output was low. We found that your kidney function was worse. You received IV fluids, and you were seen by the nephrologists. They looked at your urine under the microscope, and it appears that your condition was caused by dehydration, which injured the kidney. Medications that likely contributed to this injury are torsemide and irbesartan. It will be important to wait before restarting either of these medications, to allow your kidneys to continue to heal. Please continue to take your other medications as listed below. Please follow up with the appointment listed below, at which point your doctor ___ determine what dose of torsemide to re-start. If you notice new or worsening symptoms, please seek medical care. It has been a pleasure taking part in your care, and we wish you the best. - Your ___ care team Followup Instructions: ___	[ "N170", "I130", "E1122", "I5032", "I4891", "E860", "E871", "I701", "F329", "T501X5A", "T465X5A", "Y929", "Z794", "N184", "G8929", "I2510", "Z955", "Z7901", "D649", "E785", "E039", "I252", "E669", "Z87891", "R791", "T45515A", "M109", "Z6833", "F419" ]	Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: low urine output Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] female with a history of insulin-dependent diabetes and chronic renal failure who has been evaluated for possible transplant for dialysis but has not yet proceed with same, CAD s/p DES, CKD, HFpEF (EF>60%) on torsemide, AF on coumadin, recently hospitalized in [MASKED] for pneumonia and concurrent AoCKD improved with treatment of pneumonia, presenting for evaluation of decreased urine output over the last 12 hours. Unfortunately I was only able to briefly speak with her in the emergency department until I was called away. Upon my return, she stated "son of a bitch. It's 4 o clok in the morning, leave me a alone!" removed my hands from examining her. Per ED history: patient states that she has been unable to pee since morning, with the exception of a small amount of dribbling. She has not had any pain or other associated symptoms. She drinks several juice boxes and was still unable to pee. She does not feel like she has a sense of bladder distention at this time. To me she stated denied PND, orthopnea, worsened leg swelling, worsened weight. Per RN: denied changed urine color, foul smelling urine, dysuria. In ED: Initial VS: 97.1 77 107/58 18 96% RA Examination soft obese abdomen with no tenderness or discomfort in the suprapubic region. No CVA tenderness. No edema of legs Pt voided 20 ml yellow urine - post void residule on bladder scanner approx. 5 Labs notable for: hyponatremia (129), elevated BUN/Cr to 140/3.9 from 67/1.7 on discharge in [MASKED]. WBC 1.3, anemia stable from prir 8.3/26.1; Urine Na <20, Cl <20, Prot/Cr 2.0 Renal u/s: Normal sonographic appearance of bilateral kidneys. No hydronephrosis Renal c/s: Please wait for bicarb level, use d5w-150meq bicarb drip if bicarb<20, otherwise use normal saline. Check urine protein/CT ratio also. Following 1L NS administration, patient voided unknown amount in ED. Patient voided 175cc on the floor. Per RN patient stated that she felt better after IVF, didn't realize she was dehydrated. Past Medical History: HTN, labile HLD HYPOTHYROIDISM RETINAL ARTERY OCCLUSION - BRANCH MIGRAINE EQUIVALENT CAD/MI (MIs in [MASKED] and [MASKED]: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) CHF (EF 60-65% in [MASKED] OBESITY, insulin-dependent DMII Gout Renal artery stenosis CKDIII Anemia afib on anticoagulation Depression Social History: [MASKED] Family History: Non-contributory Physical Exam: Admission Physical Exam: ======================== Vital Signs: 98.1 PO 100 / 53 Sitting 81 18 93 RA Weight: 93 kg General: sitting up in bed, appears comfortable, NAD CV: Irreg irreg no murmurs, rubs, gallops Lungs: Poor inspiratory effort. Poor air movement throught, diffuse crackles Patient declined further exam . Discharge Physical Exam: ======================== Vital Signs: 97.9 134/82 65 18 95% RA Weight: 94.89kg <- 94.94kg General: Lying in bed comfortably, in NAD HEENT: NA/AT, EOMI Neck: supple CV: RRR, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally anteriorly Extremities: varicose veins, some mild lower extremity edema around ankles b/l, appears improved from yesterday Pertinent Results: Admission Labs: =============== [MASKED] 07:00PM BLOOD WBC-11.3* RBC-2.63* Hgb-8.3* Hct-26.1* MCV-99* MCH-31.6 MCHC-31.8* RDW-14.6 RDWSD-53.1* Plt [MASKED] [MASKED] 07:00PM BLOOD Neuts-80.1* Lymphs-9.5* Monos-8.1 Eos-1.0 Baso-0.1 Im [MASKED] AbsNeut-9.08* AbsLymp-1.08* AbsMono-0.92* AbsEos-0.11 AbsBaso-0.01 [MASKED] 06:35AM BLOOD [MASKED] PTT-47.9* [MASKED] [MASKED] 07:00PM BLOOD Glucose-256* UreaN-140* Creat-3.9# Na-129 K-4.4 Cl-85* HCO3-23 AnGap-25* [MASKED] 06:35AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.2 [MASKED] 06:35AM BLOOD Digoxin-1.0 . Imaging: ======== [MASKED] Renal US: Normal sonographic appearance of bilateral kidneys. No hydronephrosis. . [MASKED] CXR: In comparison with the study of [MASKED], there again is hyperexpansion of the lungs consistent with chronic pulmonary disease and substantial enlargement of the cardiac silhouette. Mild indistinctness of pulmonary vessels could reflect minimal vascular congestion. Blunting of the costophrenic angles is again seen. No evidence of acute focal pneumonia. . Discharge Labs: =============== [MASKED] 07:00AM BLOOD WBC-9.0 RBC-2.68* Hgb-7.9* Hct-26.0* MCV-97 MCH-29.5 MCHC-30.4* RDW-14.6 RDWSD-51.5* Plt [MASKED] [MASKED] 07:00AM BLOOD Plt [MASKED] [MASKED] 07:00AM BLOOD [MASKED] PTT-41.1* [MASKED] [MASKED] 07:00AM BLOOD Glucose-186* UreaN-137* Creat-3.2* Na-136 K-4.2 Cl-93* HCO3-19* AnGap-28* [MASKED] 07:00AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.[MASKED] with PMH CAD s/p DES, CKD, HFpEF (EF>60%) on torsemide, AF on coumadin, who presented with low UOP and was found to have [MASKED]. She received 3L of IV fluids without initial improvement in creatinine. Home irbesartan was held. The renal team was consulted and recommended holding torsemide and irbesartan, and monitoring Cr, which improved by time of discharge. Thought to [MASKED] secondary to ATN. TRANSITIONAL ISSUES: -- Weight at discharge: 94.9 kg -- Cr at discharge: 3.2 (in setting of [MASKED], recent baseline of 1.7-2.3) -- INR at discharge was 2.7. Please check. Initially patient was supratherapeutic and Coumadin was held. Restarted prior to discharge. -- HELD Irbesartan (SBPs during admission 100s-140s) -- HELD Torsemide in setting [MASKED] -- Please recheck electrolytes at next appointment on [MASKED], restart torsemide if improving kidney function, consider lower dose Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Carvedilol 50 mg PO BID 4. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 5. Ezetimibe 10 mg PO DAILY 6. Febuxostat 40 mg PO DAILY 7. Levothyroxine Sodium 112 mcg PO DAILY 8. LORazepam 0.5 mg PO BID:PRN anxiety 9. Methylprednisolone 4 mg PO DAILY 10. Ondansetron 4 mg PO Q8H:PRN nausea 11. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN 12. Torsemide 60 mg PO BID 13. Vitamin D [MASKED] UNIT PO DAILY 14. Warfarin 3.75 mg PO 5X/WEEK ([MASKED]) 15. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 16. Ferrous Sulfate 325 mg PO BID 17. Metolazone 2.5 mg PO DAILY 18. Miconazole Powder 2% 1 Appl TP BID 19. nystatin 100,000 unit/gram topical [MASKED] daily 20. Fluticasone Propionate 110mcg 2 PUFF IH BID 21. Warfarin 5 mg PO 2X/WEEK ([MASKED]) 22. irbesartan 150 mg oral DAILY 23. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Simethicone 40-80 mg PO QID:PRN bloating 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 3. Aspirin 81 mg PO DAILY 4. BuPROPion (Sustained Release) 150 mg PO QAM 5. Carvedilol 50 mg PO BID 6. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 7. Ezetimibe 10 mg PO DAILY 8. Febuxostat 40 mg PO DAILY 9. Ferrous Sulfate 325 mg PO BID 10. Fluticasone Propionate 110mcg 2 PUFF IH BID 11. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Levothyroxine Sodium 112 mcg PO DAILY 13. LORazepam 0.5 mg PO BID:PRN anxiety 14. Methylprednisolone 4 mg PO DAILY 15. Miconazole Powder 2% 1 Appl TP BID 16. nystatin 100,000 unit/gram topical [MASKED] daily 17. Ondansetron 4 mg PO Q8H:PRN nausea 18. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN 19. Vitamin D [MASKED] UNIT PO DAILY 20. Warfarin 3.75 mg PO 5X/WEEK ([MASKED]) 21. Warfarin 5 mg PO 2X/WEEK ([MASKED]) 22. HELD- irbesartan 150 mg oral DAILY This medication was held. Do not restart irbesartan until discussing restarting this medication with your doctor on [MASKED]. HELD- Metolazone 2.5 mg PO DAILY This medication was held. Do not restart Metolazone until discussing restarting this medication with your doctor on [MASKED]. HELD- Torsemide 60 mg PO BID This medication was held. Do not restart Torsemide until after you see your doctor on [MASKED] Discharge Disposition: Home Discharge Diagnosis: Primary: Acute on chronic kidney injury Secondary: Type 2 DM on insulin Hypertension Gout Chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You came to the hospital because you noticed that your urine output was low. We found that your kidney function was worse. You received IV fluids, and you were seen by the nephrologists. They looked at your urine under the microscope, and it appears that your condition was caused by dehydration, which injured the kidney. Medications that likely contributed to this injury are torsemide and irbesartan. It will be important to wait before restarting either of these medications, to allow your kidneys to continue to heal. Please continue to take your other medications as listed below. Please follow up with the appointment listed below, at which point your doctor [MASKED] determine what dose of torsemide to re-start. If you notice new or worsening symptoms, please seek medical care. It has been a pleasure taking part in your care, and we wish you the best. - Your [MASKED] care team Followup Instructions: [MASKED]	[]	[ "I130", "E1122", "I5032", "I4891", "E871", "F329", "Y929", "Z794", "G8929", "I2510", "Z955", "Z7901", "D649", "E785", "E039", "I252", "E669", "Z87891", "M109", "F419" ]	[ "N170: Acute kidney failure with tubular necrosis", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "I4891: Unspecified atrial fibrillation", "E860: Dehydration", "E871: Hypo-osmolality and hyponatremia", "I701: Atherosclerosis of renal artery", "F329: Major depressive disorder, single episode, unspecified", "T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter", "T465X5A: Adverse effect of other antihypertensive drugs, initial encounter", "Y929: Unspecified place or not applicable", "Z794: Long term (current) use of insulin", "N184: Chronic kidney disease, stage 4 (severe)", "G8929: Other chronic pain", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z7901: Long term (current) use of anticoagulants", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "I252: Old myocardial infarction", "E669: Obesity, unspecified", "Z87891: Personal history of nicotine dependence", "R791: Abnormal coagulation profile", "T45515A: Adverse effect of anticoagulants, initial encounter", "M109: Gout, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "F419: Anxiety disorder, unspecified" ]
10,040,025	25,933,959	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: peripheral arterial disease, non-healing ulcer left foot Major Surgical or Invasive Procedure: ___: -L fem-AK pop w/ nrGSV -Sciatic nerve block -Left foot wound debridement -VAC to left foot History of Present Illness: Ms. ___ is a ___ recently admitted for management of a chronic, non-healing left foot ulcer who presents s/p diagnostic angiogram of the left lower extremity (___) for planned left femoral-popliteal bypass. Past Medical History: PMH: -HTN, labile -HLD -HYPOTHYROIDISM -RETINAL ARTERY OCCLUSION -Migraine -CAD/MI (MIs in ___ and ___: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) -CHF (EF 60-65% in ___ -OBESITY -insulin-dependent DMII -Gout -Renal artery stenosis -CKDIII -Anemia -afib -Depression Social History: ___ Family History: Father died of colon cancer in ___. Physical Exam: At admission: GEN: NAD, annoyed--speaking in short, sarcastic, profranity-filled sentences HEENT: EOMI, MMM CV: RRR PULM: non-labored breathing ABD: soft, nontender, nondistended EXT: 2+ edema bilaterally, approximately 2x2 cm ulcer over left lateral dorsum of foot without foul odor or drainage, minimal surrounding erythema, L shallow heel ulcer, shallow clean based ulcer over posterior aspect left calf; right shallow clean based heel ulcer dressed with adaptic, Kerlix and ACE NEURO: A&Ox3 At discharge: GEN: NAD, wearing glasses CV: RRR PULM: non-labored breathing ABD: soft, nontender, nondistended EXT: 2+ edema bilaterally; incision with skin staples along medial side of left thigh; approximately 2x2 cm ulcer over left lateral dorsum of foot without foul odor or drainage; L shallow heel ulcer, shallow clean based ulcer over posterior aspect left calf; right shallow clean based heel ulcer NEURO: A&Ox3 Pertinent Results: LABS ___ 07:20AM BLOOD WBC-8.6 RBC-3.03* Hgb-8.9* Hct-29.0* MCV-96 MCH-29.4 MCHC-30.7* RDW-19.6* RDWSD-69.0* Plt ___ ___ 06:52AM BLOOD WBC-9.0 RBC-2.94* Hgb-8.8* Hct-28.5* MCV-97 MCH-29.9 MCHC-30.9* RDW-19.6* RDWSD-68.8* Plt ___ ___ 05:54PM BLOOD WBC-8.3 RBC-2.94* Hgb-8.9* Hct-28.9* MCV-98 MCH-30.3 MCHC-30.8* RDW-19.7* RDWSD-70.4* Plt ___ ___ 06:45AM BLOOD WBC-9.2 RBC-3.15* Hgb-9.4* Hct-30.7* MCV-98 MCH-29.8 MCHC-30.6* RDW-19.6* RDWSD-69.1* Plt ___ ___ 01:30PM BLOOD WBC-8.9 RBC-3.27* Hgb-9.8* Hct-31.9* MCV-98 MCH-30.0 MCHC-30.7* RDW-19.8* RDWSD-69.6* Plt ___ ___ 08:52AM BLOOD WBC-10.9* RBC-3.16* Hgb-9.5* Hct-30.6* MCV-97 MCH-30.1 MCHC-31.0* RDW-19.6* RDWSD-69.6* Plt ___ ___ 06:45AM BLOOD WBC-10.6* RBC-2.97* Hgb-8.9* Hct-29.0* MCV-98 MCH-30.0 MCHC-30.7* RDW-19.8* RDWSD-70.7* Plt ___ ___ 06:50AM BLOOD WBC-12.6* RBC-3.01* Hgb-9.0* Hct-29.3* MCV-97 MCH-29.9 MCHC-30.7* RDW-19.9* RDWSD-70.1* Plt ___ ___ 06:15AM BLOOD WBC-9.6 RBC-2.88* Hgb-8.6* Hct-27.4* MCV-95 MCH-29.9 MCHC-31.4* RDW-19.7* RDWSD-68.8* Plt ___ ___ 01:32PM BLOOD WBC-9.1 RBC-3.18* Hgb-9.4* Hct-30.0* MCV-94 MCH-29.6 MCHC-31.3* RDW-19.6* RDWSD-68.1* Plt ___ ___ 09:17PM BLOOD WBC-6.9 RBC-3.63* Hgb-11.0* Hct-34.7 MCV-96 MCH-30.3 MCHC-31.7* RDW-19.9* RDWSD-68.3* Plt ___ ___ 07:20AM BLOOD Glucose-106* UreaN-75* Creat-1.9* Na-135 K-3.9 Cl-97 HCO3-26 AnGap-16 ___ 06:52AM BLOOD Glucose-186* UreaN-80* Creat-2.2* Na-135 K-4.0 Cl-98 HCO3-20* AnGap-21* ___ 05:54PM BLOOD Glucose-257* UreaN-82* Creat-2.2* Na-129* K-4.6 Cl-93* HCO3-21* AnGap-20 ___ 11:12AM BLOOD Glucose-208* UreaN-87* Creat-2.3* Na-132* K-5.5* Cl-96 HCO3-16* AnGap-26* ___ 06:45AM BLOOD Glucose-212* UreaN-87* Creat-2.3* Na-133 K-5.5* Cl-92* HCO3-20* AnGap-27* ___ 01:30PM BLOOD Glucose-130* UreaN-82* Creat-2.3* Na-133 K-5.6* Cl-98 HCO3-23 AnGap-18 ___ 08:52AM BLOOD Glucose-125* UreaN-83* Creat-2.3* Na-135 K-5.1 Cl-99 HCO3-26 AnGap-15 ___ 06:45AM BLOOD Glucose-89 UreaN-79* Creat-2.5* Na-134 K-4.7 Cl-97 HCO3-23 AnGap-19 ___ 06:50AM BLOOD Glucose-61* UreaN-74* Creat-2.1* Na-135 K-4.5 Cl-100 HCO3-26 AnGap-14 ___ 06:15AM BLOOD Glucose-29* UreaN-71* Creat-2.0* Na-138 K-3.6 Cl-101 HCO3-25 AnGap-16 ___ 01:32PM BLOOD Glucose-114* UreaN-73* Creat-2.3* Na-135 K-4.1 Cl-98 HCO3-24 AnGap-17 ___ 09:17PM BLOOD Glucose-270* UreaN-78* Creat-2.6* Na-133 K-3.9 Cl-93* HCO___ AnG___* IMAGING ___ Chest xray: The focal lateral left basilar opacity identified on portable radiograph 5 hours prior persists on the dedicated AP upright view, but is not definitively identified on the lateral view. Could repeat radiographs tomorrow to assess for resolution as this could reflect atelectasis. If continued persistence, CT would be a reasonable next step. Brief Hospital Course: Ms. ___ was admitted to ___ on ___ for planned surgery. On arrival, her left foot wound was noted to be worsened with signs of infection. She was started on IV antibiotics (Vancomycin/Ciprofloxacin/Flagyl). She was taken to the Operating Room on ___ where she underwent a left femoral-below knee popliteal artery bypass with non-reversed saphenous vein graft, sciatic nerve block, left foot wound debridement and VAC placement. For full details of the procedure, please refer to the separately dictated Operative Report. She was extubated and returned to the PACU in stable condition. Following satisfactory recovery from anesthesia, she was transferred to the surgical floor for further monitoring. Pain was controlled with oral medications and a continuous bupivacaine infusion peripheral nerve block. Nerve block catheters were removed on ___. Her foley was also removed on ___, and her wound vac was removed on ___. Physical therapy was consulted and recommended rehab. She was discharged to rehab on ___. At the time of discharge, she was ambulating with rolling walk, tolerating a regular diet, voiding spontaneously, and pain was well controlled with oral medications. She will follow up in 3 weeks with Dr. ___ staple removal with duplex US at 4 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Bisacodyl ___AILY:PRN constipation 4. BuPROPion (Sustained Release) 150 mg PO QAM 5. Digoxin 0.125 mg PO 3X/WEEK (___) 6. Docusate Sodium 100 mg PO BID constipation 7. Ezetimibe 10 mg PO DAILY 8. Febuxostat 40 mg PO DAILY 9. Ferrous Sulfate 325 mg PO BID 10. Fluticasone Propionate 110mcg 2 PUFF IH BID 11. FoLIC Acid 1 mg PO DAILY 12. HydrALAZINE 20 mg PO Q8H 13. Isosorbide Dinitrate 20 mg PO TID 14. Levothyroxine Sodium 112 mcg PO DAILY 15. Methylprednisolone 4 mg PO DAILY 16. Metolazone 2.5 mg PO PRN as directed by cardiologist 17. Metoprolol Succinate XL 200 mg PO DAILY 18. Miconazole Powder 2% 1 Appl TP BID 19. Omeprazole 20 mg PO DAILY 20. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 21. Polyethylene Glycol 17 g PO DAILY constipation 22. Prasugrel 10 mg PO DAILY 23. Senna 8.6 mg PO BID:PRN constipation 24. Simethicone 40-80 mg PO QID:PRN bloating 25. Spironolactone 12.5 mg PO DAILY 26. Torsemide 60 mg PO BID 27. Vitamin D ___ UNIT PO DAILY 28. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 29. nystatin 100,000 unit/gram topical ___ daily 30. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Glargine 30 Units Bedtime Insulin SC Sliding Scale using REG Insulin 2. Levofloxacin 500 mg PO Q48H foot infection Duration: 14 Days RX levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth every other day Disp #7 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q8H 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 5. Aspirin 81 mg PO DAILY 6. Bisacodyl ___AILY:PRN constipation 7. BuPROPion (Sustained Release) 150 mg PO QAM 8. Digoxin 0.125 mg PO 3X/WEEK (___) 9. Docusate Sodium 100 mg PO BID constipation 10. Ezetimibe 10 mg PO DAILY 11. Febuxostat 40 mg PO DAILY 12. Ferrous Sulfate 325 mg PO BID 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. FoLIC Acid 1 mg PO DAILY 15. HydrALAZINE 20 mg PO Q8H 16. Isosorbide Dinitrate 20 mg PO TID 17. Levothyroxine Sodium 112 mcg PO DAILY 18. Methylprednisolone 4 mg PO DAILY 19. Metolazone 2.5 mg PO PRN as directed by cardiologist 20. Metoprolol Succinate XL 200 mg PO DAILY 21. Miconazole Powder 2% 1 Appl TP BID 22. nystatin 100,000 unit/gram topical ___ daily 23. Omeprazole 20 mg PO DAILY 24. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 25. Polyethylene Glycol 17 g PO DAILY constipation 26. Prasugrel 10 mg PO DAILY 27. Senna 8.6 mg PO BID:PRN constipation 28. Simethicone 40-80 mg PO QID:PRN bloating 29. Spironolactone 12.5 mg PO DAILY 30. Torsemide 60 mg PO BID 31. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: peripheral arterial disease: -occluded left SFA -occluded distal ___ non-healing ulcer of left foot Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ for bypass surgery to help improve the blood flow to your legs. The non-healing wound on your left foot was debrided and a wound VAC was placed. You have recovered well and are now ready for discharge. Please follow the instructions below regarding your care to ensure a speedy recovery: 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 aspirin as instructed Follow your discharge medication instructions ACTIVITIES: No driving until post-op visit and you are no longer taking pain medications Unless you were told not to bear any weight on operative foot: 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 CALL THE OFFICE FOR: ___ Redness that extends away from your incision A sudden increase in pain that is not controlled with pain medication A sudden change in the ability to move or use your leg or the ability to feel your leg Temperature greater than 100.5F for 24 hours Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Thank you for allowing us to participate in your care. Sincerely, Your ___ Surgery Team Followup Instructions: ___	[ "E11621", "L03116", "L97529", "E1122", "I130", "I509", "Z794", "I7789", "E11649", "N183", "Z87891", "E785", "E039", "I2510", "Z955", "I252", "Z7902", "E669", "Z6830", "M109", "D649", "F329", "I701", "I4891" ]	Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: peripheral arterial disease, non-healing ulcer left foot Major Surgical or Invasive Procedure: [MASKED]: -L fem-AK pop w/ nrGSV -Sciatic nerve block -Left foot wound debridement -VAC to left foot History of Present Illness: Ms. [MASKED] is a [MASKED] recently admitted for management of a chronic, non-healing left foot ulcer who presents s/p diagnostic angiogram of the left lower extremity ([MASKED]) for planned left femoral-popliteal bypass. Past Medical History: PMH: -HTN, labile -HLD -HYPOTHYROIDISM -RETINAL ARTERY OCCLUSION -Migraine -CAD/MI (MIs in [MASKED] and [MASKED]: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) -CHF (EF 60-65% in [MASKED] -OBESITY -insulin-dependent DMII -Gout -Renal artery stenosis -CKDIII -Anemia -afib -Depression Social History: [MASKED] Family History: Father died of colon cancer in [MASKED]. Physical Exam: At admission: GEN: NAD, annoyed--speaking in short, sarcastic, profranity-filled sentences HEENT: EOMI, MMM CV: RRR PULM: non-labored breathing ABD: soft, nontender, nondistended EXT: 2+ edema bilaterally, approximately 2x2 cm ulcer over left lateral dorsum of foot without foul odor or drainage, minimal surrounding erythema, L shallow heel ulcer, shallow clean based ulcer over posterior aspect left calf; right shallow clean based heel ulcer dressed with adaptic, Kerlix and ACE NEURO: A&Ox3 At discharge: GEN: NAD, wearing glasses CV: RRR PULM: non-labored breathing ABD: soft, nontender, nondistended EXT: 2+ edema bilaterally; incision with skin staples along medial side of left thigh; approximately 2x2 cm ulcer over left lateral dorsum of foot without foul odor or drainage; L shallow heel ulcer, shallow clean based ulcer over posterior aspect left calf; right shallow clean based heel ulcer NEURO: A&Ox3 Pertinent Results: LABS [MASKED] 07:20AM BLOOD WBC-8.6 RBC-3.03* Hgb-8.9* Hct-29.0* MCV-96 MCH-29.4 MCHC-30.7* RDW-19.6* RDWSD-69.0* Plt [MASKED] [MASKED] 06:52AM BLOOD WBC-9.0 RBC-2.94* Hgb-8.8* Hct-28.5* MCV-97 MCH-29.9 MCHC-30.9* RDW-19.6* RDWSD-68.8* Plt [MASKED] [MASKED] 05:54PM BLOOD WBC-8.3 RBC-2.94* Hgb-8.9* Hct-28.9* MCV-98 MCH-30.3 MCHC-30.8* RDW-19.7* RDWSD-70.4* Plt [MASKED] [MASKED] 06:45AM BLOOD WBC-9.2 RBC-3.15* Hgb-9.4* Hct-30.7* MCV-98 MCH-29.8 MCHC-30.6* RDW-19.6* RDWSD-69.1* Plt [MASKED] [MASKED] 01:30PM BLOOD WBC-8.9 RBC-3.27* Hgb-9.8* Hct-31.9* MCV-98 MCH-30.0 MCHC-30.7* RDW-19.8* RDWSD-69.6* Plt [MASKED] [MASKED] 08:52AM BLOOD WBC-10.9* RBC-3.16* Hgb-9.5* Hct-30.6* MCV-97 MCH-30.1 MCHC-31.0* RDW-19.6* RDWSD-69.6* Plt [MASKED] [MASKED] 06:45AM BLOOD WBC-10.6* RBC-2.97* Hgb-8.9* Hct-29.0* MCV-98 MCH-30.0 MCHC-30.7* RDW-19.8* RDWSD-70.7* Plt [MASKED] [MASKED] 06:50AM BLOOD WBC-12.6* RBC-3.01* Hgb-9.0* Hct-29.3* MCV-97 MCH-29.9 MCHC-30.7* RDW-19.9* RDWSD-70.1* Plt [MASKED] [MASKED] 06:15AM BLOOD WBC-9.6 RBC-2.88* Hgb-8.6* Hct-27.4* MCV-95 MCH-29.9 MCHC-31.4* RDW-19.7* RDWSD-68.8* Plt [MASKED] [MASKED] 01:32PM BLOOD WBC-9.1 RBC-3.18* Hgb-9.4* Hct-30.0* MCV-94 MCH-29.6 MCHC-31.3* RDW-19.6* RDWSD-68.1* Plt [MASKED] [MASKED] 09:17PM BLOOD WBC-6.9 RBC-3.63* Hgb-11.0* Hct-34.7 MCV-96 MCH-30.3 MCHC-31.7* RDW-19.9* RDWSD-68.3* Plt [MASKED] [MASKED] 07:20AM BLOOD Glucose-106* UreaN-75* Creat-1.9* Na-135 K-3.9 Cl-97 HCO3-26 AnGap-16 [MASKED] 06:52AM BLOOD Glucose-186* UreaN-80* Creat-2.2* Na-135 K-4.0 Cl-98 HCO3-20* AnGap-21* [MASKED] 05:54PM BLOOD Glucose-257* UreaN-82* Creat-2.2* Na-129* K-4.6 Cl-93* HCO3-21* AnGap-20 [MASKED] 11:12AM BLOOD Glucose-208* UreaN-87* Creat-2.3* Na-132* K-5.5* Cl-96 HCO3-16* AnGap-26* [MASKED] 06:45AM BLOOD Glucose-212* UreaN-87* Creat-2.3* Na-133 K-5.5* Cl-92* HCO3-20* AnGap-27* [MASKED] 01:30PM BLOOD Glucose-130* UreaN-82* Creat-2.3* Na-133 K-5.6* Cl-98 HCO3-23 AnGap-18 [MASKED] 08:52AM BLOOD Glucose-125* UreaN-83* Creat-2.3* Na-135 K-5.1 Cl-99 HCO3-26 AnGap-15 [MASKED] 06:45AM BLOOD Glucose-89 UreaN-79* Creat-2.5* Na-134 K-4.7 Cl-97 HCO3-23 AnGap-19 [MASKED] 06:50AM BLOOD Glucose-61* UreaN-74* Creat-2.1* Na-135 K-4.5 Cl-100 HCO3-26 AnGap-14 [MASKED] 06:15AM BLOOD Glucose-29* UreaN-71* Creat-2.0* Na-138 K-3.6 Cl-101 HCO3-25 AnGap-16 [MASKED] 01:32PM BLOOD Glucose-114* UreaN-73* Creat-2.3* Na-135 K-4.1 Cl-98 HCO3-24 AnGap-17 [MASKED] 09:17PM BLOOD Glucose-270* UreaN-78* Creat-2.6* Na-133 K-3.9 Cl-93* HCO AnG * IMAGING [MASKED] Chest xray: The focal lateral left basilar opacity identified on portable radiograph 5 hours prior persists on the dedicated AP upright view, but is not definitively identified on the lateral view. Could repeat radiographs tomorrow to assess for resolution as this could reflect atelectasis. If continued persistence, CT would be a reasonable next step. Brief Hospital Course: Ms. [MASKED] was admitted to [MASKED] on [MASKED] for planned surgery. On arrival, her left foot wound was noted to be worsened with signs of infection. She was started on IV antibiotics (Vancomycin/Ciprofloxacin/Flagyl). She was taken to the Operating Room on [MASKED] where she underwent a left femoral-below knee popliteal artery bypass with non-reversed saphenous vein graft, sciatic nerve block, left foot wound debridement and VAC placement. For full details of the procedure, please refer to the separately dictated Operative Report. She was extubated and returned to the PACU in stable condition. Following satisfactory recovery from anesthesia, she was transferred to the surgical floor for further monitoring. Pain was controlled with oral medications and a continuous bupivacaine infusion peripheral nerve block. Nerve block catheters were removed on [MASKED]. Her foley was also removed on [MASKED], and her wound vac was removed on [MASKED]. Physical therapy was consulted and recommended rehab. She was discharged to rehab on [MASKED]. At the time of discharge, she was ambulating with rolling walk, tolerating a regular diet, voiding spontaneously, and pain was well controlled with oral medications. She will follow up in 3 weeks with Dr. [MASKED] staple removal with duplex US at 4 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Bisacodyl AILY:PRN constipation 4. BuPROPion (Sustained Release) 150 mg PO QAM 5. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 6. Docusate Sodium 100 mg PO BID constipation 7. Ezetimibe 10 mg PO DAILY 8. Febuxostat 40 mg PO DAILY 9. Ferrous Sulfate 325 mg PO BID 10. Fluticasone Propionate 110mcg 2 PUFF IH BID 11. FoLIC Acid 1 mg PO DAILY 12. HydrALAZINE 20 mg PO Q8H 13. Isosorbide Dinitrate 20 mg PO TID 14. Levothyroxine Sodium 112 mcg PO DAILY 15. Methylprednisolone 4 mg PO DAILY 16. Metolazone 2.5 mg PO PRN as directed by cardiologist 17. Metoprolol Succinate XL 200 mg PO DAILY 18. Miconazole Powder 2% 1 Appl TP BID 19. Omeprazole 20 mg PO DAILY 20. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 21. Polyethylene Glycol 17 g PO DAILY constipation 22. Prasugrel 10 mg PO DAILY 23. Senna 8.6 mg PO BID:PRN constipation 24. Simethicone 40-80 mg PO QID:PRN bloating 25. Spironolactone 12.5 mg PO DAILY 26. Torsemide 60 mg PO BID 27. Vitamin D [MASKED] UNIT PO DAILY 28. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 29. nystatin 100,000 unit/gram topical [MASKED] daily 30. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Glargine 30 Units Bedtime Insulin SC Sliding Scale using REG Insulin 2. Levofloxacin 500 mg PO Q48H foot infection Duration: 14 Days RX levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth every other day Disp #7 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q8H 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 5. Aspirin 81 mg PO DAILY 6. Bisacodyl AILY:PRN constipation 7. BuPROPion (Sustained Release) 150 mg PO QAM 8. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 9. Docusate Sodium 100 mg PO BID constipation 10. Ezetimibe 10 mg PO DAILY 11. Febuxostat 40 mg PO DAILY 12. Ferrous Sulfate 325 mg PO BID 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. FoLIC Acid 1 mg PO DAILY 15. HydrALAZINE 20 mg PO Q8H 16. Isosorbide Dinitrate 20 mg PO TID 17. Levothyroxine Sodium 112 mcg PO DAILY 18. Methylprednisolone 4 mg PO DAILY 19. Metolazone 2.5 mg PO PRN as directed by cardiologist 20. Metoprolol Succinate XL 200 mg PO DAILY 21. Miconazole Powder 2% 1 Appl TP BID 22. nystatin 100,000 unit/gram topical [MASKED] daily 23. Omeprazole 20 mg PO DAILY 24. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 25. Polyethylene Glycol 17 g PO DAILY constipation 26. Prasugrel 10 mg PO DAILY 27. Senna 8.6 mg PO BID:PRN constipation 28. Simethicone 40-80 mg PO QID:PRN bloating 29. Spironolactone 12.5 mg PO DAILY 30. Torsemide 60 mg PO BID 31. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: peripheral arterial disease: -occluded left SFA -occluded distal [MASKED] non-healing ulcer of left foot Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] for bypass surgery to help improve the blood flow to your legs. The non-healing wound on your left foot was debrided and a wound VAC was placed. You have recovered well and are now ready for discharge. Please follow the instructions below regarding your care to ensure a speedy recovery: 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 aspirin as instructed Follow your discharge medication instructions ACTIVITIES: No driving until post-op visit and you are no longer taking pain medications Unless you were told not to bear any weight on operative foot: 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 CALL THE OFFICE FOR: [MASKED] Redness that extends away from your incision A sudden increase in pain that is not controlled with pain medication A sudden change in the ability to move or use your leg or the ability to feel your leg Temperature greater than 100.5F for 24 hours Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Thank you for allowing us to participate in your care. Sincerely, Your [MASKED] Surgery Team Followup Instructions: [MASKED]	[]	[ "E1122", "I130", "Z794", "Z87891", "E785", "E039", "I2510", "Z955", "I252", "Z7902", "E669", "M109", "D649", "F329", "I4891" ]	[ "E11621: Type 2 diabetes mellitus with foot ulcer", "L03116: Cellulitis of left lower limb", "L97529: Non-pressure chronic ulcer of other part of left foot with unspecified severity", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I509: Heart failure, unspecified", "Z794: Long term (current) use of insulin", "I7789: Other specified disorders of arteries and arterioles", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "N183: Chronic kidney disease, stage 3 (moderate)", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E669: Obesity, unspecified", "Z6830: Body mass index [BMI]30.0-30.9, adult", "M109: Gout, unspecified", "D649: Anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I701: Atherosclerosis of renal artery", "I4891: Unspecified atrial fibrillation" ]
10,040,025	27,259,207	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: left foot ulcer Major Surgical or Invasive Procedure: ___: Excisional debridement down to tendon of left diabetic foot ulcer ___: diagnostic angiogram, left lower extremity History of Present Illness: Ms. ___ presents for evaluation of an infected left foot diabetic ulcer. She complains of severe pain and tenderness over the site. She tells me that approximately 7 weeks ago, she dropped a pacemaker cell onto her left foot while in the hospital. She developed a blister that broke down and became infected. She has received topical wound care but no vascular assessment as of yet. Past Medical History: HTN, labile HLD HYPOTHYROIDISM RETINAL ARTERY OCCLUSION - BRANCH MIGRAINE EQUIVALENT CAD/MI (MIs in ___ and ___: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) CHF (EF 60-65% in ___ OBESITY, insulin-dependent DMII Gout Renal artery stenosis CKDIII Anemia afib on anticoagulation Depression Social History: ___ Family History: Father died of colon cancer in ___. Physical Exam: At admission: VS: 96.6 78 126/87 16 98% RA General: Alert, oriented, no acute distress HEENT: Pale conjunctivae, MMM, oropharynx clear Neck: supple, no LAD Lungs: CTAB anteriorly CV: ___ Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pitting edema ___ bilateral heel ulceration; dorsum of left foot with purulent, foul smelling defect with eschar edges and erythema extending from it. ulceration along posterior left leg 2x2cm Left: DP ___ none; Right: ___ doppler Neuro: CN2-12 intact, no focal deficits At discharge: GEN: NAD, annoyed--speaking in short, sarcastic, profranity-filled sentences HEENT: EOMI, MMM CV: RRR PULM: non-labored breathing ABD: soft, nontender, nondistended EXT: 2+ edema bilaterally, approximately 2x2 cm ulcer over left lateral dorsum of foot without foul odor or drainage, minimal surrounding erythema, L shallow heel ulcer, shallow clean based ulcer over posterior aspect left calf; right shallow clean based heel ulcer dressed with adaptic, Kerlix and ACE NEURO: A&Ox3 Pertinent Results: ABI/PVR (___): FINDINGS: TBIs obtained bilaterally and measuring 0.28 in the right lower extremity and 0.19 the left lower extremity. Wound Culture (L foot) ___: PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Brief Hospital Course: Ms. ___ was admitted to ___ On ___ with a non-healing left diabetic foot ulcer. She was started on IV antibiotics and taken to the Operating Room on ___ for debridement and application of VAC. For full details of the procedure, please refer to the separately dictated Operative Report. She was returned to the PACU in stable condition and after satisfactory recovery from anesthesia, she was transferred to the floor for further monitoring and wound care. ___ was consulted on ___ and recommended discharge to rehab. On ___, patient demanded that wound VAC be removed and refused replacement. Plastic surgery was consulted for wound care and also recommended VAC therapy. Patient was counseled that this was optimal medical care, yet she persisted in her refusal. Daily wet-to-dry dressings were initiated. ABI/PVRs were done on ___ and were consistent with severe peripheral vascular disease. Both Vascular Surgery and Plastics were in agreement that patient should have an angiogram. She was consented for procedure and taken to the Endovascular Suite on ___. She was on the table and Foley had been placed when she refused all procedures. She was returned to the floor where she continued to refused recommended treatment. She was transitioned to oral antibiotics on ___ when culture data resulted. She returned to the Operating Room on ___ for angiogram which showed long segment occlusion of the left SFA. Vein mapping studies were obtained for OR planning for a left femoral to AK-popliteal artery bypass. She was discharged to rehab on ___ with plan for antibiotics to continue through ___. She will follow up in clinic with Dr. ___ to discuss operative planning. At the time of discharge, she was tolerating a regular diet, ambulating independently to the rest room and with assistance in the hallways, voiding spontaneously and pain was well controlled. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Digoxin 0.125 mg PO 3X/WEEK (___) 4. Ezetimibe 10 mg PO DAILY 5. Febuxostat 40 mg PO DAILY 6. Ferrous Sulfate 325 mg PO BID 7. HydrALAZINE 20 mg PO Q8H 8. Isosorbide Dinitrate 20 mg PO TID 9. Levothyroxine Sodium 112 mcg PO DAILY 10. Methylprednisolone 4 mg PO DAILY 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Miconazole Powder 2% 1 Appl TP BID 13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 14. Prasugrel 10 mg PO DAILY 15. Simethicone 40-80 mg PO QID:PRN bloating 16. Torsemide 60 mg PO BID 17. Vitamin D ___ UNIT PO DAILY 18. Acetaminophen 650 mg PO Q8H 19. Bisacodyl ___AILY:PRN constipation 20. Docusate Sodium 100 mg PO BID constipation 21. FoLIC Acid 1 mg PO DAILY 22. Omeprazole 20 mg PO DAILY 23. Polyethylene Glycol 17 g PO DAILY constipation 24. Senna 8.6 mg PO BID:PRN constipation 25. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 26. Fluticasone Propionate 110mcg 2 PUFF IH BID 27. Metolazone 2.5 mg PO PRN as directed by cardiologist 28. nystatin 100,000 unit/gram topical ___ daily 29. Spironolactone 12.5 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #12 Tablet Refills:0 3. Glargine 30 Units Bedtime Insulin SC Sliding Scale using REG Insulin 4. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #18 Tablet Refills:0 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #30 Tablet Refills:*0 6. Acetaminophen 650 mg PO Q8H 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 8. Aspirin 81 mg PO DAILY 9. Bisacodyl ___AILY:PRN constipation 10. BuPROPion (Sustained Release) 150 mg PO QAM 11. Digoxin 0.125 mg PO 3X/WEEK (___) 12. Docusate Sodium 100 mg PO BID constipation 13. Ezetimibe 10 mg PO DAILY 14. Febuxostat 40 mg PO DAILY 15. Ferrous Sulfate 325 mg PO BID 16. Fluticasone Propionate 110mcg 2 PUFF IH BID 17. FoLIC Acid 1 mg PO DAILY 18. HydrALAZINE 20 mg PO Q8H 19. Isosorbide Dinitrate 20 mg PO TID 20. Levothyroxine Sodium 112 mcg PO DAILY 21. Methylprednisolone 4 mg PO DAILY 22. Metolazone 2.5 mg PO PRN as directed by cardiologist 23. Metoprolol Succinate XL 200 mg PO DAILY 24. Miconazole Powder 2% 1 Appl TP BID 25. nystatin 100,000 unit/gram topical ___ daily 26. Omeprazole 20 mg PO DAILY 27. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 28. Polyethylene Glycol 17 g PO DAILY constipation 29. Prasugrel 10 mg PO DAILY 30. Senna 8.6 mg PO BID:PRN constipation 31. Simethicone 40-80 mg PO QID:PRN bloating 32. Spironolactone 12.5 mg PO DAILY 33. Torsemide 60 mg PO BID 34. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: non-healing left lateral diabetic foot ulcer long segment left SFA occlusion 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 ___ with a non-healing left foot ulcer. You were taken to the Operating Room for debridement and a VAC was applied to the wound. You then refused replacement of the VAC and were started on wet-to-dry dressing changes. You were started on antibiotics (Augmentin) which you are being discharged with. Plastic Surgery was consulted and also recommended VAC treatment and angiogram. You were taken to the Operating Room for angiogram which showed blockage of arteries in your leg. You will need a bypass surgery at a later date. you are being discharged to rehab with follow up in 2 weeks with Dr. ___ to discuss the results of your vein mapping studies and to discuss the date of your operation. Thank you for allowing us to participate in your care. Sincerely, Your ___ Surgery Team Followup Instructions: ___	[ "E11621", "I70262", "L97523", "L97429", "L97419", "E11622", "L97229", "E1152", "E11628", "L03116", "B965", "I130", "I5022", "E1122", "I4891", "N183", "E785", "E039", "I2510", "E669", "Z6832", "M109", "D649", "F329", "E11649", "I252", "Z955", "Z7902", "Z794", "Z87891" ]	Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: left foot ulcer Major Surgical or Invasive Procedure: [MASKED]: Excisional debridement down to tendon of left diabetic foot ulcer [MASKED]: diagnostic angiogram, left lower extremity History of Present Illness: Ms. [MASKED] presents for evaluation of an infected left foot diabetic ulcer. She complains of severe pain and tenderness over the site. She tells me that approximately 7 weeks ago, she dropped a pacemaker cell onto her left foot while in the hospital. She developed a blister that broke down and became infected. She has received topical wound care but no vascular assessment as of yet. Past Medical History: HTN, labile HLD HYPOTHYROIDISM RETINAL ARTERY OCCLUSION - BRANCH MIGRAINE EQUIVALENT CAD/MI (MIs in [MASKED] and [MASKED]: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) CHF (EF 60-65% in [MASKED] OBESITY, insulin-dependent DMII Gout Renal artery stenosis CKDIII Anemia afib on anticoagulation Depression Social History: [MASKED] Family History: Father died of colon cancer in [MASKED]. Physical Exam: At admission: VS: 96.6 78 126/87 16 98% RA General: Alert, oriented, no acute distress HEENT: Pale conjunctivae, MMM, oropharynx clear Neck: supple, no LAD Lungs: CTAB anteriorly CV: [MASKED] Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pitting edema [MASKED] bilateral heel ulceration; dorsum of left foot with purulent, foul smelling defect with eschar edges and erythema extending from it. ulceration along posterior left leg 2x2cm Left: DP [MASKED] none; Right: [MASKED] doppler Neuro: CN2-12 intact, no focal deficits At discharge: GEN: NAD, annoyed--speaking in short, sarcastic, profranity-filled sentences HEENT: EOMI, MMM CV: RRR PULM: non-labored breathing ABD: soft, nontender, nondistended EXT: 2+ edema bilaterally, approximately 2x2 cm ulcer over left lateral dorsum of foot without foul odor or drainage, minimal surrounding erythema, L shallow heel ulcer, shallow clean based ulcer over posterior aspect left calf; right shallow clean based heel ulcer dressed with adaptic, Kerlix and ACE NEURO: A&Ox3 Pertinent Results: ABI/PVR ([MASKED]): FINDINGS: TBIs obtained bilaterally and measuring 0.28 in the right lower extremity and 0.19 the left lower extremity. Wound Culture (L foot) [MASKED]: PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Brief Hospital Course: Ms. [MASKED] was admitted to [MASKED] On [MASKED] with a non-healing left diabetic foot ulcer. She was started on IV antibiotics and taken to the Operating Room on [MASKED] for debridement and application of VAC. For full details of the procedure, please refer to the separately dictated Operative Report. She was returned to the PACU in stable condition and after satisfactory recovery from anesthesia, she was transferred to the floor for further monitoring and wound care. [MASKED] was consulted on [MASKED] and recommended discharge to rehab. On [MASKED], patient demanded that wound VAC be removed and refused replacement. Plastic surgery was consulted for wound care and also recommended VAC therapy. Patient was counseled that this was optimal medical care, yet she persisted in her refusal. Daily wet-to-dry dressings were initiated. ABI/PVRs were done on [MASKED] and were consistent with severe peripheral vascular disease. Both Vascular Surgery and Plastics were in agreement that patient should have an angiogram. She was consented for procedure and taken to the Endovascular Suite on [MASKED]. She was on the table and Foley had been placed when she refused all procedures. She was returned to the floor where she continued to refused recommended treatment. She was transitioned to oral antibiotics on [MASKED] when culture data resulted. She returned to the Operating Room on [MASKED] for angiogram which showed long segment occlusion of the left SFA. Vein mapping studies were obtained for OR planning for a left femoral to AK-popliteal artery bypass. She was discharged to rehab on [MASKED] with plan for antibiotics to continue through [MASKED]. She will follow up in clinic with Dr. [MASKED] to discuss operative planning. At the time of discharge, she was tolerating a regular diet, ambulating independently to the rest room and with assistance in the hallways, voiding spontaneously and pain was well controlled. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 4. Ezetimibe 10 mg PO DAILY 5. Febuxostat 40 mg PO DAILY 6. Ferrous Sulfate 325 mg PO BID 7. HydrALAZINE 20 mg PO Q8H 8. Isosorbide Dinitrate 20 mg PO TID 9. Levothyroxine Sodium 112 mcg PO DAILY 10. Methylprednisolone 4 mg PO DAILY 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Miconazole Powder 2% 1 Appl TP BID 13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 14. Prasugrel 10 mg PO DAILY 15. Simethicone 40-80 mg PO QID:PRN bloating 16. Torsemide 60 mg PO BID 17. Vitamin D [MASKED] UNIT PO DAILY 18. Acetaminophen 650 mg PO Q8H 19. Bisacodyl AILY:PRN constipation 20. Docusate Sodium 100 mg PO BID constipation 21. FoLIC Acid 1 mg PO DAILY 22. Omeprazole 20 mg PO DAILY 23. Polyethylene Glycol 17 g PO DAILY constipation 24. Senna 8.6 mg PO BID:PRN constipation 25. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 26. Fluticasone Propionate 110mcg 2 PUFF IH BID 27. Metolazone 2.5 mg PO PRN as directed by cardiologist 28. nystatin 100,000 unit/gram topical [MASKED] daily 29. Spironolactone 12.5 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #12 Tablet Refills:0 3. Glargine 30 Units Bedtime Insulin SC Sliding Scale using REG Insulin 4. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #18 Tablet Refills:0 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #30 Tablet Refills:*0 6. Acetaminophen 650 mg PO Q8H 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 8. Aspirin 81 mg PO DAILY 9. Bisacodyl AILY:PRN constipation 10. BuPROPion (Sustained Release) 150 mg PO QAM 11. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 12. Docusate Sodium 100 mg PO BID constipation 13. Ezetimibe 10 mg PO DAILY 14. Febuxostat 40 mg PO DAILY 15. Ferrous Sulfate 325 mg PO BID 16. Fluticasone Propionate 110mcg 2 PUFF IH BID 17. FoLIC Acid 1 mg PO DAILY 18. HydrALAZINE 20 mg PO Q8H 19. Isosorbide Dinitrate 20 mg PO TID 20. Levothyroxine Sodium 112 mcg PO DAILY 21. Methylprednisolone 4 mg PO DAILY 22. Metolazone 2.5 mg PO PRN as directed by cardiologist 23. Metoprolol Succinate XL 200 mg PO DAILY 24. Miconazole Powder 2% 1 Appl TP BID 25. nystatin 100,000 unit/gram topical [MASKED] daily 26. Omeprazole 20 mg PO DAILY 27. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 28. Polyethylene Glycol 17 g PO DAILY constipation 29. Prasugrel 10 mg PO DAILY 30. Senna 8.6 mg PO BID:PRN constipation 31. Simethicone 40-80 mg PO QID:PRN bloating 32. Spironolactone 12.5 mg PO DAILY 33. Torsemide 60 mg PO BID 34. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: non-healing left lateral diabetic foot ulcer long segment left SFA occlusion 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] with a non-healing left foot ulcer. You were taken to the Operating Room for debridement and a VAC was applied to the wound. You then refused replacement of the VAC and were started on wet-to-dry dressing changes. You were started on antibiotics (Augmentin) which you are being discharged with. Plastic Surgery was consulted and also recommended VAC treatment and angiogram. You were taken to the Operating Room for angiogram which showed blockage of arteries in your leg. You will need a bypass surgery at a later date. you are being discharged to rehab with follow up in 2 weeks with Dr. [MASKED] to discuss the results of your vein mapping studies and to discuss the date of your operation. Thank you for allowing us to participate in your care. Sincerely, Your [MASKED] Surgery Team Followup Instructions: [MASKED]	[]	[ "I130", "E1122", "I4891", "E785", "E039", "I2510", "E669", "M109", "D649", "F329", "I252", "Z955", "Z7902", "Z794", "Z87891" ]	[ "E11621: Type 2 diabetes mellitus with foot ulcer", "I70262: Atherosclerosis of native arteries of extremities with gangrene, left leg", "L97523: Non-pressure chronic ulcer of other part of left foot with necrosis of muscle", "L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity", "L97419: Non-pressure chronic ulcer of right heel and midfoot with unspecified severity", "E11622: Type 2 diabetes mellitus with other skin ulcer", "L97229: Non-pressure chronic ulcer of left calf with unspecified severity", "E1152: Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene", "E11628: Type 2 diabetes mellitus with other skin complications", "L03116: Cellulitis of left lower limb", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5022: Chronic systolic (congestive) heart failure", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I4891: Unspecified atrial fibrillation", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "M109: Gout, unspecified", "D649: Anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence" ]
10,040,025	27,876,215	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: ___ female with history of CAD, CKD (s/p multiple stents), HFrEF(44%), IDDM, AF on coumadin, recently hospitalized for ___ presenting from home for evaluation of painless but large quantity bright red blood per rectum. She was taking senna/colace for constipation when she started having looser stools. Overnight, pt notes waking up in a large pool of red blood. She has never had a colonoscopy. Her father died in his ___ of colon cancer. Patient denies epigastric pain, chest pain, shortness of breath, weakness, or other preceding symptoms. Woke in a large pile of bright red blood per rectum. Has had at least several episodes since initial evaluation. Patient recently had a 3 week admission at ___ for AMS (thought to be from oxycodone, marijuana) and NSTEMI now s/p suspected DES to LCx (___) on aspirin, prasugrel, and Coumadin. Her course was complicated by ___ and bronchitis. In the ED, initial vitals: 97.3 88 114/55 16 100% RA - Exam notable for: Awake, alert Clear to auscultation bilaterally Nontender abdomen Visible red blood, no melena, grossly guaiac positive - Labs notable for: Anemia to 7.2 (baseline ~9), Cr to 2.2 (recent baseline ~2.0), recent ferritin to 170s, Tsat 8%, INR 3.5 - Pt given: IV 10mg vitamin K, Kcentra, 1L NS, and 1u blood, IV pantoprazole 40mg - Vitals prior to transfer: 97.9 86 ___ 99% RA On arrival to the floor, pt reports pain in her left foot from previously dropping a telemetry box on it. She is unsure of her medications since leaving rehab. She recounts and confirms the above story. I have also corroborated her previous hospital course with cardiologist on-call at ___. Past Medical History: HTN, labile HLD HYPOTHYROIDISM RETINAL ARTERY OCCLUSION - BRANCH MIGRAINE EQUIVALENT CAD/MI (MIs in ___ and ___ CHF (EF 60-65% in ___ OBESITY, insulin-dependent DMII Gout Renal artery stenosis CKDIII Anemia afib on anticoagulation Depression Social History: ___ Family History: Father died of colon cancer in ___. Physical Exam: ADMISSION Vitals: 97.2 PO 124 / 91 91 20 100 2L NC General: Alert, oriented, no acute distress HEENT: Pale conjunctivae, MMM, oropharynx clear Neck: supple, JVP 12cm, no LAD Lungs: CTAB anteriorly, crackles posterior bases CV: ___, Nl S1, S2, II/VI systolic murmur Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: 2+ pitting edema ___ Neuro: CN2-12 intact, no focal deficits DISCHARGE Vitals: 97.5 PO 150 / 97 88 18 100 Ra General: Alert, oriented, no acute distress HEENT: Pale conjunctivae, MMM, oropharynx clear Neck: supple, JVP 12cm, no LAD Lungs: CTAB anteriorly, crackles posterior bases CV: ___, Nl S1, S2, II/VI systolic murmur Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: 2+ pitting edema ___, PICC in place, left foot with soft tissue edema and ecchymosis. Neuro: face symmetric, MAE, no dysarthria Pertinent Results: ADMISSION ___ 04:50AM BLOOD WBC-9.0 RBC-2.54* Hgb-7.2* Hct-24.1* MCV-95 MCH-28.3 MCHC-29.9* RDW-18.1* RDWSD-61.3* Plt ___ ___ 04:50AM BLOOD ___ PTT-41.1* ___ ___ 04:50AM BLOOD Ret Aut-3.5* Abs Ret-0.09 ___ 04:50AM BLOOD Glucose-170* UreaN-68* Creat-2.2* Na-137 K-4.5 Cl-96 HCO3-30 AnGap-16 ___ 04:50AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.1 ___ 04:50AM BLOOD Digoxin-0.2* ___ 04:59AM BLOOD Lactate-1.8 DISCHARGE ___ 04:59AM BLOOD WBC-9.8 RBC-2.76* Hgb-8.3* Hct-26.9* MCV-98 MCH-30.1 MCHC-30.9* RDW-19.9* RDWSD-58.7* Plt ___ ___ 04:59AM BLOOD Glucose-157* UreaN-76* Creat-2.4* Na-139 K-3.9 Cl-98 HCO3-30 AnGap-15 ___ 04:59AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2 L Foot XR No acute fracture. Brief Hospital Course: ___ y/o F with DES to LCx 1 month ago, HFrEF, AFib on coumadin, IDDM, CKD, and chronic anemia who presents with hematochezia and anemia. # Acute Blood Loss on Chronic Anemia: Patient presented with hematochezia which worsened chronic anemia. Patient was supratherapeutic on admission. Suspected source as diverticulosis/LGIB but patient has never had colonoscopy. Initial plan for endoscopy deferred per patient's wishes. Hct stable s/p 2u pRBC. Supratherapeutic INR was reversed with vitamin K and Kcentra. Baseline anemia likely from to be AICD/CKD with component of iron deficiency. Patient's bleed stabilized off warfarin. Risk/benefit discussion was offered regarding restarting Coumadin, holding Coumadin, or a trial of heparin to watch for re-bleed. Patient prefers to hold Coumadin until seeing PCP. She expressed understanding of the risk of stroke. She received a b12 shot on ___ and was started on daily folic acid as well. # CAD s/p stenting: Patient had recent DES to LCx at ___. ___ on ___. She was continued on ASA81 and prasugrel. Metoprolol XL 200mg was continued. Isordil/hydralazine was continued by discharge. She continues on enzetimibe given statin intolerance # Acute on Chronic Systolic Heart Failure HFrEF (44%), biventricular # Mod posteriorly directed MR # Pulm HTN She was continued on torsemide 60mg BID, as well as isordil/hydral and metoprolol XL. Spironolactone was held in setting of mild ___ on CKD. Her discharge weight was: She has a follow up appointment with At___ Cardiology on ___ 4:30 ___ with Dr ___. # Left foot pain: A telemetry box at a previous hospitalization was dropped on her left foot. Xrays were previously negative. The foot caused her significant pain with notable. A repeat XR was negative for fracture as well. She had significant soft tissue swelling, ecchymosis. Supportive care with elevation and ice was offered. Podiatry recommended a surgical shoe and can follow up as an outpatient. Patient's oxycodone frequency was increased to q4h. # Depression - continued wellbutrin 150mg # ___ on CKD: Patient's base line CR 2.0-2.2. Discharged at 2.4, which has been stable. # A-Fib: Warfarin was reversed with K-centra and vitamin K as above. Per patient preference, she wanted to discuss restarting anticoagulation with her PCP. She was continued on digoxin and metoprolol # Diabetes - Continued home Glargine + ISS # Gout - Continued home Febuxostat - Continued home Methylprednisolone 4mg # Hypothyroidism - Continued home Levothyroxine #CODE: presumed full #COMMUNICATION: daughter, ___ ___ TRANSITIONAL ISSUES: Discharge weight: 195.3 lbs Discharge Cr: 2.4 [ ] continue to evaluate weights daily and metabolic panels weekly for whether patient's diuretic regimen can be changed. Discharged on 60 mg Torsemide PO BID [ ] Please monitor CBCs weekly for anemia [ ] Note patient is a difficult lab draw. She had a PICC line in place for her hospitalization. [ ] Discuss re-starting Coumadin for Afib. In setting of recent bleed, would suggest avoiding triple therapy. Per WOEST trial, could consider Clopidogrel/Coumadin or by extension, prasugrel/Coumadin [ ] Patient adamantly refuses colonoscopy. Consider alternative method of colon cancer screening given family history. [ ] Encourage supportive measures to reduce foot swelling [ ] Titrate oxycodone back to q6hrs or even further spaced out as foot swelling resolves [ ] Consider restarting spironolactone if creatinine stable [ ] Attempt to stop omeprazole after 1 month Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 2. Aspirin 81 mg PO DAILY 3. BuPROPion (Sustained Release) 150 mg PO QAM 4. Digoxin 0.125 mg PO 3X/WEEK (___) 5. Ezetimibe 10 mg PO DAILY 6. Febuxostat 40 mg PO DAILY 7. Ferrous Sulfate 325 mg PO BID 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Levothyroxine Sodium 112 mcg PO DAILY 10. Methylprednisolone 4 mg PO DAILY 11. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN 12. Warfarin 3.75 mg PO 5X/WEEK (___) 13. Vitamin D ___ UNIT PO DAILY 14. Warfarin 5 mg PO 2X/WEEK (___) 15. Torsemide 60 mg PO BID 16. Metolazone 2.5 mg PO DAILY 17. Simethicone 40-80 mg PO QID:PRN bloating 18. Prasugrel 10 mg PO DAILY 19. nystatin 100,000 unit/gram topical ___ daily 20. Miconazole Powder 2% 1 Appl TP BID 21. Metoprolol Succinate XL 200 mg PO DAILY 22. Spironolactone 12.5 mg PO DAILY 23. Isosorbide Dinitrate 20 mg PO TID 24. HydrALAZINE 20 mg PO Q8H Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. Bisacodyl ___AILY:PRN constipation 3. Docusate Sodium 100 mg PO BID constipation 4. FoLIC Acid 1 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY constipation 7. Senna 8.6 mg PO BID:PRN constipation 8. Metolazone 2.5 mg PO PRN as directed by cardiologist 9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe RX oxycodone 10 mg 1 tablet(s) by mouth q4-6h Disp #18 Tablet Refills:*0 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 11. Aspirin 81 mg PO DAILY 12. BuPROPion (Sustained Release) 150 mg PO QAM 13. Digoxin 0.125 mg PO 3X/WEEK (___) 14. Ezetimibe 10 mg PO DAILY 15. Febuxostat 40 mg PO DAILY 16. Ferrous Sulfate 325 mg PO BID 17. Fluticasone Propionate 110mcg 2 PUFF IH BID 18. HydrALAZINE 20 mg PO Q8H 19. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 20. Isosorbide Dinitrate 20 mg PO TID 21. Levothyroxine Sodium 112 mcg PO DAILY 22. Methylprednisolone 4 mg PO DAILY 23. Metoprolol Succinate XL 200 mg PO DAILY 24. Miconazole Powder 2% 1 Appl TP BID 25. nystatin 100,000 unit/gram topical ___ daily 26. Prasugrel 10 mg PO DAILY 27. Simethicone 40-80 mg PO QID:PRN bloating 28. Torsemide 60 mg PO BID 29. Vitamin D ___ UNIT PO DAILY 30. HELD- Spironolactone 12.5 mg PO DAILY This medication was held. Do not restart Spironolactone until your doctor tells you to restart 31. HELD- Warfarin 3.75 mg PO 5X/WEEK (___) This medication was held. Do not restart Warfarin until your doctor tells you to restart 32. HELD- Warfarin 5 mg PO 2X/WEEK (___) This medication was held. Do not restart Warfarin until your doctor tells you to restart Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Hematochezia Acute Blood Loss Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - occasionally requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the ___ for bleeding from your GI tract. What was done ============== - Your blood thinning with Warfarin was reversed. You were not restarted on this medication. - Your bleeding stopped and your blood counts were stable. - You received a B12 shot - You had a Xray of your left foot that did not show a fracture What to do next ================ - Please take all medications as prescribed. A list of your updated medications is attached. - You should discuss restarting Warfarin with your PCP. When your blood is not thinned, you are at risk of stroke. - Follow up with your PCP after discharge from rehab - Tell your doctors ___ have further bleeding or worsening symptoms - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. - Try to keep your foot elevated to relieve swelling We wish you the best of health moving forward Followup Instructions: ___	[ "K5791", "I130", "I5023", "E1122", "N183", "N179", "D62", "I4891", "I272", "R791", "D631", "D509", "I2510", "I340", "S9032XA", "W208XXA", "Y92239", "F329", "M109", "E785", "E039", "E669", "Z6830", "I252", "Z794", "Z7901", "Z7902", "Z955", "Z87891", "Z800" ]	Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] female with history of CAD, CKD (s/p multiple stents), HFrEF(44%), IDDM, AF on coumadin, recently hospitalized for [MASKED] presenting from home for evaluation of painless but large quantity bright red blood per rectum. She was taking senna/colace for constipation when she started having looser stools. Overnight, pt notes waking up in a large pool of red blood. She has never had a colonoscopy. Her father died in his [MASKED] of colon cancer. Patient denies epigastric pain, chest pain, shortness of breath, weakness, or other preceding symptoms. Woke in a large pile of bright red blood per rectum. Has had at least several episodes since initial evaluation. Patient recently had a 3 week admission at [MASKED] for AMS (thought to be from oxycodone, marijuana) and NSTEMI now s/p suspected DES to LCx ([MASKED]) on aspirin, prasugrel, and Coumadin. Her course was complicated by [MASKED] and bronchitis. In the ED, initial vitals: 97.3 88 114/55 16 100% RA - Exam notable for: Awake, alert Clear to auscultation bilaterally Nontender abdomen Visible red blood, no melena, grossly guaiac positive - Labs notable for: Anemia to 7.2 (baseline ~9), Cr to 2.2 (recent baseline ~2.0), recent ferritin to 170s, Tsat 8%, INR 3.5 - Pt given: IV 10mg vitamin K, Kcentra, 1L NS, and 1u blood, IV pantoprazole 40mg - Vitals prior to transfer: 97.9 86 [MASKED] 99% RA On arrival to the floor, pt reports pain in her left foot from previously dropping a telemetry box on it. She is unsure of her medications since leaving rehab. She recounts and confirms the above story. I have also corroborated her previous hospital course with cardiologist on-call at [MASKED]. Past Medical History: HTN, labile HLD HYPOTHYROIDISM RETINAL ARTERY OCCLUSION - BRANCH MIGRAINE EQUIVALENT CAD/MI (MIs in [MASKED] and [MASKED] CHF (EF 60-65% in [MASKED] OBESITY, insulin-dependent DMII Gout Renal artery stenosis CKDIII Anemia afib on anticoagulation Depression Social History: [MASKED] Family History: Father died of colon cancer in [MASKED]. Physical Exam: ADMISSION Vitals: 97.2 PO 124 / 91 91 20 100 2L NC General: Alert, oriented, no acute distress HEENT: Pale conjunctivae, MMM, oropharynx clear Neck: supple, JVP 12cm, no LAD Lungs: CTAB anteriorly, crackles posterior bases CV: [MASKED], Nl S1, S2, II/VI systolic murmur Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: 2+ pitting edema [MASKED] Neuro: CN2-12 intact, no focal deficits DISCHARGE Vitals: 97.5 PO 150 / 97 88 18 100 Ra General: Alert, oriented, no acute distress HEENT: Pale conjunctivae, MMM, oropharynx clear Neck: supple, JVP 12cm, no LAD Lungs: CTAB anteriorly, crackles posterior bases CV: [MASKED], Nl S1, S2, II/VI systolic murmur Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: 2+ pitting edema [MASKED], PICC in place, left foot with soft tissue edema and ecchymosis. Neuro: face symmetric, MAE, no dysarthria Pertinent Results: ADMISSION [MASKED] 04:50AM BLOOD WBC-9.0 RBC-2.54* Hgb-7.2* Hct-24.1* MCV-95 MCH-28.3 MCHC-29.9* RDW-18.1* RDWSD-61.3* Plt [MASKED] [MASKED] 04:50AM BLOOD [MASKED] PTT-41.1* [MASKED] [MASKED] 04:50AM BLOOD Ret Aut-3.5* Abs Ret-0.09 [MASKED] 04:50AM BLOOD Glucose-170* UreaN-68* Creat-2.2* Na-137 K-4.5 Cl-96 HCO3-30 AnGap-16 [MASKED] 04:50AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.1 [MASKED] 04:50AM BLOOD Digoxin-0.2* [MASKED] 04:59AM BLOOD Lactate-1.8 DISCHARGE [MASKED] 04:59AM BLOOD WBC-9.8 RBC-2.76* Hgb-8.3* Hct-26.9* MCV-98 MCH-30.1 MCHC-30.9* RDW-19.9* RDWSD-58.7* Plt [MASKED] [MASKED] 04:59AM BLOOD Glucose-157* UreaN-76* Creat-2.4* Na-139 K-3.9 Cl-98 HCO3-30 AnGap-15 [MASKED] 04:59AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2 L Foot XR No acute fracture. Brief Hospital Course: [MASKED] y/o F with DES to LCx 1 month ago, HFrEF, AFib on coumadin, IDDM, CKD, and chronic anemia who presents with hematochezia and anemia. # Acute Blood Loss on Chronic Anemia: Patient presented with hematochezia which worsened chronic anemia. Patient was supratherapeutic on admission. Suspected source as diverticulosis/LGIB but patient has never had colonoscopy. Initial plan for endoscopy deferred per patient's wishes. Hct stable s/p 2u pRBC. Supratherapeutic INR was reversed with vitamin K and Kcentra. Baseline anemia likely from to be AICD/CKD with component of iron deficiency. Patient's bleed stabilized off warfarin. Risk/benefit discussion was offered regarding restarting Coumadin, holding Coumadin, or a trial of heparin to watch for re-bleed. Patient prefers to hold Coumadin until seeing PCP. She expressed understanding of the risk of stroke. She received a b12 shot on [MASKED] and was started on daily folic acid as well. # CAD s/p stenting: Patient had recent DES to LCx at [MASKED]. [MASKED] on [MASKED]. She was continued on ASA81 and prasugrel. Metoprolol XL 200mg was continued. Isordil/hydralazine was continued by discharge. She continues on enzetimibe given statin intolerance # Acute on Chronic Systolic Heart Failure HFrEF (44%), biventricular # Mod posteriorly directed MR # Pulm HTN She was continued on torsemide 60mg BID, as well as isordil/hydral and metoprolol XL. Spironolactone was held in setting of mild [MASKED] on CKD. Her discharge weight was: She has a follow up appointment with At Cardiology on [MASKED] 4:30 [MASKED] with Dr [MASKED]. # Left foot pain: A telemetry box at a previous hospitalization was dropped on her left foot. Xrays were previously negative. The foot caused her significant pain with notable. A repeat XR was negative for fracture as well. She had significant soft tissue swelling, ecchymosis. Supportive care with elevation and ice was offered. Podiatry recommended a surgical shoe and can follow up as an outpatient. Patient's oxycodone frequency was increased to q4h. # Depression - continued wellbutrin 150mg # [MASKED] on CKD: Patient's base line CR 2.0-2.2. Discharged at 2.4, which has been stable. # A-Fib: Warfarin was reversed with K-centra and vitamin K as above. Per patient preference, she wanted to discuss restarting anticoagulation with her PCP. She was continued on digoxin and metoprolol # Diabetes - Continued home Glargine + ISS # Gout - Continued home Febuxostat - Continued home Methylprednisolone 4mg # Hypothyroidism - Continued home Levothyroxine #CODE: presumed full #COMMUNICATION: daughter, [MASKED] [MASKED] TRANSITIONAL ISSUES: Discharge weight: 195.3 lbs Discharge Cr: 2.4 [ ] continue to evaluate weights daily and metabolic panels weekly for whether patient's diuretic regimen can be changed. Discharged on 60 mg Torsemide PO BID [ ] Please monitor CBCs weekly for anemia [ ] Note patient is a difficult lab draw. She had a PICC line in place for her hospitalization. [ ] Discuss re-starting Coumadin for Afib. In setting of recent bleed, would suggest avoiding triple therapy. Per WOEST trial, could consider Clopidogrel/Coumadin or by extension, prasugrel/Coumadin [ ] Patient adamantly refuses colonoscopy. Consider alternative method of colon cancer screening given family history. [ ] Encourage supportive measures to reduce foot swelling [ ] Titrate oxycodone back to q6hrs or even further spaced out as foot swelling resolves [ ] Consider restarting spironolactone if creatinine stable [ ] Attempt to stop omeprazole after 1 month Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 2. Aspirin 81 mg PO DAILY 3. BuPROPion (Sustained Release) 150 mg PO QAM 4. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 5. Ezetimibe 10 mg PO DAILY 6. Febuxostat 40 mg PO DAILY 7. Ferrous Sulfate 325 mg PO BID 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Levothyroxine Sodium 112 mcg PO DAILY 10. Methylprednisolone 4 mg PO DAILY 11. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH PAIN 12. Warfarin 3.75 mg PO 5X/WEEK ([MASKED]) 13. Vitamin D [MASKED] UNIT PO DAILY 14. Warfarin 5 mg PO 2X/WEEK ([MASKED]) 15. Torsemide 60 mg PO BID 16. Metolazone 2.5 mg PO DAILY 17. Simethicone 40-80 mg PO QID:PRN bloating 18. Prasugrel 10 mg PO DAILY 19. nystatin 100,000 unit/gram topical [MASKED] daily 20. Miconazole Powder 2% 1 Appl TP BID 21. Metoprolol Succinate XL 200 mg PO DAILY 22. Spironolactone 12.5 mg PO DAILY 23. Isosorbide Dinitrate 20 mg PO TID 24. HydrALAZINE 20 mg PO Q8H Discharge Medications: 1. Acetaminophen 650 mg PO Q8H 2. Bisacodyl AILY:PRN constipation 3. Docusate Sodium 100 mg PO BID constipation 4. FoLIC Acid 1 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY constipation 7. Senna 8.6 mg PO BID:PRN constipation 8. Metolazone 2.5 mg PO PRN as directed by cardiologist 9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe RX oxycodone 10 mg 1 tablet(s) by mouth q4-6h Disp #18 Tablet Refills:*0 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 11. Aspirin 81 mg PO DAILY 12. BuPROPion (Sustained Release) 150 mg PO QAM 13. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 14. Ezetimibe 10 mg PO DAILY 15. Febuxostat 40 mg PO DAILY 16. Ferrous Sulfate 325 mg PO BID 17. Fluticasone Propionate 110mcg 2 PUFF IH BID 18. HydrALAZINE 20 mg PO Q8H 19. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 20. Isosorbide Dinitrate 20 mg PO TID 21. Levothyroxine Sodium 112 mcg PO DAILY 22. Methylprednisolone 4 mg PO DAILY 23. Metoprolol Succinate XL 200 mg PO DAILY 24. Miconazole Powder 2% 1 Appl TP BID 25. nystatin 100,000 unit/gram topical [MASKED] daily 26. Prasugrel 10 mg PO DAILY 27. Simethicone 40-80 mg PO QID:PRN bloating 28. Torsemide 60 mg PO BID 29. Vitamin D [MASKED] UNIT PO DAILY 30. HELD- Spironolactone 12.5 mg PO DAILY This medication was held. Do not restart Spironolactone until your doctor tells you to restart 31. HELD- Warfarin 3.75 mg PO 5X/WEEK ([MASKED]) This medication was held. Do not restart Warfarin until your doctor tells you to restart 32. HELD- Warfarin 5 mg PO 2X/WEEK ([MASKED]) This medication was held. Do not restart Warfarin until your doctor tells you to restart Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Hematochezia Acute Blood Loss Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - occasionally requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to the [MASKED] for bleeding from your GI tract. What was done ============== - Your blood thinning with Warfarin was reversed. You were not restarted on this medication. - Your bleeding stopped and your blood counts were stable. - You received a B12 shot - You had a Xray of your left foot that did not show a fracture What to do next ================ - Please take all medications as prescribed. A list of your updated medications is attached. - You should discuss restarting Warfarin with your PCP. When your blood is not thinned, you are at risk of stroke. - Follow up with your PCP after discharge from rehab - Tell your doctors [MASKED] have further bleeding or worsening symptoms - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. - Try to keep your foot elevated to relieve swelling We wish you the best of health moving forward Followup Instructions: [MASKED]	[]	[ "I130", "E1122", "N179", "D62", "I4891", "D509", "I2510", "F329", "M109", "E785", "E039", "E669", "I252", "Z794", "Z7901", "Z7902", "Z955", "Z87891" ]	[ "K5791: Diverticulosis of intestine, part unspecified, without perforation or abscess with bleeding", "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", "N183: Chronic kidney disease, stage 3 (moderate)", "N179: Acute kidney failure, unspecified", "D62: Acute posthemorrhagic anemia", "I4891: Unspecified atrial fibrillation", "I272: Other secondary pulmonary hypertension", "R791: Abnormal coagulation profile", "D631: Anemia in chronic kidney disease", "D509: Iron deficiency anemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I340: Nonrheumatic mitral (valve) insufficiency", "S9032XA: Contusion of left foot, initial encounter", "W208XXA: Other cause of strike by thrown, projected or falling object, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "F329: Major depressive disorder, single episode, unspecified", "M109: Gout, unspecified", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "E669: Obesity, unspecified", "Z6830: Body mass index [BMI]30.0-30.9, adult", "I252: Old myocardial infarction", "Z794: Long term (current) use of insulin", "Z7901: Long term (current) use of anticoagulants", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z955: Presence of coronary angioplasty implant and graft", "Z87891: Personal history of nicotine dependence", "Z800: Family history of malignant neoplasm of digestive organs" ]
10,040,025	27,996,267	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Attending: ___. Chief Complaint: Left lower extremity surgical site infection Major Surgical or Invasive Procedure: ___ Left lower extremity incision and drainage, debridement of left foot ulcer ___ Left lower extremity washout, wound vac placement ___ Left lower extremity wound vac change, debridement left lower extremity ulcers History of Present Illness: Ms. ___ is a ___ year old female recently admitted for management of a chronic, non-healing left foot ulcer who underwent a left femoral to above knee popliteal bypass with NRGSV and left foot ulcer debridement with wound vac placement. She was seen in clinic 3 days ago with left leg incision healing slowly and evidence of skin separation and wound infection in the left thigh. There was weeping fluid but not purulent and staples intact. There also was significant surrounding erythema and so she was sent to rehab with augmentin and was to follow-up in clinic in 2 weeks. She presents to the ED today with worsening pain and L groin to medial though wound dehiscence and purulent drainage. She is otherwise feeling well without fevers or chills, nausea or vomiting. She was admitted to the vascular surgery service for management of suspected left lower extremity surgical site infection. Past Medical History: PMH: -HTN, labile -HLD -HYPOTHYROIDISM -RETINAL ARTERY OCCLUSION -Migraine -CAD/MI (MIs in ___ and ___: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) -CHF (EF 60-65% in ___ -OBESITY -insulin-dependent DMII -Gout -Renal artery stenosis -CKDIII -Anemia -afib -Depression PSH: -Debridement of L foot infected ulcer -LLE diagnostic angiogram -L fem-AK pop bypass Social History: ___ Family History: Father died of colon cancer in ___. Physical Exam: General: NAD CV: RRR Pulm: No respiratory distress Extremities: left groin wound with dressings in place. Bilateral chronic nonhealing ulcers of the lower extremities Pertinent Results: ADMISSION LABS: ___ 04:00PM BLOOD Neuts-86* Bands-1 Lymphs-3* Monos-9 Eos-1 Baso-0 ___ Myelos-0 AbsNeut-7.57* AbsLymp-0.26* AbsMono-0.78 AbsEos-0.09 AbsBaso-0.00* ___ 04:00PM BLOOD ___ PTT-53.7* ___ ___ 04:00PM BLOOD Glucose-118* UreaN-57* Creat-1.8* Na-139 K-4.8 Cl-97 HCO3-28 AnGap-14 DISCHARGE LABS: ___ 05:46AM BLOOD WBC-11.9* RBC-2.95* Hgb-8.7* Hct-27.5* MCV-93 MCH-29.5 MCHC-31.6* RDW-18.4* RDWSD-59.9* Plt ___ ___ 05:46AM BLOOD Plt ___ ___ 05:46AM BLOOD ___ PTT-28.0 ___ ___ 05:46AM BLOOD Glucose-79 UreaN-68* Creat-2.2* Na-136 K-3.7 Cl-96 HCO3-27 AnGap-13 ___ 05:46AM BLOOD Calcium-7.6* Phos-5.3* Mg-2.1 Brief Hospital Course: Ms. ___ presented on ___ to the emergency room with a concern for a surgical site infection and was given vanc/cipro/flagyl immediately. Her INR was also noted to be 5, so she received 10 of vitamin K in the emergency room. Her repeat INR was 2.3 preop. She was then taken to the operating room in the morning of ___ for a debridement and washout of the LLE. Please see OP note for more details regarding the procedure. Postoperatively, the LLE continued to exsanguinate. Cauterization and compression was done in the PACU and she was transferred to the wards. On ___ evening, she was noted to be hypotensive to SBP ___ and her Hct had drifted from 27 to 21. She was transferred to the SICU for monitoring. She received 2 units of pRBC and 1 unit of FFP along with 10 of vitamin K. Her INR was noted to be 1.7 with Hct stable at 28. Since her last echo was only done in ___, a repeat echo was done that revealed her EF to be 40%, and so she was carefully volume resuscitated in preparation for another debridement, washout and vac placement on ___. Please see op report for more details. Following her ___ postop course, her summary will be written by systems. #NEURO: Patient was kept intubated and sedated to help facilitate multiple evaluation of her wound, however she was extubated on HD4 due to hypotension. Her pain was controlled with oxycodone and dilaudid. #CV: Patient was noted to become transiently hypotensive to SBP ___ while she was sedated and so required levo on HD4. Her pressures improved once she was extubated. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. #PULMONARY: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. She was extubated on HD4 without issues. #GI/GU/FEN: The patient had a foley placed intra-operatively for volume monitoring as well as to keep her incision clean. She was restarted on her home torsemide on ___. The patient was given oral diet once extubated, which she tolerated well. She was noted to have loose bowel movements and incontinent. Her C.diff was negative and so was given a flexiseal on HD3 to keep her wound clean. #ID: The patient's fever curves were closely watched for signs of infection. She was kept on vanc/cipro/flagyl as her initial wound cultures from her initial washout was noted to be 4+GNR, 2+ GPC in pairs and chains and 1+ GPRs. On HD4, her cultures showed enterococcus and acinetobacter that were resistant to cipro and so was transitioned to ___ on HD4. ID was consulted on HD5. Given that there were no cultures showing MRSA and her vanc trough continued to be high, they recommended holding off on vanc. Her VAC was changed q3d and on her second VAC change, tissue swabs and cultures were sent that showed GPC in chains and pairs and GNRs. Updated culture data suggested VRE and daptomycin was started per ID recs. At the time of her discharge, antibiotics were discontinued according to the patient and her daughter's wishes (see below). #HEME: Patient received several units of blood over her hospital course for low hematocrits related to bleeding from her left thigh wound. Her last transfusion was ___ and her hematocrits were stable the following two days. #WOUNDS: The patient's left thigh wound vac was changed every ___ days. She was also found to have bilateral lower extremity pressure ulcers, more extensive on the left than the right leg. The ulcers on the left leg were found to have purulent discharge, so she was taken to the operating room again on HD9 (___) for debridement of her left lower extremity pressure ulcers. Santyl was used on these ulcers for the first 3 days post operatively. At the time of discharge to hospice, the wound vac was removed and the thigh wound was redressed with wet to dry gauze and overlying curlex. On ___ a family meeting was held with the patient's daughter and healthcare proxy with a discussion about the lack of progression in her wounds. The following day a second meeting was held with the patient's daughter as well as representatives from palliative care, social work, case management, and vascular surgery. At that time the patient and her daughter elected to transfer the patient to a ___ facility and enact a DNR/DNI order. At the time of her discharge, the patient's vitals were stable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 3. Aspirin 81 mg PO DAILY 4. Bisacodyl ___AILY:PRN constipation 5. BuPROPion (Sustained Release) 150 mg PO QAM 6. Digoxin 0.125 mg PO 3X/WEEK (___) 7. Docusate Sodium 100 mg PO BID constipation 8. Ezetimibe 10 mg PO DAILY 9. Febuxostat 40 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. FoLIC Acid 1 mg PO DAILY 13. HydrALAZINE 20 mg PO Q8H 14. Isosorbide Dinitrate 20 mg PO TID 15. Levothyroxine Sodium 112 mcg PO DAILY 16. Methylprednisolone 4 mg PO DAILY 17. Metoprolol Succinate XL 200 mg PO DAILY 18. Miconazole Powder 2% 1 Appl TP BID 19. nystatin 100,000 unit/gram topical ___ daily 20. Omeprazole 20 mg PO DAILY 21. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 22. Polyethylene Glycol 17 g PO DAILY constipation 23. Prasugrel 10 mg PO DAILY 24. Senna 8.6 mg PO BID:PRN constipation 25. Vitamin D ___ UNIT PO DAILY 26. Metolazone 2.5 mg PO PRN as directed by cardiologist 27. Simethicone 40-80 mg PO QID:PRN bloating 28. Spironolactone 12.5 mg PO DAILY 29. Torsemide 60 mg PO BID 30. Levofloxacin 500 mg PO Q48H foot infection Discharge Medications: 1. Gabapentin 100 mg PO BID 2. Insulin SC Sliding Scale Fingerstick QACHS, HS Insulin SC Sliding Scale using REG Insulin 3. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H RX oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours Disp #4 Tablet Refills:0 4. Acetaminophen 650 mg PO Q8H 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 6. Aspirin 81 mg PO DAILY 7. Bisacodyl ___AILY:PRN constipation 8. BuPROPion (Sustained Release) 150 mg PO QAM 9. Docusate Sodium 100 mg PO BID constipation 10. Ezetimibe 10 mg PO DAILY 11. Febuxostat 40 mg PO DAILY 12. Ferrous Sulfate 325 mg PO BID 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. FoLIC Acid 1 mg PO DAILY 15. HydrALAZINE 20 mg PO Q8H 16. Isosorbide Dinitrate 20 mg PO TID 17. Levofloxacin 500 mg PO Q48H foot infection 18. Levothyroxine Sodium 112 mcg PO DAILY 19. Methylprednisolone 4 mg PO DAILY 20. Metoprolol Succinate XL 200 mg PO DAILY 21. Miconazole Powder 2% 1 Appl TP BID 22. nystatin 100,000 unit/gram topical ___ daily 23. Omeprazole 20 mg PO DAILY 24. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 25. Polyethylene Glycol 17 g PO DAILY constipation 26. Prasugrel 10 mg PO DAILY 27. Senna 8.6 mg PO BID:PRN constipation 28. Simethicone 40-80 mg PO QID:PRN bloating 29. Spironolactone 12.5 mg PO DAILY 30. Torsemide 60 mg PO BID 31. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Surgical site infection of left thigh Infection of left lower extremity pressure ulcers Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: somnolent but arousable. Activity Status: Out of Bed with lift assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to ___ on ___ with a surgical site infection of your left thigh. You were started on antibiotics and taken to the operating room for left thigh debridement and subsequently for placement of a wound vac. You were also found to have left lower extremity pressure ulcers which appeared to be infected, so you were taken back to the operating room for debridement to ensure removal of any dead or infected tissue. At this time, you have elected to be transferred to a hospice facility. You ongoing care will be under the direction of the hospice team. Followup Instructions: ___	[ "T814XXA", "I5033", "N179", "N184", "D62", "E1152", "F05", "T8119XA", "T8131XA", "I130", "Y832", "Y929", "E1122", "Z66", "Z515", "Z781", "R791", "B952", "Z1621", "B9689", "Z1623", "B954", "L89899", "E785", "E039", "I2510", "M109", "I4891", "F329", "J449", "K219", "E11621", "L97529", "R159", "R197", "R748", "K5903", "T402X5A", "Y92230" ]	Allergies: allopurinol / Statins-Hmg-Coa Reductase Inhibitors Chief Complaint: Left lower extremity surgical site infection Major Surgical or Invasive Procedure: [MASKED] Left lower extremity incision and drainage, debridement of left foot ulcer [MASKED] Left lower extremity washout, wound vac placement [MASKED] Left lower extremity wound vac change, debridement left lower extremity ulcers History of Present Illness: Ms. [MASKED] is a [MASKED] year old female recently admitted for management of a chronic, non-healing left foot ulcer who underwent a left femoral to above knee popliteal bypass with NRGSV and left foot ulcer debridement with wound vac placement. She was seen in clinic 3 days ago with left leg incision healing slowly and evidence of skin separation and wound infection in the left thigh. There was weeping fluid but not purulent and staples intact. There also was significant surrounding erythema and so she was sent to rehab with augmentin and was to follow-up in clinic in 2 weeks. She presents to the ED today with worsening pain and L groin to medial though wound dehiscence and purulent drainage. She is otherwise feeling well without fevers or chills, nausea or vomiting. She was admitted to the vascular surgery service for management of suspected left lower extremity surgical site infection. Past Medical History: PMH: -HTN, labile -HLD -HYPOTHYROIDISM -RETINAL ARTERY OCCLUSION -Migraine -CAD/MI (MIs in [MASKED] and [MASKED]: This demonstrated a mid RCA lesion which was stented with a drug-eluting stent. LAD had a proximal 30% stenosis, left circumflex had a ostial 50% stenosis. The distal RCA also had a 50% stenosis) -CHF (EF 60-65% in [MASKED] -OBESITY -insulin-dependent DMII -Gout -Renal artery stenosis -CKDIII -Anemia -afib -Depression PSH: -Debridement of L foot infected ulcer -LLE diagnostic angiogram -L fem-AK pop bypass Social History: [MASKED] Family History: Father died of colon cancer in [MASKED]. Physical Exam: General: NAD CV: RRR Pulm: No respiratory distress Extremities: left groin wound with dressings in place. Bilateral chronic nonhealing ulcers of the lower extremities Pertinent Results: ADMISSION LABS: [MASKED] 04:00PM BLOOD Neuts-86* Bands-1 Lymphs-3* Monos-9 Eos-1 Baso-0 [MASKED] Myelos-0 AbsNeut-7.57* AbsLymp-0.26* AbsMono-0.78 AbsEos-0.09 AbsBaso-0.00* [MASKED] 04:00PM BLOOD [MASKED] PTT-53.7* [MASKED] [MASKED] 04:00PM BLOOD Glucose-118* UreaN-57* Creat-1.8* Na-139 K-4.8 Cl-97 HCO3-28 AnGap-14 DISCHARGE LABS: [MASKED] 05:46AM BLOOD WBC-11.9* RBC-2.95* Hgb-8.7* Hct-27.5* MCV-93 MCH-29.5 MCHC-31.6* RDW-18.4* RDWSD-59.9* Plt [MASKED] [MASKED] 05:46AM BLOOD Plt [MASKED] [MASKED] 05:46AM BLOOD [MASKED] PTT-28.0 [MASKED] [MASKED] 05:46AM BLOOD Glucose-79 UreaN-68* Creat-2.2* Na-136 K-3.7 Cl-96 HCO3-27 AnGap-13 [MASKED] 05:46AM BLOOD Calcium-7.6* Phos-5.3* Mg-2.1 Brief Hospital Course: Ms. [MASKED] presented on [MASKED] to the emergency room with a concern for a surgical site infection and was given vanc/cipro/flagyl immediately. Her INR was also noted to be 5, so she received 10 of vitamin K in the emergency room. Her repeat INR was 2.3 preop. She was then taken to the operating room in the morning of [MASKED] for a debridement and washout of the LLE. Please see OP note for more details regarding the procedure. Postoperatively, the LLE continued to exsanguinate. Cauterization and compression was done in the PACU and she was transferred to the wards. On [MASKED] evening, she was noted to be hypotensive to SBP [MASKED] and her Hct had drifted from 27 to 21. She was transferred to the SICU for monitoring. She received 2 units of pRBC and 1 unit of FFP along with 10 of vitamin K. Her INR was noted to be 1.7 with Hct stable at 28. Since her last echo was only done in [MASKED], a repeat echo was done that revealed her EF to be 40%, and so she was carefully volume resuscitated in preparation for another debridement, washout and vac placement on [MASKED]. Please see op report for more details. Following her [MASKED] postop course, her summary will be written by systems. #NEURO: Patient was kept intubated and sedated to help facilitate multiple evaluation of her wound, however she was extubated on HD4 due to hypotension. Her pain was controlled with oxycodone and dilaudid. #CV: Patient was noted to become transiently hypotensive to SBP [MASKED] while she was sedated and so required levo on HD4. Her pressures improved once she was extubated. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. #PULMONARY: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. She was extubated on HD4 without issues. #GI/GU/FEN: The patient had a foley placed intra-operatively for volume monitoring as well as to keep her incision clean. She was restarted on her home torsemide on [MASKED]. The patient was given oral diet once extubated, which she tolerated well. She was noted to have loose bowel movements and incontinent. Her C.diff was negative and so was given a flexiseal on HD3 to keep her wound clean. #ID: The patient's fever curves were closely watched for signs of infection. She was kept on vanc/cipro/flagyl as her initial wound cultures from her initial washout was noted to be 4+GNR, 2+ GPC in pairs and chains and 1+ GPRs. On HD4, her cultures showed enterococcus and acinetobacter that were resistant to cipro and so was transitioned to [MASKED] on HD4. ID was consulted on HD5. Given that there were no cultures showing MRSA and her vanc trough continued to be high, they recommended holding off on vanc. Her VAC was changed q3d and on her second VAC change, tissue swabs and cultures were sent that showed GPC in chains and pairs and GNRs. Updated culture data suggested VRE and daptomycin was started per ID recs. At the time of her discharge, antibiotics were discontinued according to the patient and her daughter's wishes (see below). #HEME: Patient received several units of blood over her hospital course for low hematocrits related to bleeding from her left thigh wound. Her last transfusion was [MASKED] and her hematocrits were stable the following two days. #WOUNDS: The patient's left thigh wound vac was changed every [MASKED] days. She was also found to have bilateral lower extremity pressure ulcers, more extensive on the left than the right leg. The ulcers on the left leg were found to have purulent discharge, so she was taken to the operating room again on HD9 ([MASKED]) for debridement of her left lower extremity pressure ulcers. Santyl was used on these ulcers for the first 3 days post operatively. At the time of discharge to hospice, the wound vac was removed and the thigh wound was redressed with wet to dry gauze and overlying curlex. On [MASKED] a family meeting was held with the patient's daughter and healthcare proxy with a discussion about the lack of progression in her wounds. The following day a second meeting was held with the patient's daughter as well as representatives from palliative care, social work, case management, and vascular surgery. At that time the patient and her daughter elected to transfer the patient to a [MASKED] facility and enact a DNR/DNI order. At the time of her discharge, the patient's vitals were stable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 3. Aspirin 81 mg PO DAILY 4. Bisacodyl AILY:PRN constipation 5. BuPROPion (Sustained Release) 150 mg PO QAM 6. Digoxin 0.125 mg PO 3X/WEEK ([MASKED]) 7. Docusate Sodium 100 mg PO BID constipation 8. Ezetimibe 10 mg PO DAILY 9. Febuxostat 40 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. FoLIC Acid 1 mg PO DAILY 13. HydrALAZINE 20 mg PO Q8H 14. Isosorbide Dinitrate 20 mg PO TID 15. Levothyroxine Sodium 112 mcg PO DAILY 16. Methylprednisolone 4 mg PO DAILY 17. Metoprolol Succinate XL 200 mg PO DAILY 18. Miconazole Powder 2% 1 Appl TP BID 19. nystatin 100,000 unit/gram topical [MASKED] daily 20. Omeprazole 20 mg PO DAILY 21. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 22. Polyethylene Glycol 17 g PO DAILY constipation 23. Prasugrel 10 mg PO DAILY 24. Senna 8.6 mg PO BID:PRN constipation 25. Vitamin D [MASKED] UNIT PO DAILY 26. Metolazone 2.5 mg PO PRN as directed by cardiologist 27. Simethicone 40-80 mg PO QID:PRN bloating 28. Spironolactone 12.5 mg PO DAILY 29. Torsemide 60 mg PO BID 30. Levofloxacin 500 mg PO Q48H foot infection Discharge Medications: 1. Gabapentin 100 mg PO BID 2. Insulin SC Sliding Scale Fingerstick QACHS, HS Insulin SC Sliding Scale using REG Insulin 3. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H RX oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours Disp #4 Tablet Refills:0 4. Acetaminophen 650 mg PO Q8H 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob 6. Aspirin 81 mg PO DAILY 7. Bisacodyl AILY:PRN constipation 8. BuPROPion (Sustained Release) 150 mg PO QAM 9. Docusate Sodium 100 mg PO BID constipation 10. Ezetimibe 10 mg PO DAILY 11. Febuxostat 40 mg PO DAILY 12. Ferrous Sulfate 325 mg PO BID 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. FoLIC Acid 1 mg PO DAILY 15. HydrALAZINE 20 mg PO Q8H 16. Isosorbide Dinitrate 20 mg PO TID 17. Levofloxacin 500 mg PO Q48H foot infection 18. Levothyroxine Sodium 112 mcg PO DAILY 19. Methylprednisolone 4 mg PO DAILY 20. Metoprolol Succinate XL 200 mg PO DAILY 21. Miconazole Powder 2% 1 Appl TP BID 22. nystatin 100,000 unit/gram topical [MASKED] daily 23. Omeprazole 20 mg PO DAILY 24. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 25. Polyethylene Glycol 17 g PO DAILY constipation 26. Prasugrel 10 mg PO DAILY 27. Senna 8.6 mg PO BID:PRN constipation 28. Simethicone 40-80 mg PO QID:PRN bloating 29. Spironolactone 12.5 mg PO DAILY 30. Torsemide 60 mg PO BID 31. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Surgical site infection of left thigh Infection of left lower extremity pressure ulcers Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: somnolent but arousable. Activity Status: Out of Bed with lift assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] on [MASKED] with a surgical site infection of your left thigh. You were started on antibiotics and taken to the operating room for left thigh debridement and subsequently for placement of a wound vac. You were also found to have left lower extremity pressure ulcers which appeared to be infected, so you were taken back to the operating room for debridement to ensure removal of any dead or infected tissue. At this time, you have elected to be transferred to a hospice facility. You ongoing care will be under the direction of the hospice team. Followup Instructions: [MASKED]	[]	[ "N179", "D62", "I130", "Y929", "E1122", "Z66", "Z515", "E785", "E039", "I2510", "M109", "I4891", "F329", "J449", "K219", "Y92230" ]	[ "T814XXA: Infection following a procedure", "I5033: Acute on chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "N184: Chronic kidney disease, stage 4 (severe)", "D62: Acute posthemorrhagic anemia", "E1152: Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene", "F05: Delirium due to known physiological condition", "T8119XA: Other postprocedural shock, initial encounter", "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z781: Physical restraint status", "R791: Abnormal coagulation profile", "B952: Enterococcus as the cause of diseases classified elsewhere", "Z1621: Resistance to vancomycin", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "Z1623: Resistance to quinolones and fluoroquinolones", "B954: Other streptococcus as the cause of diseases classified elsewhere", "L89899: Pressure ulcer of other site, unspecified stage", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M109: Gout, unspecified", "I4891: Unspecified atrial fibrillation", "F329: Major depressive disorder, single episode, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E11621: Type 2 diabetes mellitus with foot ulcer", "L97529: Non-pressure chronic ulcer of other part of left foot with unspecified severity", "R159: Full incontinence of feces", "R197: Diarrhea, unspecified", "R748: Abnormal levels of other serum enzymes", "K5903: Drug induced constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,040,149	21,810,717	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: aspirin Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ female history of hypertension, cholecystectomy, hernia repair, hysterectomy, nephrectomy, transferred from ___ for bowel obstruction seen on CT scan. Patient has had a day of diffuse abdominal pain vomiting and diarrhea. No similar symptoms in past. No fever, chest pain, shortness of breath, cough. Past Medical History: PMH: Hypertension UTI Hypothyroidism CAD Pyelonephritis AAA PSH: CABG Cholecystectomy Hernia repair Hysterectomy L nephrectomy EVAR Social History: ___ Family History: noncontributory Physical Exam: Admission Physical Examination Temp: 97.4 HR: 58 BP: 112/67 Resp: 20 O2 Sat: 94 Low Constitutional: Elderly woman seated in bed, awake and alert, speaking in full sentences, in no acute distress Head / Eyes: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact ENT / Neck: Moist mucous membranes. NG tube in place. Chest/Resp: Breathing comfortably on room air, speaking full sentences. Mild scattered rhonchi on auscultation without wheezes or crackles. Cardiovascular: Regular Rate and Rhythm GI / Abdominal: Soft, mildly distended, mild TTP throughout, worst on left side of abdomen. GU/Flank: No costovertebral angle tenderness Musc/Extr/Back: No peripheral edema. No midline spinal TTP. Skin: Warm and dry Neuro: Speech fluent. PERRL. EOMI. Facial movements symmetric. Moving all extremities Discharge Physical Exam: VS: 97.5, 156/92, 55, 18, 94 Ra Gen: A&O, intermittently confused Pulm: LS w/ faint expiratory wheeze CV: HRR Abd: softly distended. mildly TTP over left side of abdomen (has chronic pain here from ? hernia) Ext: WWP . no edema Pertinent Results: ___ 06:40AM BLOOD WBC-5.5 RBC-4.60 Hgb-12.6 Hct-40.4 MCV-88 MCH-27.4 MCHC-31.2* RDW-16.7* RDWSD-53.1* Plt ___ ___ 06:58AM BLOOD WBC-4.0 RBC-4.39 Hgb-11.9 Hct-38.6 MCV-88 MCH-27.1 MCHC-30.8* RDW-16.2* RDWSD-51.8* Plt ___ ___ 06:11AM BLOOD WBC-6.0 RBC-4.24 Hgb-11.4 Hct-37.7 MCV-89 MCH-26.9 MCHC-30.2* RDW-16.0* RDWSD-52.4* Plt ___ ___ 08:45AM BLOOD WBC-4.8 RBC-4.30 Hgb-11.7 Hct-38.8 MCV-90 MCH-27.2 MCHC-30.2* RDW-16.2* RDWSD-53.7* Plt ___ ___ 07:18AM BLOOD WBC-6.9 RBC-4.22 Hgb-11.4 Hct-37.5 MCV-89 MCH-27.0 MCHC-30.4* RDW-16.3* RDWSD-53.2* Plt ___ ___ 05:25PM BLOOD WBC-6.2 RBC-4.35 Hgb-11.8 Hct-38.3 MCV-88 MCH-27.1 MCHC-30.8* RDW-16.3* RDWSD-52.7* Plt ___ ___ 11:46AM BLOOD WBC-5.8 RBC-3.56* Hgb-9.6* Hct-32.5* MCV-91 MCH-27.0 MCHC-29.5* RDW-16.5* RDWSD-55.5* Plt ___ ___ 06:40AM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-140 K-4.9 Cl-102 HCO3-29 AnGap-9* ___ 06:58AM BLOOD Glucose-79 UreaN-13 Creat-1.3* Na-140 K-4.8 Cl-101 HCO3-29 AnGap-10 ___ 06:11AM BLOOD Glucose-106* UreaN-9 Creat-0.8 Na-140 K-3.9 Cl-104 HCO3-26 AnGap-10 ___ 08:45AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-143 K-4.2 Cl-106 HCO3-25 AnGap-12 ___ 07:18AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-143 K-3.5 Cl-106 HCO3-28 AnGap-9* ___ 06:40AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0 ___ 06:58AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0 ___ 06:11AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.1 Imaging: OSH CT abdomen pelvis without contrast - 1. Distention of the stomach proximal and mid small bowel to the level of a lumbar abdominal wall hernia above the left iliac crest. 2. Status post endograft stenting of the infrarenal abdominal aorta and common iliac arteries ___ ECG - Baseline artifact but probable sinus bradycardia with atrio-ventricular conduction delay. Inferior infarction of indeterminate age. Intraventricular conduction delay. Delayed R wave transition. Non-specific ST segment changes. Left ventricular hypertrophy. Compared to the previous tracing of ___ the overall findings are similar. ___ Abdomen - 1. Mild pulmonary edema. 2. Oral contrast has progressed to the level of the proximal transverse colon excluding obstruction. There remains mild distension of the small and large bowel loops suggesting ileus. Brief Hospital Course: ___ with history of hypertension, prior UTI, hypothyroidism, cholecystectomy, hernia repair, hysterectomy, and left nephrectomy, who presents as a transfer from ___ with concern for small bowel obstruction and incidental finding of UTI. The patient was admitted for bowel rest, IV fluids, and close monitoring of her abdominal exam. She was hemodynamically stable. She was given antibiotics for the UTI. Nasogastric tube was inserted for stomach decompression. Oral contrast was given via the NGT. Eight hours after contrast had been given, an abdominal x-ray showed that oral contrast has progressed to the level of the proximal transverse colon, excluding obstruction. On HD2, the NGT was removed. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. Because the patient was elderly and deconditioned, ___ evaluated the patient to determine the safest disposition. They recommended she be discharged to rehab. The patient was refusing rehab and currently lived with one of her sons who she stated provided assistance with her care. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with a walker, voiding without assistance, having bowel movements, and denied pain. The patient was discharged home with services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Levothyroxine Sodium 75 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain and were found on CT scan to have a small bowel obstruction. You were managed non-operatively with a nasogastric tube for stomach decompression, bowel rest, IV fluids, and close monitoring of your abdominal exam. Once your obstruction resolved, your diet was advanced and you are now tolerating regular food and having bowel movements. You are ready for discharge home to continue your recovery. Please note the following: 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 Followup Instructions: ___	[ "K5650", "N390", "Z951", "E039", "K432", "I10", "I2510", "Z9049" ]	Allergies: aspirin Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female history of hypertension, cholecystectomy, hernia repair, hysterectomy, nephrectomy, transferred from [MASKED] for bowel obstruction seen on CT scan. Patient has had a day of diffuse abdominal pain vomiting and diarrhea. No similar symptoms in past. No fever, chest pain, shortness of breath, cough. Past Medical History: PMH: Hypertension UTI Hypothyroidism CAD Pyelonephritis AAA PSH: CABG Cholecystectomy Hernia repair Hysterectomy L nephrectomy EVAR Social History: [MASKED] Family History: noncontributory Physical Exam: Admission Physical Examination Temp: 97.4 HR: 58 BP: 112/67 Resp: 20 O2 Sat: 94 Low Constitutional: Elderly woman seated in bed, awake and alert, speaking in full sentences, in no acute distress Head / Eyes: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact ENT / Neck: Moist mucous membranes. NG tube in place. Chest/Resp: Breathing comfortably on room air, speaking full sentences. Mild scattered rhonchi on auscultation without wheezes or crackles. Cardiovascular: Regular Rate and Rhythm GI / Abdominal: Soft, mildly distended, mild TTP throughout, worst on left side of abdomen. GU/Flank: No costovertebral angle tenderness Musc/Extr/Back: No peripheral edema. No midline spinal TTP. Skin: Warm and dry Neuro: Speech fluent. PERRL. EOMI. Facial movements symmetric. Moving all extremities Discharge Physical Exam: VS: 97.5, 156/92, 55, 18, 94 Ra Gen: A&O, intermittently confused Pulm: LS w/ faint expiratory wheeze CV: HRR Abd: softly distended. mildly TTP over left side of abdomen (has chronic pain here from ? hernia) Ext: WWP . no edema Pertinent Results: [MASKED] 06:40AM BLOOD WBC-5.5 RBC-4.60 Hgb-12.6 Hct-40.4 MCV-88 MCH-27.4 MCHC-31.2* RDW-16.7* RDWSD-53.1* Plt [MASKED] [MASKED] 06:58AM BLOOD WBC-4.0 RBC-4.39 Hgb-11.9 Hct-38.6 MCV-88 MCH-27.1 MCHC-30.8* RDW-16.2* RDWSD-51.8* Plt [MASKED] [MASKED] 06:11AM BLOOD WBC-6.0 RBC-4.24 Hgb-11.4 Hct-37.7 MCV-89 MCH-26.9 MCHC-30.2* RDW-16.0* RDWSD-52.4* Plt [MASKED] [MASKED] 08:45AM BLOOD WBC-4.8 RBC-4.30 Hgb-11.7 Hct-38.8 MCV-90 MCH-27.2 MCHC-30.2* RDW-16.2* RDWSD-53.7* Plt [MASKED] [MASKED] 07:18AM BLOOD WBC-6.9 RBC-4.22 Hgb-11.4 Hct-37.5 MCV-89 MCH-27.0 MCHC-30.4* RDW-16.3* RDWSD-53.2* Plt [MASKED] [MASKED] 05:25PM BLOOD WBC-6.2 RBC-4.35 Hgb-11.8 Hct-38.3 MCV-88 MCH-27.1 MCHC-30.8* RDW-16.3* RDWSD-52.7* Plt [MASKED] [MASKED] 11:46AM BLOOD WBC-5.8 RBC-3.56* Hgb-9.6* Hct-32.5* MCV-91 MCH-27.0 MCHC-29.5* RDW-16.5* RDWSD-55.5* Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-86 UreaN-15 Creat-1.0 Na-140 K-4.9 Cl-102 HCO3-29 AnGap-9* [MASKED] 06:58AM BLOOD Glucose-79 UreaN-13 Creat-1.3* Na-140 K-4.8 Cl-101 HCO3-29 AnGap-10 [MASKED] 06:11AM BLOOD Glucose-106* UreaN-9 Creat-0.8 Na-140 K-3.9 Cl-104 HCO3-26 AnGap-10 [MASKED] 08:45AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-143 K-4.2 Cl-106 HCO3-25 AnGap-12 [MASKED] 07:18AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-143 K-3.5 Cl-106 HCO3-28 AnGap-9* [MASKED] 06:40AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0 [MASKED] 06:58AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0 [MASKED] 06:11AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.1 Imaging: OSH CT abdomen pelvis without contrast - 1. Distention of the stomach proximal and mid small bowel to the level of a lumbar abdominal wall hernia above the left iliac crest. 2. Status post endograft stenting of the infrarenal abdominal aorta and common iliac arteries [MASKED] ECG - Baseline artifact but probable sinus bradycardia with atrio-ventricular conduction delay. Inferior infarction of indeterminate age. Intraventricular conduction delay. Delayed R wave transition. Non-specific ST segment changes. Left ventricular hypertrophy. Compared to the previous tracing of [MASKED] the overall findings are similar. [MASKED] Abdomen - 1. Mild pulmonary edema. 2. Oral contrast has progressed to the level of the proximal transverse colon excluding obstruction. There remains mild distension of the small and large bowel loops suggesting ileus. Brief Hospital Course: [MASKED] with history of hypertension, prior UTI, hypothyroidism, cholecystectomy, hernia repair, hysterectomy, and left nephrectomy, who presents as a transfer from [MASKED] with concern for small bowel obstruction and incidental finding of UTI. The patient was admitted for bowel rest, IV fluids, and close monitoring of her abdominal exam. She was hemodynamically stable. She was given antibiotics for the UTI. Nasogastric tube was inserted for stomach decompression. Oral contrast was given via the NGT. Eight hours after contrast had been given, an abdominal x-ray showed that oral contrast has progressed to the level of the proximal transverse colon, excluding obstruction. On HD2, the NGT was removed. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. Because the patient was elderly and deconditioned, [MASKED] evaluated the patient to determine the safest disposition. They recommended she be discharged to rehab. The patient was refusing rehab and currently lived with one of her sons who she stated provided assistance with her care. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with a walker, voiding without assistance, having bowel movements, and denied pain. The patient was discharged home with services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Levothyroxine Sodium 75 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain and were found on CT scan to have a small bowel obstruction. You were managed non-operatively with a nasogastric tube for stomach decompression, bowel rest, IV fluids, and close monitoring of your abdominal exam. Once your obstruction resolved, your diet was advanced and you are now tolerating regular food and having bowel movements. You are ready for discharge home to continue your recovery. Please note the following: 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 Followup Instructions: [MASKED]	[]	[ "N390", "Z951", "E039", "I10", "I2510" ]	[ "K5650: Intestinal adhesions [bands], unspecified as to partial versus complete obstruction", "N390: Urinary tract infection, site not specified", "Z951: Presence of aortocoronary bypass graft", "E039: Hypothyroidism, unspecified", "K432: Incisional hernia without obstruction or gangrene", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z9049: Acquired absence of other specified parts of digestive tract" ]
10,040,202	26,210,601	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Demerol / codeine / Vicodin / Compazine / Macrobid / Keflex / erythromycin base / ciprofloxacin / Sulfa (Sulfonamide Antibiotics) / Penicillins Attending: ___. Chief Complaint: R leg pain Major Surgical or Invasive Procedure: R knee-spanning ex-fix ___, ___ ORIF R tibial plateau fracture ___, ___ History of Present Illness: ___ year old female with history of HTN and CVA presenting with a right tibial plateau fracture s/p fall off back of pickup truck. No HS/LOC, CTH negative. No pain in other extremities. On exam this is a closed injury and the patient is neurovascularly intact. This injury will require surgical fixation. Past Medical History: PMH/PSH: HTN CVA Heart murmur Ectopic pregnancy Hysterectomy Social History: ___ Family History: non-contributory Physical Exam: Exam: Vitals: AF, BP 155/66, other VSS and within normal limits General: Well-appearing, breathing comfortably MSK: LLE: Dressings c/d/i after dressing change yesterday Fires ___ SILT in all distributions Well perfused Pertinent Results: ___ 06:05AM BLOOD WBC-9.8 RBC-3.34* Hgb-9.8* Hct-30.0* MCV-90 MCH-29.3 MCHC-32.7 RDW-12.8 RDWSD-42.0 Plt ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right bicondylar tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for application of an external fixator and again on ___ for removal of the fixator and ORIF of the bicondylar tibial plateau, both of which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touch-down weight bearing 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. Valsartan 80 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5 TIMES DAILY 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Diovan HCT (valsartan-hydrochlorothiazide) 80-12.5 mg oral DAILY 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC QHS Duration: 26 Days Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 Units subcutaneous daily Disp #26 Syringe Refills:0 6. Gabapentin 300 mg PO TID 7. TraMADol 25 mg PO Q6H:PRN pain RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6h prn Disp #30 Tablet Refills:0 8. Hydrochlorothiazide 12.5 mg PO DAILY 9. Valsartan 80 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right bicondylar tibial plateau fracture Discharge Condition: AVSS NAD, A&Ox3 RLE: Incision well approximated. Dressing clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP pulse, wwp distally. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch-down weight bearing right lower extremity in unlocked ___ brace 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. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___	[ "S82141A", "I10", "W1789XA", "Y9289", "Z8673", "Z87891", "Z7901" ]	Allergies: Demerol / codeine / Vicodin / Compazine / Macrobid / Keflex / erythromycin base / ciprofloxacin / Sulfa (Sulfonamide Antibiotics) / Penicillins Chief Complaint: R leg pain Major Surgical or Invasive Procedure: R knee-spanning ex-fix [MASKED], [MASKED] ORIF R tibial plateau fracture [MASKED], [MASKED] History of Present Illness: [MASKED] year old female with history of HTN and CVA presenting with a right tibial plateau fracture s/p fall off back of pickup truck. No HS/LOC, CTH negative. No pain in other extremities. On exam this is a closed injury and the patient is neurovascularly intact. This injury will require surgical fixation. Past Medical History: PMH/PSH: HTN CVA Heart murmur Ectopic pregnancy Hysterectomy Social History: [MASKED] Family History: non-contributory Physical Exam: Exam: Vitals: AF, BP 155/66, other VSS and within normal limits General: Well-appearing, breathing comfortably MSK: LLE: Dressings c/d/i after dressing change yesterday Fires [MASKED] SILT in all distributions Well perfused Pertinent Results: [MASKED] 06:05AM BLOOD WBC-9.8 RBC-3.34* Hgb-9.8* Hct-30.0* MCV-90 MCH-29.3 MCHC-32.7 RDW-12.8 RDWSD-42.0 Plt [MASKED] Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right bicondylar tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for application of an external fixator and again on [MASKED] for removal of the fixator and ORIF of the bicondylar tibial plateau, both of which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touch-down weight bearing 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. Valsartan 80 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5 TIMES DAILY 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Diovan HCT (valsartan-hydrochlorothiazide) 80-12.5 mg oral DAILY 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC QHS Duration: 26 Days Start: Today - [MASKED], First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 Units subcutaneous daily Disp #26 Syringe Refills:0 6. Gabapentin 300 mg PO TID 7. TraMADol 25 mg PO Q6H:PRN pain RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6h prn Disp #30 Tablet Refills:0 8. Hydrochlorothiazide 12.5 mg PO DAILY 9. Valsartan 80 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Right bicondylar tibial plateau fracture Discharge Condition: AVSS NAD, A&Ox3 RLE: Incision well approximated. Dressing clean and dry. Fires FHL, [MASKED], TA, GCS. SILT [MASKED] n distributions. 1+ DP pulse, wwp distally. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch-down weight bearing right lower extremity in unlocked [MASKED] brace 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. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: [MASKED]	[]	[ "I10", "Z8673", "Z87891", "Z7901" ]	[ "S82141A: Displaced bicondylar fracture of right tibia, initial encounter for closed fracture", "I10: Essential (primary) hypertension", "W1789XA: Other fall from one level to another, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants" ]
10,040,284	26,059,791	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, foreign body ingestion Major Surgical or Invasive Procedure: ___: EGD with removal of foreign objects (magnets) and clipping/injection of gastric ulcerations History of Present Illness: ___ w PMH Schizophrenia, depression, PTSD and prior suicide attempts, presenting with abdominal pain following magnet ingestion. Pt recently discharged from ___ after presenting on ___ with ingestion of 4 magnets. The ingestion on ___ was with intent for self harm, so she was admitted to the psychiatric unit, started on SSRI and mood stabilizer and discharged on ___. She presents to ___ today after reportedly swallowing three magnets on ___. Says they were cylindrical, strong magnets taken from an office where she works in ___. She developed LUQ abdominal pain so she came to the ED. Patient reports swallowing magnets so as to come to the hospital and avoid her family, in a desire to save her family. She states that she heard voices telling her to hurt her family members, so she decided to swallow the magnets, in an attempt for help from the medical community. Denies SI or HI; endorses continued auditory hallucinations. She does not wish that her family know about this. Magnets were small, approx. 1x1cm; she swallowed them separately with 30 minute interval between them. Reports retrosternal pain initially after swallowing magnets. Today has developed epigastric and LLQ pain, worse with movement. No n/v/d. No bloody stool or melena In the ED, initial vitals: 98.0 69 120/56 18 100% RA. Physical exam significant for disorganized thought process epigastric and LLQ pain with involuntary guarding, no rebound tenderness. - Labs were significant for normal CBC, BMP, urine toxicology. UA + large blood, trace protein, trace ketones, 2 epithelial cells. - CXR significant for three connected oblong structures projecting over the expected area of stomach. - She received 2mg morphine and 1L NS. - She was taking emergently for EGD for attempted magnetic removal. Upon arrival to the floor, she endorsed sore throat and mild epigastric pain. Past Medical History: - PTSD - Depression - Dissociative Disorder - Schizophrenia - Multiple prior suicide attempts: clonazepam ingestion, magnet ingestion Social History: ___ Family History: + schizophrenia, alcoholism - father Physical ___: ADMISSION PHYSICAL: ===================== VS: T 98.1, BP 102/47, HR 68, R 18, SpO2 100%/RA 68.6 kg GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Clear bilaterally without wheeze or rhonchi COR: RRR (+)S1/S2 with faint grade I systolic murmur at bilateral upper sternal borders ABD: Soft, non-distended, mild TTP over epigastrium, normal bowel sounds EXTREM: Warm, well-perfused, no edema NEURO: face symmetric, moving all extremities well PSYCH: appropriate, denies SI, HI, AH, VH DISCHARGE PHYSICAL: =================== VITALS: 98 107/42 74 16 99% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated RESP: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops ABD: +BS, soft, nondistended, ttp in LUQ without rebound GU: no foley EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: =================== ___ 03:01PM BLOOD WBC-5.4 RBC-3.82* Hgb-11.6 Hct-34.4 MCV-90 MCH-30.4 MCHC-33.7 RDW-11.9 RDWSD-38.4 Plt ___ ___ 03:01PM BLOOD Neuts-56.1 ___ Monos-4.8* Eos-0.4* Baso-0.7 Im ___ AbsNeut-3.04 AbsLymp-2.05 AbsMono-0.26 AbsEos-0.02* AbsBaso-0.04 ___ 03:01PM BLOOD Glucose-90 UreaN-6 Creat-0.6 Na-137 K-3.5 Cl-101 HCO3-27 AnGap-13 DISCHARGE LABS: ================= ___ 07:35AM BLOOD WBC-4.6 RBC-3.68* Hgb-11.1* Hct-33.8* MCV-92 MCH-30.2 MCHC-32.8 RDW-11.9 RDWSD-39.7 Plt ___ IMAGING: ============= CXR ___ No acute cardiopulmonary process. Three connected oblong structures are seen projecting over the expected area of the stomach, likely representing ingested magnets. KUB ___ IMPRESSION: 3 cylindrical radiopaque densities vertically aligned end-to-end with each other likely reflective of ingested magnets in the left upper quadrant abdomen, possibly within the stomach. No free intraperitoneal gas. EGD ___: Foreign body in the stomach (foreign body removal) Ulcers in the stomach (injection, endoclip) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: ___ w PMH depression, ? schizophrenia, PTSD and prior suicide attempts, presenting with abdominal pain following magnet ingestion. # Magnet ingestion: Presented with abdominal pain following ingestion of 3 magnets which were seen on CXR and KUB. GI was consulted and patient underwent EGD on ___ with removal of magnets. Per patient, was not suicide attempt but rather was trying to get away from her family. While she has a history of prior episodes of magnet ingestion, psychiatric evaluation was unrevealing for true SI/HI and her attempt was felt to be related to an attempt to deal with ego dystonic thoughts related towards her anger towards her family. As such, she did not meet ___ criteria and the patient was felt to need assistance with housing outside of her current living situation. She was maintained on a 1:1 sitter prior to discharge to avoid further ingestions. Her abdominal pain was improved prior to discharge. Patient was discharged with cab voucher to take her to ___ ___ and was provided with clothes, a new cell phone, outpatient psych resources and T passes prior to discharge. # Gastric ulcers: Likely related to ingestion of magnets with pinching of gastric lining s/p clipping and epi injection. Patient was treated with 24 hours of IV pantoprazole BID and then transitioned to PO pantoprazole prior to discharge. Her diet was advanced to regular. # Anemia: Normocytic anemia in young female. Could be due to menstrual blood loss vs bleeding from gastric ulcers depending on duration (ie caused by prior magnet ingestion). Stable during this admission. Will require further work-up as outpatient if persists. # Depression: Patient with a history of ? schizophrenia, depression, and recent admission at ___ following intentional magnetic ingestion, representing with the same. As above, does not appear to be true voices suggesting psychosis but rather her own voice related to her anger at her current living situation. She had no active SI/HI and given that presentation was not felt to be true suicide attempt, she did not meet criteria for ___. She was started on aripiprazole (previously taking) per psychiatry recommendation and continued on home fluoxetine, trazodone and clonazepam. She had outpatient psychiatry ___ scheduled for ___ ___s access to the ___ women's program and was provided with the number for BEST on discharge. TRANSITIONAL ISSUES: ====================== [ ]Patient will benefit from ongoing psychiatric evaluation for depression and medication management [ ]Please have patient continue on BID PPI for at least one month (through ___ [ ]Please repeat Hemoglobin and hematocrit at PCP ___ on ___. If persistent anemia, consider further work-up for unexplained anemia Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. TraZODone 50 mg PO QHS 2. Fluoxetine 30 mg PO DAILY 3. ClonazePAM 1 mg PO BID:PRN anxiety Discharge Medications: 1. ClonazePAM 1 mg PO BID:PRN anxiety RX clonazepam 1 mg 1 tablet by mouth twice a day Disp #6 Tablet Refills:0 2. Fluoxetine 30 mg PO DAILY RX fluoxetine 10 mg 3 tablets by mouth daily Disp #45 Tablet Refills:0 3. TraZODone 50 mg PO QHS RX trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #15 Tablet Refills:0 4. ARIPiprazole 10 mg PO DAILY RX aripiprazole 10 mg 1 tablet(s) by mouth Daily Disp #15 Tablet Refills:0 5. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Foreign body (magnet) Ingestion Gastric Ulcers Depression 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 after swallowing several magnets. You underwent a procedure called an endoscopy to remove the magnets. The endoscopy showed several ulcerations (cuts) from the magnets which were repaired. You were started on a new medication called pantoprazole to help your stomach heal. It is important that you take this medication as prescribed. You were seen by psychiatry in the hospital who felt that you were safe for discharge as you were not having thoughts of hurting yourself or others. You were restarted on abilify and continued on your other psychiatric medications. It is very important that you ___ with your psychiatrist as scheduled on ___ (see below). Additionally, please call the partial hospital program for women at ___ HRI at ___ to set up an intake appointment. Finally, you were seen by social work who helped to provide you with resources for when you leave the hospital. If you find that you need additional assistance when you leave the hospital, you have several options: 1. ___ CSA in ___ for care coordination at ___. 2. ___ Emergency Services Team (BEST) for emergency mental health concerns at ___ We wish you the best in your recovery. It was a pleasure taking care of you, Your ___ Care Team Followup Instructions: ___	[ "T182XXA", "X58XXXA", "Y929", "K254", "F329", "D649", "F4310", "F4329", "F17210" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain, foreign body ingestion Major Surgical or Invasive Procedure: [MASKED]: EGD with removal of foreign objects (magnets) and clipping/injection of gastric ulcerations History of Present Illness: [MASKED] w PMH Schizophrenia, depression, PTSD and prior suicide attempts, presenting with abdominal pain following magnet ingestion. Pt recently discharged from [MASKED] after presenting on [MASKED] with ingestion of 4 magnets. The ingestion on [MASKED] was with intent for self harm, so she was admitted to the psychiatric unit, started on SSRI and mood stabilizer and discharged on [MASKED]. She presents to [MASKED] today after reportedly swallowing three magnets on [MASKED]. Says they were cylindrical, strong magnets taken from an office where she works in [MASKED]. She developed LUQ abdominal pain so she came to the ED. Patient reports swallowing magnets so as to come to the hospital and avoid her family, in a desire to save her family. She states that she heard voices telling her to hurt her family members, so she decided to swallow the magnets, in an attempt for help from the medical community. Denies SI or HI; endorses continued auditory hallucinations. She does not wish that her family know about this. Magnets were small, approx. 1x1cm; she swallowed them separately with 30 minute interval between them. Reports retrosternal pain initially after swallowing magnets. Today has developed epigastric and LLQ pain, worse with movement. No n/v/d. No bloody stool or melena In the ED, initial vitals: 98.0 69 120/56 18 100% RA. Physical exam significant for disorganized thought process epigastric and LLQ pain with involuntary guarding, no rebound tenderness. - Labs were significant for normal CBC, BMP, urine toxicology. UA + large blood, trace protein, trace ketones, 2 epithelial cells. - CXR significant for three connected oblong structures projecting over the expected area of stomach. - She received 2mg morphine and 1L NS. - She was taking emergently for EGD for attempted magnetic removal. Upon arrival to the floor, she endorsed sore throat and mild epigastric pain. Past Medical History: - PTSD - Depression - Dissociative Disorder - Schizophrenia - Multiple prior suicide attempts: clonazepam ingestion, magnet ingestion Social History: [MASKED] Family History: + schizophrenia, alcoholism - father Physical [MASKED]: ADMISSION PHYSICAL: ===================== VS: T 98.1, BP 102/47, HR 68, R 18, SpO2 100%/RA 68.6 kg GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Clear bilaterally without wheeze or rhonchi COR: RRR (+)S1/S2 with faint grade I systolic murmur at bilateral upper sternal borders ABD: Soft, non-distended, mild TTP over epigastrium, normal bowel sounds EXTREM: Warm, well-perfused, no edema NEURO: face symmetric, moving all extremities well PSYCH: appropriate, denies SI, HI, AH, VH DISCHARGE PHYSICAL: =================== VITALS: 98 107/42 74 16 99% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated RESP: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops ABD: +BS, soft, nondistended, ttp in LUQ without rebound GU: no foley EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: =================== [MASKED] 03:01PM BLOOD WBC-5.4 RBC-3.82* Hgb-11.6 Hct-34.4 MCV-90 MCH-30.4 MCHC-33.7 RDW-11.9 RDWSD-38.4 Plt [MASKED] [MASKED] 03:01PM BLOOD Neuts-56.1 [MASKED] Monos-4.8* Eos-0.4* Baso-0.7 Im [MASKED] AbsNeut-3.04 AbsLymp-2.05 AbsMono-0.26 AbsEos-0.02* AbsBaso-0.04 [MASKED] 03:01PM BLOOD Glucose-90 UreaN-6 Creat-0.6 Na-137 K-3.5 Cl-101 HCO3-27 AnGap-13 DISCHARGE LABS: ================= [MASKED] 07:35AM BLOOD WBC-4.6 RBC-3.68* Hgb-11.1* Hct-33.8* MCV-92 MCH-30.2 MCHC-32.8 RDW-11.9 RDWSD-39.7 Plt [MASKED] IMAGING: ============= CXR [MASKED] No acute cardiopulmonary process. Three connected oblong structures are seen projecting over the expected area of the stomach, likely representing ingested magnets. KUB [MASKED] IMPRESSION: 3 cylindrical radiopaque densities vertically aligned end-to-end with each other likely reflective of ingested magnets in the left upper quadrant abdomen, possibly within the stomach. No free intraperitoneal gas. EGD [MASKED]: Foreign body in the stomach (foreign body removal) Ulcers in the stomach (injection, endoclip) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: [MASKED] w PMH depression, ? schizophrenia, PTSD and prior suicide attempts, presenting with abdominal pain following magnet ingestion. # Magnet ingestion: Presented with abdominal pain following ingestion of 3 magnets which were seen on CXR and KUB. GI was consulted and patient underwent EGD on [MASKED] with removal of magnets. Per patient, was not suicide attempt but rather was trying to get away from her family. While she has a history of prior episodes of magnet ingestion, psychiatric evaluation was unrevealing for true SI/HI and her attempt was felt to be related to an attempt to deal with ego dystonic thoughts related towards her anger towards her family. As such, she did not meet [MASKED] criteria and the patient was felt to need assistance with housing outside of her current living situation. She was maintained on a 1:1 sitter prior to discharge to avoid further ingestions. Her abdominal pain was improved prior to discharge. Patient was discharged with cab voucher to take her to [MASKED] [MASKED] and was provided with clothes, a new cell phone, outpatient psych resources and T passes prior to discharge. # Gastric ulcers: Likely related to ingestion of magnets with pinching of gastric lining s/p clipping and epi injection. Patient was treated with 24 hours of IV pantoprazole BID and then transitioned to PO pantoprazole prior to discharge. Her diet was advanced to regular. # Anemia: Normocytic anemia in young female. Could be due to menstrual blood loss vs bleeding from gastric ulcers depending on duration (ie caused by prior magnet ingestion). Stable during this admission. Will require further work-up as outpatient if persists. # Depression: Patient with a history of ? schizophrenia, depression, and recent admission at [MASKED] following intentional magnetic ingestion, representing with the same. As above, does not appear to be true voices suggesting psychosis but rather her own voice related to her anger at her current living situation. She had no active SI/HI and given that presentation was not felt to be true suicide attempt, she did not meet criteria for [MASKED]. She was started on aripiprazole (previously taking) per psychiatry recommendation and continued on home fluoxetine, trazodone and clonazepam. She had outpatient psychiatry [MASKED] scheduled for [MASKED] s access to the [MASKED] women's program and was provided with the number for BEST on discharge. TRANSITIONAL ISSUES: ====================== [ ]Patient will benefit from ongoing psychiatric evaluation for depression and medication management [ ]Please have patient continue on BID PPI for at least one month (through [MASKED] [ ]Please repeat Hemoglobin and hematocrit at PCP [MASKED] on [MASKED]. If persistent anemia, consider further work-up for unexplained anemia Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. TraZODone 50 mg PO QHS 2. Fluoxetine 30 mg PO DAILY 3. ClonazePAM 1 mg PO BID:PRN anxiety Discharge Medications: 1. ClonazePAM 1 mg PO BID:PRN anxiety RX clonazepam 1 mg 1 tablet by mouth twice a day Disp #6 Tablet Refills:0 2. Fluoxetine 30 mg PO DAILY RX fluoxetine 10 mg 3 tablets by mouth daily Disp #45 Tablet Refills:0 3. TraZODone 50 mg PO QHS RX trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #15 Tablet Refills:0 4. ARIPiprazole 10 mg PO DAILY RX aripiprazole 10 mg 1 tablet(s) by mouth Daily Disp #15 Tablet Refills:0 5. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Foreign body (magnet) Ingestion Gastric Ulcers Depression 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 after swallowing several magnets. You underwent a procedure called an endoscopy to remove the magnets. The endoscopy showed several ulcerations (cuts) from the magnets which were repaired. You were started on a new medication called pantoprazole to help your stomach heal. It is important that you take this medication as prescribed. You were seen by psychiatry in the hospital who felt that you were safe for discharge as you were not having thoughts of hurting yourself or others. You were restarted on abilify and continued on your other psychiatric medications. It is very important that you [MASKED] with your psychiatrist as scheduled on [MASKED] (see below). Additionally, please call the partial hospital program for women at [MASKED] HRI at [MASKED] to set up an intake appointment. Finally, you were seen by social work who helped to provide you with resources for when you leave the hospital. If you find that you need additional assistance when you leave the hospital, you have several options: 1. [MASKED] CSA in [MASKED] for care coordination at [MASKED]. 2. [MASKED] Emergency Services Team (BEST) for emergency mental health concerns at [MASKED] We wish you the best in your recovery. It was a pleasure taking care of you, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "Y929", "F329", "D649", "F17210" ]	[ "T182XXA: Foreign body in stomach, initial encounter", "X58XXXA: Exposure to other specified factors, initial encounter", "Y929: Unspecified place or not applicable", "K254: Chronic or unspecified gastric ulcer with hemorrhage", "F329: Major depressive disorder, single episode, unspecified", "D649: Anemia, unspecified", "F4310: Post-traumatic stress disorder, unspecified", "F4329: Adjustment disorder with other symptoms", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,040,602	25,984,377	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Amoxicillin Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with H/O cardiomyopathy (LVEF 30%), lung cancer s/p right upper lobectomy, hypertension, and hyperlipidemia presented with chest pain. Patient reports acute onset of chest pain that woke him up from sleep the morning of presentation at about 3A. He described the pain as sharp and worse with inspiration. It had been constant throughout the course of the day and notably not worse with exertion. Pain was mainly across the ___ his chest, but he also has the sensation that it was "traveling down my esophagus and across the top of my back." There was no radiation down the arm or to the jaw. He reported some limitation in his ability to take a deep breath due to pain but no shortness of breath per se. He denied palpitations or diaphoresis. Patient has never had pain like this before. There was no significant improvement in pain by leaning forward. He denied any recent URI. He did recently travel to a resort in the ___. He denied fevers, chills, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. In the ED, initial vitals: HR 47 BP 112/54 RR 20 SaO2 99% on RA. EKG showed new inferior T waver inversions. Labs/studies notable for Hgb/Hct 12.7/38.0, WBC 9.3, plt 185, Na 140, K 4.5, BUN 36, Cr 1.8, Troponin-T negative x2, NT-pro-BNP 970. D-Dimer 1108. CXR showed that the heart size and mediastinum were stable with unchanged vascular enlargement in the hila, but no evidence of acute exacerbation of congestive heart failure. CTA showed no evidence of pulmonary embolism or acute aortic abnormality, no acute etiology identified for pleuritic chest pain, no focal consolidation concerning for underlying infection. There was enlargement of the pulmonary arterial system, consistent with pulmonary arterial hypertension. There was an unchanged soft tissue mass in the prevascular mediastinum, which has been slowly growing since ___ and appears stable since ___, probably an encapsulated thymoma. Thickening the mediastinal esophagus was unchanged compared ___ and may be sequela of chronic esophageal inflammation. Patient was given Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO, Donnatal 10 mL PO, Lidocaine Viscous 2% 10 mL PO, famotidine 20 mg IV, Nitroglycerin infusion starting at 0.35 mcg/kg/min. After arrival to the cardiology ward, the patient reported persistent, pleuritic chest pain. He said the nitroglycerin gtt might be helping marginally. He had been resting comfortably in bed prior to being woken up to give the above history. Past Medical History: 1. CAD RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY -Dilated cardiomyopathy attributed to PVC burden - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY -Lung cancer s/p lobectomy (no chemo/XRT) -Nephrolithiasis -Colonic polyps -High-grade prostatic intraepithelial neoplasia -Neuropathy Social History: ___ Family History: Mother with rheumatic heart disease, father with diabetes and required open heart surgery. Physical Exam: On admission GENERAL: Pleasant elderly white man in NAD VS: T 98 BP 112/66 HR 65 RR 20 SaO2 99% on RA HEENT: NCAT, mucous membranes moist CV: RRR; no murmurs, rubs or gallops PULM: CTAB GI: Soft, non-tender, not distended, BS+ EXTREMITIES: warm and well perfused; no clubbing, cyanosis or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric At discharge GENERAL: Pleasant elderly man in NAD VS: 24 HR Data (last updated ___ @ ___ Temp: 98.3 (Tm 99.5), BP: 99/62 (99-145/62-83), HR: 48 (48-58), RR: 20 (___), O2 sat: 96% (94-98), O2 delivery: RA HEENT: NCAT, mucous membranes moist CV: RRR; no murmurs, rubs or gallops PULM: CTAB GI: Soft, non-tender, not distended, BS+ EXTREMITIES: warm and well perfused; no clubbing, cyanosis or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric Pertinent Results: ___ 10:56AM BLOOD WBC-9.3 RBC-4.01* Hgb-12.7* Hct-38.0* MCV-95 MCH-31.7 MCHC-33.4 RDW-12.9 RDWSD-44.4 Plt ___ ___ 10:56AM BLOOD Neuts-74.1* Lymphs-12.9* Monos-11.6 Eos-0.9* Baso-0.3 Im ___ AbsNeut-6.88* AbsLymp-1.20 AbsMono-1.08* AbsEos-0.08 AbsBaso-0.03 ___ 10:56AM BLOOD Glucose-111* UreaN-36* Creat-1.8* Na-140 K-4.5 Cl-100 HCO3-26 AnGap-14 ___ 10:56AM BLOOD CRP-32.7* ___ 06:30AM BLOOD VitB12-691 Folate-19 Hapto-126 ___ 10:56AM BLOOD proBNP-970* ___ 10:56AM BLOOD cTropnT-<0.01 ___ 03:05PM BLOOD cTropnT-<0.01 ___ 06:30AM BLOOD cTropnT-<0.01 DISCHARGE LABS ___ 05:50AM BLOOD WBC-5.5 RBC-3.83* Hgb-12.1* Hct-36.6* MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt ___ ___ 05:50AM BLOOD Glucose-129* UreaN-23* Creat-1.5* Na-138 K-4.3 Cl-101 HCO3-25 AnGap-12 ___ 05:50AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.2 ___ ECGs ECG: stable anterior J point elevation, new inferior T wave inversions, with subsequent widening of the QRS duration into a not-quite-LBBB IVCD. ___ CXR Heart size and mediastinum are stable in appearance. Vascular enlargement in the hila is unchanged, with no evidence of acute exacerbation of congestive heart failure on the radiograph. Postsurgical changes in the right lung are stable. There is no pleural effusion. There is no pneumothorax. ___ CTA Chest HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. There is enlargement of the main, right main, and left main pulmonary arteries, measuring up to 3.8, 3.1, and 2.8 cm, respectively. These findings are likely suggestive of pulmonary arterial hypertension. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: Mediastinal esophagus appears thickened throughout its course (series 2; image 21), similar compared to prior and suggestive of underlying chronic esophageal inflammation. Again seen in the mediastinum, along the superior aspect of the left ventricle, adjacent to the main pulmonary artery, there is a lobulated, homogeneous 3.4 x 2.2 cm soft tissue density, which previously measured 3.5 x 2.0 cm. This mass is been slowly growing since ___ and likely represent an encapsulated thymoma. It appears to now abut the myocardium over a couple of cm. There is no axillary lymphadenopathy. There are prominent subcarinal and right hilar lymph nodes, which are nonspecific. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Changes seen after right upper lobectomy. There is bibasilar atelectasis, right greater than left, without focal consolidation concerning for infection. Incidentally noted is an azygos lobe. 4 mm nodule in the right upper lobe (series 3; image 84) is unchanged compared to ___ and now stable for 32 months. No additional concerning nodules are identified. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. No acute etiology identified for pleuritic chest pain. No focal consolidation concerning for underlying infection. 2. Enlargement of the pulmonary arterial system, consistent with pulmonary arterial hypertension. 3. Unchanged soft tissue mass in the prevascular mediastinum, which has been slowly growing since ___ and appears stable since ___. This is probably an encapsulated thymoma. 4. Thickening the mediastinal esophagus is unchanged compared ___ and may be sequela of chronic esophageal inflammation. EGD could be pursued on a nonurgent basis if clinically indicated. ___ Echocardiogram The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is mild-moderate global left ventricular hypokinesis. The visually estimated left ventricular ejection fraction is 35%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE (images not available for review) of ___, the estimated PA systolic pressure is now increased. Brief Hospital Course: ___ with H/O cardiomyopathy (LVEF 30%), lung cancer s/p right upper lobectomy, hypertension, and hyperlipidemia presented with chest pain. He had negative troponin-T x3. He was also found to have esophagitis, with chest pain improved with initiation of PPI and Aluminum-Magnesium Hydrox-Simethicone. ACUTE ISSUES: # Chest pain, esophagitis: Patient was admitted with acute onset chest pain described as burning around esophagus, radiating across shoulders and to lesser degree across chest, not classic for ACS. ECG initially with some inferoapical T wave inversion (non-specific) though no other changes suggestive of acute ischemia, but troponin-T and CK-MB negative x3. Initial treatment with nitroglycerin gtt without obvious improvement in pain. CTA also negative after patient noted to recently have been on relatively long plane flight and with elevated D-Dimer. Patient reported no symptoms during recent trip to ___ ___ but a lot of stress during the flight home. Most likely etiologies of chest pain felt to be esophagitis (given thickened mediastinal esophagus on CTA) vs pericarditis with elevated CRP. Significant relief of chest pain with empiric treatment of esophagitis with GI cocktail and pantoprazole, therefore treatment of pericarditis not initiated. At time of discharge, chest pain was almost completely gone, and patient only reported faint sensation of burning around esophagus. # Non-conducted P waves, bradycardia. ___ telemetry pause with non-conducted P waves (2.5 sec longer QRS-free interval than expected if single non-conducted PAC with apparent AV block after a likely P wave vs artifact--failure of ventricular escape and/or AV block). Patient does not recall what he was doing at the time. Pause and tracing reviewed with several electrophysiologists. As sinus node dysfunction isolated and asymptomatic, no further intervention was felt warranted at present. Patient mentioned that Dr. ___ mentioned possibility of ICD (presumably primary prevention). Patient discharged with outpatient EP F/U with Dr. ___. We decreased home metoprolol succinate dose given occasional bradycardia (HR ___. # Dilated cardiomyopathy: LVEF 30% in ___ -> 44% on CMR in ___, presumed to be secondary to VEA burden. Per recent cardiology note, "Initially started on metoprolol and lisinopril with reduction in PVC burden to 15% and subsequently was initiated on amiodarone therapy in ___ with most recent Holter on ___ showing reduction VPC burden to 8% with multiple morphologies." Continued home amiodarone. Decreased dose of metoprolol, as above. CHRONIC ISSUES: # CKD stage 3 with ___: Cr on admission 1.8 (baseline 1.3-1.8) downtrended to 1.5 this admission. # Hypertension: Continued home hydralazine (once daily dosing confirmed by patient), HCTZ, metoprolol. # Hyperlipidemia: Continued home statin. # Lung CA s/p right upper lobectomy (no chemo/XRT): Surveillance imaging as outpatient. # Primary prevention against CAD: Continued home aspirin, statin, metoprolol. TRANSITIONAL ISSUES: ==================== [ ] Follow up resolution of chest pain with GI cocktail and pantoprazole. [ ] Further workup of esophagitis, would recommend endoscopy with Dr. ___. [ ] Follow up of non-conducted P waves in clinic with Dr. ___ ICD for primary prevention. [ ] He was noted to have left leg calf pain which is suspicious for claudication and PAD, would recommend an outpatient ABI and vascular medicine follow up to assess this. [ ] Consider ETT-MIBI or R-MIBI (develops claudication after walking 0.5 miles slowly, but useful to assess functional capacity) if symptoms not improve with aggressive GI regimen. [ ] Follow up of likely thymoma noted on CTA. - New Meds: GI cocktail QID, pantoprazole 40 mg daily - Stopped/Held Meds: None - Changed Meds: Metoprolol succinate XL 50 mg -> 25 mg daily - Follow-up appointments: PCP appointment with Dr. ___ appointment with Dr. ___ follow up with Dr. ___. - Post-Discharge Follow-up Labs Needed: None - Incidental Findings: Thymoma, left leg claudication - Discharge weight: 94.8kg - Discharge creatinine: 1.5 # CODE: full (presumed) # CONTACT: ___ (wife) - ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Gabapentin 100 mg PO BID 3. HydrALAZINE 25 mg PO DAILY 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Simvastatin 10 mg PO QPM 7. Aspirin 81 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY 10. Multivitamin 50 Plus (multivitamin-minerals-lutein) oral DAILY 11. selenium 200 mcg oral DAILY 12. Florastor (Saccharomyces boulardii) 250 mg oral DAILY Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID RX alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ mL by mouth four times a day Disp #1680 Milliliter Refills:0 2. Pantoprazole 40 mg PO Q24H RX pantoprazole 20 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:0 3. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth once a day Disp #60 Tablet Refills:*0 4. Amiodarone 200 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Florastor (Saccharomyces boulardii) 250 mg oral DAILY 8. Gabapentin 100 mg PO BID 9. HydrALAZINE 25 mg PO DAILY 10. Hydrochlorothiazide 12.5 mg PO DAILY 11. Multivitamin 50 Plus (multivitamin-minerals-lutein) oral DAILY 12. selenium 200 mcg oral DAILY 13. Simvastatin 10 mg PO QPM 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Chest pain # Esophagitis # Dilated cardiomyopathy/chronic left ventricular systolic heart failure # Non-conducted P waves consistent with asymptomatic sinus node dysfunction # Bradycardia # Acute kidney injury on # Chronic kidney disease, stage 3 # Normocytic anemia # Left calf claudication consistent with peripheral arterial disease # Hypertension # Hyperlipidemia # Mediastinal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___. WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because of chest pain. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were admitted to the hospital because you had chest pain. - Lab tests of your blood found that your cardiac enzymes were normal (not elevated), and you had electrocardiograms (EKGs) that did not show a heart attack. - You had an imaging test called a CT angiogram of your chest. There was no sign of a blood clot in your lung (pulmonary embolus) and no signs of aortic dissection. However, the CT angiogram showed a mass in the mediastinum that is likely a thymoma that should be followed up as an outpatient. - The CTA showed thickening of your esophagus that could be a sign of esophagitis (inflammation of the esophagus), which was likely causing your chest pain. - You were treated with a GI cocktail medication and a proton pump inhibitor that helps to reduce acid in the stomach, and your pain improved. - You were noted to have slow heart rates and a pause on cardiac telemetry monitoring. You should see your cardiologist Dr. ___ in clinic for follow up. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Continue to take the GI cocktail and proton pump inhibitor. - Follow up with your gastroenterology doctor. We recommend getting an endoscopy to look at your esophagus. - You should get a test called an ankle-brachial index (ABI) as an outpatient to work up your left calf tightness. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___	[ "K209", "J9859", "I420", "I319", "R7982", "E785", "N4231", "I10", "I2720", "Z85118", "K635", "G629", "N200", "R001", "I129", "N183", "D649", "I70212" ]	Allergies: Amoxicillin Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with H/O cardiomyopathy (LVEF 30%), lung cancer s/p right upper lobectomy, hypertension, and hyperlipidemia presented with chest pain. Patient reports acute onset of chest pain that woke him up from sleep the morning of presentation at about 3A. He described the pain as sharp and worse with inspiration. It had been constant throughout the course of the day and notably not worse with exertion. Pain was mainly across the [MASKED] his chest, but he also has the sensation that it was "traveling down my esophagus and across the top of my back." There was no radiation down the arm or to the jaw. He reported some limitation in his ability to take a deep breath due to pain but no shortness of breath per se. He denied palpitations or diaphoresis. Patient has never had pain like this before. There was no significant improvement in pain by leaning forward. He denied any recent URI. He did recently travel to a resort in the [MASKED]. He denied fevers, chills, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. In the ED, initial vitals: HR 47 BP 112/54 RR 20 SaO2 99% on RA. EKG showed new inferior T waver inversions. Labs/studies notable for Hgb/Hct 12.7/38.0, WBC 9.3, plt 185, Na 140, K 4.5, BUN 36, Cr 1.8, Troponin-T negative x2, NT-pro-BNP 970. D-Dimer 1108. CXR showed that the heart size and mediastinum were stable with unchanged vascular enlargement in the hila, but no evidence of acute exacerbation of congestive heart failure. CTA showed no evidence of pulmonary embolism or acute aortic abnormality, no acute etiology identified for pleuritic chest pain, no focal consolidation concerning for underlying infection. There was enlargement of the pulmonary arterial system, consistent with pulmonary arterial hypertension. There was an unchanged soft tissue mass in the prevascular mediastinum, which has been slowly growing since [MASKED] and appears stable since [MASKED], probably an encapsulated thymoma. Thickening the mediastinal esophagus was unchanged compared [MASKED] and may be sequela of chronic esophageal inflammation. Patient was given Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO, Donnatal 10 mL PO, Lidocaine Viscous 2% 10 mL PO, famotidine 20 mg IV, Nitroglycerin infusion starting at 0.35 mcg/kg/min. After arrival to the cardiology ward, the patient reported persistent, pleuritic chest pain. He said the nitroglycerin gtt might be helping marginally. He had been resting comfortably in bed prior to being woken up to give the above history. Past Medical History: 1. CAD RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY -Dilated cardiomyopathy attributed to PVC burden - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY -Lung cancer s/p lobectomy (no chemo/XRT) -Nephrolithiasis -Colonic polyps -High-grade prostatic intraepithelial neoplasia -Neuropathy Social History: [MASKED] Family History: Mother with rheumatic heart disease, father with diabetes and required open heart surgery. Physical Exam: On admission GENERAL: Pleasant elderly white man in NAD VS: T 98 BP 112/66 HR 65 RR 20 SaO2 99% on RA HEENT: NCAT, mucous membranes moist CV: RRR; no murmurs, rubs or gallops PULM: CTAB GI: Soft, non-tender, not distended, BS+ EXTREMITIES: warm and well perfused; no clubbing, cyanosis or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric At discharge GENERAL: Pleasant elderly man in NAD VS: 24 HR Data (last updated [MASKED] @ [MASKED] Temp: 98.3 (Tm 99.5), BP: 99/62 (99-145/62-83), HR: 48 (48-58), RR: 20 ([MASKED]), O2 sat: 96% (94-98), O2 delivery: RA HEENT: NCAT, mucous membranes moist CV: RRR; no murmurs, rubs or gallops PULM: CTAB GI: Soft, non-tender, not distended, BS+ EXTREMITIES: warm and well perfused; no clubbing, cyanosis or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric Pertinent Results: [MASKED] 10:56AM BLOOD WBC-9.3 RBC-4.01* Hgb-12.7* Hct-38.0* MCV-95 MCH-31.7 MCHC-33.4 RDW-12.9 RDWSD-44.4 Plt [MASKED] [MASKED] 10:56AM BLOOD Neuts-74.1* Lymphs-12.9* Monos-11.6 Eos-0.9* Baso-0.3 Im [MASKED] AbsNeut-6.88* AbsLymp-1.20 AbsMono-1.08* AbsEos-0.08 AbsBaso-0.03 [MASKED] 10:56AM BLOOD Glucose-111* UreaN-36* Creat-1.8* Na-140 K-4.5 Cl-100 HCO3-26 AnGap-14 [MASKED] 10:56AM BLOOD CRP-32.7* [MASKED] 06:30AM BLOOD VitB12-691 Folate-19 Hapto-126 [MASKED] 10:56AM BLOOD proBNP-970* [MASKED] 10:56AM BLOOD cTropnT-<0.01 [MASKED] 03:05PM BLOOD cTropnT-<0.01 [MASKED] 06:30AM BLOOD cTropnT-<0.01 DISCHARGE LABS [MASKED] 05:50AM BLOOD WBC-5.5 RBC-3.83* Hgb-12.1* Hct-36.6* MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt [MASKED] [MASKED] 05:50AM BLOOD Glucose-129* UreaN-23* Creat-1.5* Na-138 K-4.3 Cl-101 HCO3-25 AnGap-12 [MASKED] 05:50AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.2 [MASKED] ECGs ECG: stable anterior J point elevation, new inferior T wave inversions, with subsequent widening of the QRS duration into a not-quite-LBBB IVCD. [MASKED] CXR Heart size and mediastinum are stable in appearance. Vascular enlargement in the hila is unchanged, with no evidence of acute exacerbation of congestive heart failure on the radiograph. Postsurgical changes in the right lung are stable. There is no pleural effusion. There is no pneumothorax. [MASKED] CTA Chest HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. There is enlargement of the main, right main, and left main pulmonary arteries, measuring up to 3.8, 3.1, and 2.8 cm, respectively. These findings are likely suggestive of pulmonary arterial hypertension. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: Mediastinal esophagus appears thickened throughout its course (series 2; image 21), similar compared to prior and suggestive of underlying chronic esophageal inflammation. Again seen in the mediastinum, along the superior aspect of the left ventricle, adjacent to the main pulmonary artery, there is a lobulated, homogeneous 3.4 x 2.2 cm soft tissue density, which previously measured 3.5 x 2.0 cm. This mass is been slowly growing since [MASKED] and likely represent an encapsulated thymoma. It appears to now abut the myocardium over a couple of cm. There is no axillary lymphadenopathy. There are prominent subcarinal and right hilar lymph nodes, which are nonspecific. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Changes seen after right upper lobectomy. There is bibasilar atelectasis, right greater than left, without focal consolidation concerning for infection. Incidentally noted is an azygos lobe. 4 mm nodule in the right upper lobe (series 3; image 84) is unchanged compared to [MASKED] and now stable for 32 months. No additional concerning nodules are identified. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. No acute etiology identified for pleuritic chest pain. No focal consolidation concerning for underlying infection. 2. Enlargement of the pulmonary arterial system, consistent with pulmonary arterial hypertension. 3. Unchanged soft tissue mass in the prevascular mediastinum, which has been slowly growing since [MASKED] and appears stable since [MASKED]. This is probably an encapsulated thymoma. 4. Thickening the mediastinal esophagus is unchanged compared [MASKED] and may be sequela of chronic esophageal inflammation. EGD could be pursued on a nonurgent basis if clinically indicated. [MASKED] Echocardiogram The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is mild-moderate global left ventricular hypokinesis. The visually estimated left ventricular ejection fraction is 35%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE (images not available for review) of [MASKED], the estimated PA systolic pressure is now increased. Brief Hospital Course: [MASKED] with H/O cardiomyopathy (LVEF 30%), lung cancer s/p right upper lobectomy, hypertension, and hyperlipidemia presented with chest pain. He had negative troponin-T x3. He was also found to have esophagitis, with chest pain improved with initiation of PPI and Aluminum-Magnesium Hydrox-Simethicone. ACUTE ISSUES: # Chest pain, esophagitis: Patient was admitted with acute onset chest pain described as burning around esophagus, radiating across shoulders and to lesser degree across chest, not classic for ACS. ECG initially with some inferoapical T wave inversion (non-specific) though no other changes suggestive of acute ischemia, but troponin-T and CK-MB negative x3. Initial treatment with nitroglycerin gtt without obvious improvement in pain. CTA also negative after patient noted to recently have been on relatively long plane flight and with elevated D-Dimer. Patient reported no symptoms during recent trip to [MASKED] [MASKED] but a lot of stress during the flight home. Most likely etiologies of chest pain felt to be esophagitis (given thickened mediastinal esophagus on CTA) vs pericarditis with elevated CRP. Significant relief of chest pain with empiric treatment of esophagitis with GI cocktail and pantoprazole, therefore treatment of pericarditis not initiated. At time of discharge, chest pain was almost completely gone, and patient only reported faint sensation of burning around esophagus. # Non-conducted P waves, bradycardia. [MASKED] telemetry pause with non-conducted P waves (2.5 sec longer QRS-free interval than expected if single non-conducted PAC with apparent AV block after a likely P wave vs artifact--failure of ventricular escape and/or AV block). Patient does not recall what he was doing at the time. Pause and tracing reviewed with several electrophysiologists. As sinus node dysfunction isolated and asymptomatic, no further intervention was felt warranted at present. Patient mentioned that Dr. [MASKED] mentioned possibility of ICD (presumably primary prevention). Patient discharged with outpatient EP F/U with Dr. [MASKED]. We decreased home metoprolol succinate dose given occasional bradycardia (HR [MASKED]. # Dilated cardiomyopathy: LVEF 30% in [MASKED] -> 44% on CMR in [MASKED], presumed to be secondary to VEA burden. Per recent cardiology note, "Initially started on metoprolol and lisinopril with reduction in PVC burden to 15% and subsequently was initiated on amiodarone therapy in [MASKED] with most recent Holter on [MASKED] showing reduction VPC burden to 8% with multiple morphologies." Continued home amiodarone. Decreased dose of metoprolol, as above. CHRONIC ISSUES: # CKD stage 3 with [MASKED]: Cr on admission 1.8 (baseline 1.3-1.8) downtrended to 1.5 this admission. # Hypertension: Continued home hydralazine (once daily dosing confirmed by patient), HCTZ, metoprolol. # Hyperlipidemia: Continued home statin. # Lung CA s/p right upper lobectomy (no chemo/XRT): Surveillance imaging as outpatient. # Primary prevention against CAD: Continued home aspirin, statin, metoprolol. TRANSITIONAL ISSUES: ==================== [ ] Follow up resolution of chest pain with GI cocktail and pantoprazole. [ ] Further workup of esophagitis, would recommend endoscopy with Dr. [MASKED]. [ ] Follow up of non-conducted P waves in clinic with Dr. [MASKED] ICD for primary prevention. [ ] He was noted to have left leg calf pain which is suspicious for claudication and PAD, would recommend an outpatient ABI and vascular medicine follow up to assess this. [ ] Consider ETT-MIBI or R-MIBI (develops claudication after walking 0.5 miles slowly, but useful to assess functional capacity) if symptoms not improve with aggressive GI regimen. [ ] Follow up of likely thymoma noted on CTA. - New Meds: GI cocktail QID, pantoprazole 40 mg daily - Stopped/Held Meds: None - Changed Meds: Metoprolol succinate XL 50 mg -> 25 mg daily - Follow-up appointments: PCP appointment with Dr. [MASKED] appointment with Dr. [MASKED] follow up with Dr. [MASKED]. - Post-Discharge Follow-up Labs Needed: None - Incidental Findings: Thymoma, left leg claudication - Discharge weight: 94.8kg - Discharge creatinine: 1.5 # CODE: full (presumed) # CONTACT: [MASKED] (wife) - [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Gabapentin 100 mg PO BID 3. HydrALAZINE 25 mg PO DAILY 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Simvastatin 10 mg PO QPM 7. Aspirin 81 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY 10. Multivitamin 50 Plus (multivitamin-minerals-lutein) oral DAILY 11. selenium 200 mcg oral DAILY 12. Florastor (Saccharomyces boulardii) 250 mg oral DAILY Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone [MASKED] mL PO QID RX alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL [MASKED] mL by mouth four times a day Disp #1680 Milliliter Refills:0 2. Pantoprazole 40 mg PO Q24H RX pantoprazole 20 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:0 3. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth once a day Disp #60 Tablet Refills:*0 4. Amiodarone 200 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Florastor (Saccharomyces boulardii) 250 mg oral DAILY 8. Gabapentin 100 mg PO BID 9. HydrALAZINE 25 mg PO DAILY 10. Hydrochlorothiazide 12.5 mg PO DAILY 11. Multivitamin 50 Plus (multivitamin-minerals-lutein) oral DAILY 12. selenium 200 mcg oral DAILY 13. Simvastatin 10 mg PO QPM 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Chest pain # Esophagitis # Dilated cardiomyopathy/chronic left ventricular systolic heart failure # Non-conducted P waves consistent with asymptomatic sinus node dysfunction # Bradycardia # Acute kidney injury on # Chronic kidney disease, stage 3 # Normocytic anemia # Left calf claudication consistent with peripheral arterial disease # Hypertension # Hyperlipidemia # Mediastinal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because of chest pain. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were admitted to the hospital because you had chest pain. - Lab tests of your blood found that your cardiac enzymes were normal (not elevated), and you had electrocardiograms (EKGs) that did not show a heart attack. - You had an imaging test called a CT angiogram of your chest. There was no sign of a blood clot in your lung (pulmonary embolus) and no signs of aortic dissection. However, the CT angiogram showed a mass in the mediastinum that is likely a thymoma that should be followed up as an outpatient. - The CTA showed thickening of your esophagus that could be a sign of esophagitis (inflammation of the esophagus), which was likely causing your chest pain. - You were treated with a GI cocktail medication and a proton pump inhibitor that helps to reduce acid in the stomach, and your pain improved. - You were noted to have slow heart rates and a pause on cardiac telemetry monitoring. You should see your cardiologist Dr. [MASKED] in clinic for follow up. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Continue to take the GI cocktail and proton pump inhibitor. - Follow up with your gastroenterology doctor. We recommend getting an endoscopy to look at your esophagus. - You should get a test called an ankle-brachial index (ABI) as an outpatient to work up your left calf tightness. Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]	[]	[ "E785", "I10", "I129", "D649" ]	[ "K209: Esophagitis, unspecified", "J9859: Other diseases of mediastinum, not elsewhere classified", "I420: Dilated cardiomyopathy", "I319: Disease of pericardium, unspecified", "R7982: Elevated C-reactive protein (CRP)", "E785: Hyperlipidemia, unspecified", "N4231: Prostatic intraepithelial neoplasia", "I10: Essential (primary) hypertension", "I2720: Pulmonary hypertension, unspecified", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "K635: Polyp of colon", "G629: Polyneuropathy, unspecified", "N200: Calculus of kidney", "R001: Bradycardia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "D649: Anemia, unspecified", "I70212: Atherosclerosis of native arteries of extremities with intermittent claudication, left leg" ]
10,040,604	26,191,301	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / amoxicillin-pot clavulanate Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ female with history of GERD, hypertension, hyperlipidemia, who presented to the ED for evaluation of intermittent chest pressure with left arm tingling radiating to her left face over the past few weeks worsening over the past few days. Episodes last a few minutes at a time and were occurring more frequently up to 6 episodes per day. Worse with any exertion. Past Medical History: Shingles ___ IBS HTN Anxiety Hypercholesterolemia back injury varicose veins Recent work up for vaginal bleeding found to have a vaginal wall tear after TVUS. Social History: ___ Family History: Her mother had a myocardial infarction at age ___ (deceased from this) and father myocardial infarction at age ___ (survived to ___. Brother had coronary artery bypass graft at age ___. All members were smokers. Physical Exam: On admission - Physical Examination: General/Neuro: NAD [x] A/O [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [-] Murmur: [] systolic []diastolic __/6 RUSB [-] JVD ___cm Lungs: CTA [x] No resp distress [x] Abd: NBS []Soft [] ND [] NT [] Extremities: edema [-] ___: doppler [] palpable [x] At discharge - Physical Exam: General/Neuro: NAD [x] A/O [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [-] Murmur: [] systolic []diastolic __/6 RUSB [-] JVD ___cm Lungs: CTA [x] No resp distress [x] Abd: NBS [x]Soft [x] ND [x] NT [x] Extremities: edema [-] ___: doppler [] palpable [x] Pertinent Results: CARDIAC PERFUSION Study Date of ___ TECHNIQUE: ISOTOPE DATA: (___) 10.4 mCi Tc-99m Sestamibi Rest; (___) 32.8 mCi Tc-99m Sestamibi Stress; SUMMARY OF DATA FROM THE EXERCISE LAB: Exercise protocol: Modified ___ ___ duration: 7 minutes Reason exercise terminated: Fatigue Resting heart rate: 63 Resting blood pressure: 164/98 Peak heart rate: 142 Peak blood pressure: 212/80 Percent maximum predicted HR: 95% Symptoms during exercise: None ECG findings: 0.5-1 mm upsloping/scooping ST segment depression noted inferolaterally. Most ST segment changes resolved quickly post exercise, however, the 0.5 mm scoping ST segment depression remained throughout recovery. ST segments returned to baseline by 10 minutes post exercise. Resting perfusion images were obtained with Tc-99m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. At peak exercise, approximately three times the resting dose of Tc-99m sestamibi was administered IV. Stress images were obtained approximately 45 minutes following tracer injection. Imaging Protocol: Gated SPECT This study was interpreted using the 17-segment myocardial perfusion model. FINDINGS: Left ventricular cavity size is normal. Resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 70 % with an end-diastolic volume of 70 cc. IMPRESSION: 1. No evidence of reversible myocardial ischemia. 2. Normal left ventricular cavity size and systolic function. Stress Study Date of ___ INTERPRETATION: ___ yo woman with HL, HTN and BMI of 32.6 was referred to evaluate an atypical chest discomfort. The patient completed 7 minutes of a modified ___ protocol representing an average exercise tolerance for her age; ~ ___ METS. The exercise test was stopped due to fatigue. No chest, back, neck or arm discomforts were reported. At peak exercise, 0.5-1 mm upsloping/scooping ST segment depression was noted inferolaterally. Although these ST segment changes appeared to resolve quickly post-exercise, 0.5 mm scooping ST segment depression remained throughout recovery. The ST segments were back to baseline by 10 minutes post-exercise. The rhythm was sinus with rare isolated APBs. Resting systolic and diastolic hypertension with an appropriate hemodynamic response noted with exercise. IMPRESSION: Average exercise tolerance. Nonspecific ST segment changes in the absence of anginal symptoms. Nuclear report sent separately. Portable TTE (Complete) Done ___ at 9:47:35 AM Conclusions The left atrium is mildly dilated. 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 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 ascending aorta is mildly dilated. 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. 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. Preserved global biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Normal pulmonary pressure. CHEST (PA & LAT) Study Date of ___ 5:31 ___ IMPRESSION: No acute cardiopulmonary process. ___ 08:50AM BLOOD WBC-8.3 RBC-5.32* Hgb-14.8 Hct-44.8 MCV-84 MCH-27.8 MCHC-33.0 RDW-13.2 RDWSD-40.6 Plt ___ ___ 08:50AM BLOOD Plt ___ ___ 08:50AM BLOOD Glucose-94 UreaN-15 Creat-0.7 Na-143 K-4.2 Cl-103 HCO3-26 AnGap-14 ___ 05:00PM BLOOD WBC-10.9* RBC-5.28* Hgb-14.7 Hct-44.5 MCV-84 MCH-27.8 MCHC-33.0 RDW-13.2 RDWSD-40.7 Plt ___ ___ 05:00PM BLOOD Neuts-72.6* ___ Monos-6.0 Eos-1.5 Baso-0.5 Im ___ AbsNeut-7.90* AbsLymp-2.07 AbsMono-0.65 AbsEos-0.16 AbsBaso-0.05 ___ 05:00PM BLOOD Plt ___ ___ 05:00PM BLOOD ___ PTT-27.1 ___ ___ 05:00PM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-136 K-5.7* Cl-98 HCO3-22 AnGap-16 ___ 05:00PM BLOOD ALT-13 AST-33 AlkPhos-72 TotBili-0.5 ___ 05:00PM BLOOD Lipase-20 ___ 09:25PM BLOOD cTropnT-<0.01 ___ 05:00PM BLOOD cTropnT-<0.01 ___ 05:00PM BLOOD proBNP-221 ___ 05:00PM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.8 Mg-2.3 ___ 07:03PM BLOOD K-5.___ssessment/Plan: ___ yo woman presented in ED with midsternal chest pain pressure with intermittent complaint over past month of SOB, jaw tingling and head pressure. Negative troponin x2, ECG sinus rhythm no ST changes, admitted for stress test. # Chest pain: Has not recurred. Cardiac enzymes neg x 2. Reassuring ECHO, EKG, stress testing. # GERD: -continue home dose of ranitidine 150mg BID # Hypertension: -continue amlodipine 2.5 mg daily # Hyperlipidemia: -continue pravastatin 10 mg daily #Chronic back pain: well managed with home PRNs -continue nambumetone, hydrocodone-acetaminophen PRN back pain #Anxiety: -continue home regimen of alprazolam 1 mg PRN # Code status: Full # DISPO: Home # Transitional issues: Patient confirms she will arrange PCP appointment in ___ weeks, and prefers to make own new patient cardiologist appointment. Recommending cardiologist follow-up in ___ weeks, patient confirms understanding. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 1 mg PO TID:PRN anxiety 2. amLODIPine 2.5 mg PO DAILY 3. Ranitidine 150 mg PO BID 4. Pravastatin 10 mg PO QAM 5. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate 6. Nabumetone 1000 mg PO Q12H:PRN back pain 7. Amitriptyline 25 mg PO DAILY:PRN leg clamps Discharge Medications: 1. ALPRAZolam 1 mg PO TID:PRN anxiety 2. Amitriptyline 25 mg PO DAILY:PRN leg clamps 3. amLODIPine 2.5 mg PO DAILY 4. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate 5. Nabumetone 1000 mg PO Q12H:PRN back pain 6. Pravastatin 10 mg PO QAM 7. Ranitidine 150 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Chest Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ for work-up of chest pain. Blood tests and EKGs indicated that you did not have a heart attack. A stress test did not show abnormal heart function. These test results are reassuring that there is not a dangerous cardiac cause for your chest pain. We did not make any changes to your usual medication regimen. Please continue all of your pre-hospitalization medications exactly as prescribed. Please follow-up with your primary care physician within the next ___ weeks. Please follow-up with a cardiologist within the next ___ weeks. 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. Followup Instructions: ___	[ "R079", "E785", "I10", "K219", "F419", "M549" ]	Allergies: Percocet / amoxicillin-pot clavulanate Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female with history of GERD, hypertension, hyperlipidemia, who presented to the ED for evaluation of intermittent chest pressure with left arm tingling radiating to her left face over the past few weeks worsening over the past few days. Episodes last a few minutes at a time and were occurring more frequently up to 6 episodes per day. Worse with any exertion. Past Medical History: Shingles [MASKED] IBS HTN Anxiety Hypercholesterolemia back injury varicose veins Recent work up for vaginal bleeding found to have a vaginal wall tear after TVUS. Social History: [MASKED] Family History: Her mother had a myocardial infarction at age [MASKED] (deceased from this) and father myocardial infarction at age [MASKED] (survived to [MASKED]. Brother had coronary artery bypass graft at age [MASKED]. All members were smokers. Physical Exam: On admission - Physical Examination: General/Neuro: NAD [x] A/O [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [-] Murmur: [] systolic []diastolic /6 RUSB [-] JVD cm Lungs: CTA [x] No resp distress [x] Abd: NBS []Soft [] ND [] NT [] Extremities: edema [-] [MASKED]: doppler [] palpable [x] At discharge - Physical Exam: General/Neuro: NAD [x] A/O [x] non-focal [x] Cardiac: RRR [x] Irregular [] Nl S1 S2 [-] Murmur: [] systolic []diastolic /6 RUSB [-] JVD cm Lungs: CTA [x] No resp distress [x] Abd: NBS [x]Soft [x] ND [x] NT [x] Extremities: edema [-] [MASKED]: doppler [] palpable [x] Pertinent Results: CARDIAC PERFUSION Study Date of [MASKED] TECHNIQUE: ISOTOPE DATA: ([MASKED]) 10.4 mCi Tc-99m Sestamibi Rest; ([MASKED]) 32.8 mCi Tc-99m Sestamibi Stress; SUMMARY OF DATA FROM THE EXERCISE LAB: Exercise protocol: Modified [MASKED] [MASKED] duration: 7 minutes Reason exercise terminated: Fatigue Resting heart rate: 63 Resting blood pressure: 164/98 Peak heart rate: 142 Peak blood pressure: 212/80 Percent maximum predicted HR: 95% Symptoms during exercise: None ECG findings: 0.5-1 mm upsloping/scooping ST segment depression noted inferolaterally. Most ST segment changes resolved quickly post exercise, however, the 0.5 mm scoping ST segment depression remained throughout recovery. ST segments returned to baseline by 10 minutes post exercise. Resting perfusion images were obtained with Tc-99m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. At peak exercise, approximately three times the resting dose of Tc-99m sestamibi was administered IV. Stress images were obtained approximately 45 minutes following tracer injection. Imaging Protocol: Gated SPECT This study was interpreted using the 17-segment myocardial perfusion model. FINDINGS: Left ventricular cavity size is normal. Resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 70 % with an end-diastolic volume of 70 cc. IMPRESSION: 1. No evidence of reversible myocardial ischemia. 2. Normal left ventricular cavity size and systolic function. Stress Study Date of [MASKED] INTERPRETATION: [MASKED] yo woman with HL, HTN and BMI of 32.6 was referred to evaluate an atypical chest discomfort. The patient completed 7 minutes of a modified [MASKED] protocol representing an average exercise tolerance for her age; ~ [MASKED] METS. The exercise test was stopped due to fatigue. No chest, back, neck or arm discomforts were reported. At peak exercise, 0.5-1 mm upsloping/scooping ST segment depression was noted inferolaterally. Although these ST segment changes appeared to resolve quickly post-exercise, 0.5 mm scooping ST segment depression remained throughout recovery. The ST segments were back to baseline by 10 minutes post-exercise. The rhythm was sinus with rare isolated APBs. Resting systolic and diastolic hypertension with an appropriate hemodynamic response noted with exercise. IMPRESSION: Average exercise tolerance. Nonspecific ST segment changes in the absence of anginal symptoms. Nuclear report sent separately. Portable TTE (Complete) Done [MASKED] at 9:47:35 AM Conclusions 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. 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 ascending aorta is mildly dilated. 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. 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. Preserved global biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Normal pulmonary pressure. CHEST (PA & LAT) Study Date of [MASKED] 5:31 [MASKED] IMPRESSION: No acute cardiopulmonary process. [MASKED] 08:50AM BLOOD WBC-8.3 RBC-5.32* Hgb-14.8 Hct-44.8 MCV-84 MCH-27.8 MCHC-33.0 RDW-13.2 RDWSD-40.6 Plt [MASKED] [MASKED] 08:50AM BLOOD Plt [MASKED] [MASKED] 08:50AM BLOOD Glucose-94 UreaN-15 Creat-0.7 Na-143 K-4.2 Cl-103 HCO3-26 AnGap-14 [MASKED] 05:00PM BLOOD WBC-10.9* RBC-5.28* Hgb-14.7 Hct-44.5 MCV-84 MCH-27.8 MCHC-33.0 RDW-13.2 RDWSD-40.7 Plt [MASKED] [MASKED] 05:00PM BLOOD Neuts-72.6* [MASKED] Monos-6.0 Eos-1.5 Baso-0.5 Im [MASKED] AbsNeut-7.90* AbsLymp-2.07 AbsMono-0.65 AbsEos-0.16 AbsBaso-0.05 [MASKED] 05:00PM BLOOD Plt [MASKED] [MASKED] 05:00PM BLOOD [MASKED] PTT-27.1 [MASKED] [MASKED] 05:00PM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-136 K-5.7* Cl-98 HCO3-22 AnGap-16 [MASKED] 05:00PM BLOOD ALT-13 AST-33 AlkPhos-72 TotBili-0.5 [MASKED] 05:00PM BLOOD Lipase-20 [MASKED] 09:25PM BLOOD cTropnT-<0.01 [MASKED] 05:00PM BLOOD cTropnT-<0.01 [MASKED] 05:00PM BLOOD proBNP-221 [MASKED] 05:00PM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.8 Mg-2.3 [MASKED] 07:03PM BLOOD K-5. ssessment/Plan: [MASKED] yo woman presented in ED with midsternal chest pain pressure with intermittent complaint over past month of SOB, jaw tingling and head pressure. Negative troponin x2, ECG sinus rhythm no ST changes, admitted for stress test. # Chest pain: Has not recurred. Cardiac enzymes neg x 2. Reassuring ECHO, EKG, stress testing. # GERD: -continue home dose of ranitidine 150mg BID # Hypertension: -continue amlodipine 2.5 mg daily # Hyperlipidemia: -continue pravastatin 10 mg daily #Chronic back pain: well managed with home PRNs -continue nambumetone, hydrocodone-acetaminophen PRN back pain #Anxiety: -continue home regimen of alprazolam 1 mg PRN # Code status: Full # DISPO: Home # Transitional issues: Patient confirms she will arrange PCP appointment in [MASKED] weeks, and prefers to make own new patient cardiologist appointment. Recommending cardiologist follow-up in [MASKED] weeks, patient confirms understanding. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 1 mg PO TID:PRN anxiety 2. amLODIPine 2.5 mg PO DAILY 3. Ranitidine 150 mg PO BID 4. Pravastatin 10 mg PO QAM 5. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate 6. Nabumetone 1000 mg PO Q12H:PRN back pain 7. Amitriptyline 25 mg PO DAILY:PRN leg clamps Discharge Medications: 1. ALPRAZolam 1 mg PO TID:PRN anxiety 2. Amitriptyline 25 mg PO DAILY:PRN leg clamps 3. amLODIPine 2.5 mg PO DAILY 4. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate 5. Nabumetone 1000 mg PO Q12H:PRN back pain 6. Pravastatin 10 mg PO QAM 7. Ranitidine 150 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Chest Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [MASKED] for work-up of chest pain. Blood tests and EKGs indicated that you did not have a heart attack. A stress test did not show abnormal heart function. These test results are reassuring that there is not a dangerous cardiac cause for your chest pain. We did not make any changes to your usual medication regimen. Please continue all of your pre-hospitalization medications exactly as prescribed. Please follow-up with your primary care physician within the next [MASKED] weeks. Please follow-up with a cardiologist within the next [MASKED] weeks. 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. Followup Instructions: [MASKED]	[]	[ "E785", "I10", "K219", "F419" ]	[ "R079: Chest pain, unspecified", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "F419: Anxiety disorder, unspecified", "M549: Dorsalgia, unspecified" ]
10,040,663	22,738,336	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've been depressed." Major Surgical or Invasive Procedure: None History of Present Illness: History was noted from Dr. ___ consult note from ___, and subsequent psychiatry CL notes in OMR, confirmed with patient and updated as relevant: Briefly, Patient is a ___ year old man with history of EtOH Use Disorder, Depression and past Paranoid Ideation, medical history of HTN, HLD who presents to the ___ ___ with progressively worsening depression c/b hopelessness with suicidal ideation in the context of self-discontinuing his psychiatric medications approximately 2 weeks ago as well as multiple psychosocial stressors. Per Dr. ___ ___ consultation note: "On interview, patient states that he has been experiencing severe depression over the past two weeks with frequent thoughts of SI. He reports prominent hopelessness, low energy, sleep interruptions, poor motivation and decreased interest. He denies plan or intent in regards to suicidality, but reflects that he "wants to get help before I get that bad again." Patient reports that his depression became notably worse in the context of his brother becoming acutely ill approximately 6 months ago. During this time, he was regularly caring for his brother, who was on the waiting list for an organ transplant; however, he passed away 2 months ago before he was able to receive one. Since his brother's passing, he reports that his nieces and nephews have been taking advantage of him. Patient reports that approximately one month ago, he "checked myself into ___" for similar symptoms of depression, along with suicidal ideation and plan to kill himself by "strapping weights to my body and drowning myself." He found the hospitalization helpful, but did not follow-up with aftercare and stopped taking his psychiatric medications once he ran out. In order to "snap myself out of the depression," he recently grinded his thumb into a block of wood. He reflects that he had hoped the physical pain would improve his emotional pain, but now is experiencing both types of pain. He also reports a history of paranoid ideation, reflecting that it tends to get worse when his depression is bad. He reports that recently he has been feeling that "people are going to harm me." On admission interview, patient confirms much of the above. He reports being depressed for the past ___ months, with the depression worsening in the past couple of months after the death of his brother. He discusses how he left his own apartment to move in with his brother and care for him. His brother's two sons did not want him living there, and ultimately forced the patient to leave. Shortly after the patient moved out, his brother passed away. The patient believes it is because he was not being cared for properly. He states that his nephews may have issues with drugs. He states that he was hospitalized at ___ about 1 month ago. After he left, he went to ___. While he was there, he was told that he would be unable to leave to go to his psychiatry appointment. He left there after staying for about 5 days. He has since been living with either his sister or friends, however he suspects that his friend is involved with drugs. He reports "erratic" sleep, decreased appetite with a ___ lb weight loss in the past few weeks, decreased energy, and decreased concentration. He reports that about a month ago he thought about jumping off of a bridge with a weight attached to him, however he has since learned that suicide is a moral sin, and he no longer would want to commit suicide for that reason. Denies current SI. States that he feels safe on the unit. He reports recent self harm behaviors, as above, of rubbing his thumb into wood in order to inflict pain on himself to "snap out" of his depression. Psychiatric ROS: Depression - as per HPI Psychosis - reports that he has had paranoia for most of his adult life, stating that he used to feel like people wanted to kill him. Continues to report some paranoia, but states that it is much improved. Mania- denies symptoms including decreased need for sleep, increase in goal directed behavior, and increased energy Anxiety - denies Past psychiatric history: Per Dr. ___ (___), confirmed with patient and updated as relevant: - Hospitalizations: Recently at ___ for SI + plan ~1 month ago; reports additional hospitalization ~5 months ago. - Current treaters and treatment: Psychiatrist is Dr. ___ that he sees him approximately once/month. - Medication and ECT trials: Reports Seroquel has been helpful in the past for paranoid thoughts. Most recently reports taking Wellbutrin and Adderall, which were both helpful (but he ran out). - Self-injury: No suicide attempts; recently injured right thumb as per HPI. - Harm to others: None reported - Access to weapons: Denies Past Medical History: Per Dr. ___ (___), confirmed with patient and updated as relevant: - HTN - HLD - Back Pain Social History: ___ Family History: Per Dr. ___ (___), confirmed with patient and updated as relevant: - Reports history of BPAD in his mother; EtOH Abuse in siblings, both sides of his family Physical Exam: VS: T: 98.4, BP: 119/74, HR: 65, R: 16, O2 sat: 98% on RA General: Middle-aged male in NAD. Well-nourished, well-developed. Appears stated age. HEENT: Normocephalic, atraumatic. EOMI. Back: No significant deformity. Lungs: CTA ___. No crackles, wheezes, or rhonchi. CV: RRR, no murmurs/rubs/gallops. Abdomen: +BS, soft, nontender, nondistended. No palpable masses or organomegaly. Extremities: No clubbing, cyanosis, or edema. Skin: erythema and bruising at right thumb Neurological: Cranial Nerves: -EOM: full -Facial symmetry on eye closure and smile: symmetric -Hearing grossly normal -Phonation: normal -Shoulder shrug: intact -Tongue: midline Motor: Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength: full power ___ throughout. Gait: Steady. Normal stance and posture. No truncal ataxia. Cognition: Wakefulness/alertness: awake and alert Attention: intact to interview, states MYOB with 1 error Orientation: oriented to person, time, place, situation Executive function (go-no go, Luria, trails, FAS): not tested Memory: intact to recent and past history Fund of knowledge: consistent with education Calculations: correctly states 7 quarters in $1.75 Abstraction: not assessed Visuospatial: not assessed Speech: normal rate, volume, and tone Language: native ___ speaker, no paraphasic errors, appropriate to conversation Mental Status: Appearance: No apparent distress, appears stated age, mildly disheveled, dressed in hospital gown Behavior: Calm, cooperative, engaged, appropriate eye contact, no psychomotor agitation or retardation Mood and Affect: "depressed" / restricted Thought Process: linear, coherent, goal-oriented. No LOA. Thought Content: denies SI/HI/AH/VH, no evidence of delusions, reports mild chronic paranoia Judgment and Insight: fair/fair Pertinent Results: ___ 05:35PM BLOOD Glucose-110* UreaN-24* Creat-0.8 Na-140 K-4.4 Cl-104 HCO3-25 AnGap-11 ___ 07:18AM BLOOD %HbA1c-5.1 eAG-100 ___ 07:18AM BLOOD Triglyc-147 HDL-30* CHOL/HD-5.8 LDLcalc-116 ___ 07:18AM BLOOD TSH-2.0 ___ 05:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 05:27PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. He was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. 2. PSYCHIATRIC: Patient was admitted to inpatient psychiatry due to depression with passive suicidal ideation in the context of self-discontinuing his psychiatric medications approximately 2 weeks prior and psychosocial stressors. On admission interview, patient reported worsening depression in the context of the death of his brother 2 months prior, with associated poor sleep, decreased appetite with a ___ lb weight loss in the past few weeks, decreased energy, and decreased concentration. Denied SI on admission, stating that he realized that suicide is a moral sin, and he no longer would not commit suicide for that reason. He was continued on his home gabapentin. Discussed decreasing ___ with the patient. He was taking 30 mg BID. Continued Adderall at 10 mg BID in order to not precipitate withdrawal. During hospitalization, patient has also noted to be irritable, tangential, and hyper-verbal, concerning for an underlying bipolar disorder and current mixed state. He was started on Risperdal, which was titrated to 2 mg QHS. He was given hydroxyzine PRN and ramelteon PRN for sleep. The patient often reported to the team improved mood and sleep, however would also report irritability and "agitation." He was noted to be attending groups and social in the milieu. Obtained psychological testing, where patient endorsed depression and distress. There were also questions raising possibility of Cluster B personality traits. Although patient initially denied SI, he intermittently reported vague SI in the context of discharge planning. However, ultimately at discharge, patient was secured a bed at a CSS. He reported an improved mood and reported that he felt safe to discharge. He reported that he would be able to reach out for help if he felt poorly and would seek hospitalization if he felt unsafe. 3. SUBSTANCE USE DISORDERS: # Alcohol use disorder Patient reported a history of heavy alcohol use in the past. Reported being sober for the last month. Patient reported motivation to continue to abstain from alcohol use throughout hospitalization. # Opioid use disorder Patient was continued on suboxone ___ daily, as patient reported that he had been taking less than suboxone ___ BID that was prescribed in ___. He reported that he was trying to get off suboxone. Patient was encouraged to follow up with his outpatient provider for further adjustments in suboxone. 4. MEDICAL #)Right thumb cellulitis Patient reported that prior to admission, in order to "snap myself out of the depression," he grinded his thumb into a block of wood. He completed a course of cephalexin 500 mg PO Q6H for cellulitis. The cellulitis improved and patient reported no pain or discomfort at discharge. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient often attended these groups that focused on teaching patients various coping skills. He was noted to be pleasant and an active participant. When not in groups, he was social with peers in the milieu. There were no behavioral concerns requiring restraint or seclusion. # Homelessness Patient reported that he did not have stable housing after leaving his brothers house once his brother passed away. Patient often discussed housing issues with the team, although stated that housing was "not an issue" as he could always stay with friends. Social work assisted the patient with housing options, and he reported to the team that he completed an application for the ___ in ___. The patient was discharged to a CSS placement. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: The team called and left a message for patient's outpatient psychiatrist, Dr. ___ did not hear back. The patient declined to have the social worker contact his sister. #) Guardianship: N/A INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting risperidone, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to himself due to depression and SI. The patient is chronically at risk for self harm due to factors such as chronic mental illness, history of substance abuse, history of abuse, recent discharge from an inpatient psychiatric unit, male gender, Caucasian race, age and martial status. During hospitalization, patient reported motivation continue to abstain from alcohol. He reported improved mood. He is being discharged with protective factors that make him appropriate for outpatient care at this time, including help seeking nature, good relationship with his outpatient psychiatrist, good knowledge of resources available to him, no SI, strong religious beliefs, and future orientation with plans to follow up on housing applications and with his outpatient psychiatrist. Our Prognosis of this patient is guarded. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Gabapentin 800 mg PO TID 4. Simvastatin 20 mg PO QPM 5. Ranitidine 150 mg PO BID 6. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 7. Amphetamine-Dextroamphetamine 30 mg PO BID Discharge Medications: 1. HydrOXYzine 25 mg PO QHS:PRN anxiety/insomnia RX hydroxyzine HCl 25 mg 1 tablet by mouth at bedtime Disp #7 Tablet Refills:0 2. melatonin 5 mg oral QHS PRN RX melatonin 5 mg 1 tablet(s) by mouth at bedtime Disp #7 Tablet Refills:0 3. RisperiDONE 2 mg PO QHS mood disorder RX risperidone 2 mg 1 tablet(s) by mouth at bedtime Disp #7 Tablet Refills:0 4. Amphetamine-Dextroamphetamine 10 mg PO BID RX dextroamphetamine-amphetamine [Adderall] 10 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 5. Atenolol 100 mg PO DAILY RX atenolol 100 mg 1 tablet(s) by mouth Daily Disp #7 Tablet Refills:1 6. Gabapentin 800 mg PO BID RX gabapentin 800 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 7. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth Daily Disp #14 Tablet Refills:0 8. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 9. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #28 Tablet Refills:0 10. Simvastatin 20 mg PO QPM RX simvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #14 Tablet Refills:0 Discharge Disposition: Extended Care Discharge Diagnosis: Major depressive disorder r/o BAD I mixed Discharge Condition: Vitals: T 98.0 BP 138/89 HR 97 RR 18 O2 98% Appearance: middle aged male, no apparent distress, wearing casual street clothes, good hygiene Behavior: calm, cooperative Mood and Affect: 'good' / euthymic Thought process: linear, goal directed Thought Content: Denies SI/HI, does not report AVH Judgment and Insight: fair/fair Discharge Instructions: You were hospitalized at ___ for depression. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: ___	[ "F3160", "R45851", "F1120", "L03011", "I10", "E785", "G4700", "F419", "Z590" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I've been depressed." Major Surgical or Invasive Procedure: None History of Present Illness: History was noted from Dr. [MASKED] consult note from [MASKED], and subsequent psychiatry CL notes in OMR, confirmed with patient and updated as relevant: Briefly, Patient is a [MASKED] year old man with history of EtOH Use Disorder, Depression and past Paranoid Ideation, medical history of HTN, HLD who presents to the [MASKED] [MASKED] with progressively worsening depression c/b hopelessness with suicidal ideation in the context of self-discontinuing his psychiatric medications approximately 2 weeks ago as well as multiple psychosocial stressors. Per Dr. [MASKED] [MASKED] consultation note: "On interview, patient states that he has been experiencing severe depression over the past two weeks with frequent thoughts of SI. He reports prominent hopelessness, low energy, sleep interruptions, poor motivation and decreased interest. He denies plan or intent in regards to suicidality, but reflects that he "wants to get help before I get that bad again." Patient reports that his depression became notably worse in the context of his brother becoming acutely ill approximately 6 months ago. During this time, he was regularly caring for his brother, who was on the waiting list for an organ transplant; however, he passed away 2 months ago before he was able to receive one. Since his brother's passing, he reports that his nieces and nephews have been taking advantage of him. Patient reports that approximately one month ago, he "checked myself into [MASKED]" for similar symptoms of depression, along with suicidal ideation and plan to kill himself by "strapping weights to my body and drowning myself." He found the hospitalization helpful, but did not follow-up with aftercare and stopped taking his psychiatric medications once he ran out. In order to "snap myself out of the depression," he recently grinded his thumb into a block of wood. He reflects that he had hoped the physical pain would improve his emotional pain, but now is experiencing both types of pain. He also reports a history of paranoid ideation, reflecting that it tends to get worse when his depression is bad. He reports that recently he has been feeling that "people are going to harm me." On admission interview, patient confirms much of the above. He reports being depressed for the past [MASKED] months, with the depression worsening in the past couple of months after the death of his brother. He discusses how he left his own apartment to move in with his brother and care for him. His brother's two sons did not want him living there, and ultimately forced the patient to leave. Shortly after the patient moved out, his brother passed away. The patient believes it is because he was not being cared for properly. He states that his nephews may have issues with drugs. He states that he was hospitalized at [MASKED] about 1 month ago. After he left, he went to [MASKED]. While he was there, he was told that he would be unable to leave to go to his psychiatry appointment. He left there after staying for about 5 days. He has since been living with either his sister or friends, however he suspects that his friend is involved with drugs. He reports "erratic" sleep, decreased appetite with a [MASKED] lb weight loss in the past few weeks, decreased energy, and decreased concentration. He reports that about a month ago he thought about jumping off of a bridge with a weight attached to him, however he has since learned that suicide is a moral sin, and he no longer would want to commit suicide for that reason. Denies current SI. States that he feels safe on the unit. He reports recent self harm behaviors, as above, of rubbing his thumb into wood in order to inflict pain on himself to "snap out" of his depression. Psychiatric ROS: Depression - as per HPI Psychosis - reports that he has had paranoia for most of his adult life, stating that he used to feel like people wanted to kill him. Continues to report some paranoia, but states that it is much improved. Mania- denies symptoms including decreased need for sleep, increase in goal directed behavior, and increased energy Anxiety - denies Past psychiatric history: Per Dr. [MASKED] ([MASKED]), confirmed with patient and updated as relevant: - Hospitalizations: Recently at [MASKED] for SI + plan ~1 month ago; reports additional hospitalization ~5 months ago. - Current treaters and treatment: Psychiatrist is Dr. [MASKED] that he sees him approximately once/month. - Medication and ECT trials: Reports Seroquel has been helpful in the past for paranoid thoughts. Most recently reports taking Wellbutrin and Adderall, which were both helpful (but he ran out). - Self-injury: No suicide attempts; recently injured right thumb as per HPI. - Harm to others: None reported - Access to weapons: Denies Past Medical History: Per Dr. [MASKED] ([MASKED]), confirmed with patient and updated as relevant: - HTN - HLD - Back Pain Social History: [MASKED] Family History: Per Dr. [MASKED] ([MASKED]), confirmed with patient and updated as relevant: - Reports history of BPAD in his mother; EtOH Abuse in siblings, both sides of his family Physical Exam: VS: T: 98.4, BP: 119/74, HR: 65, R: 16, O2 sat: 98% on RA General: Middle-aged male in NAD. Well-nourished, well-developed. Appears stated age. HEENT: Normocephalic, atraumatic. EOMI. Back: No significant deformity. Lungs: CTA [MASKED]. No crackles, wheezes, or rhonchi. CV: RRR, no murmurs/rubs/gallops. Abdomen: +BS, soft, nontender, nondistended. No palpable masses or organomegaly. Extremities: No clubbing, cyanosis, or edema. Skin: erythema and bruising at right thumb Neurological: Cranial Nerves: -EOM: full -Facial symmetry on eye closure and smile: symmetric -Hearing grossly normal -Phonation: normal -Shoulder shrug: intact -Tongue: midline Motor: Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength: full power [MASKED] throughout. Gait: Steady. Normal stance and posture. No truncal ataxia. Cognition: Wakefulness/alertness: awake and alert Attention: intact to interview, states MYOB with 1 error Orientation: oriented to person, time, place, situation Executive function (go-no go, Luria, trails, FAS): not tested Memory: intact to recent and past history Fund of knowledge: consistent with education Calculations: correctly states 7 quarters in $1.75 Abstraction: not assessed Visuospatial: not assessed Speech: normal rate, volume, and tone Language: native [MASKED] speaker, no paraphasic errors, appropriate to conversation Mental Status: Appearance: No apparent distress, appears stated age, mildly disheveled, dressed in hospital gown Behavior: Calm, cooperative, engaged, appropriate eye contact, no psychomotor agitation or retardation Mood and Affect: "depressed" / restricted Thought Process: linear, coherent, goal-oriented. No LOA. Thought Content: denies SI/HI/AH/VH, no evidence of delusions, reports mild chronic paranoia Judgment and Insight: fair/fair Pertinent Results: [MASKED] 05:35PM BLOOD Glucose-110* UreaN-24* Creat-0.8 Na-140 K-4.4 Cl-104 HCO3-25 AnGap-11 [MASKED] 07:18AM BLOOD %HbA1c-5.1 eAG-100 [MASKED] 07:18AM BLOOD Triglyc-147 HDL-30* CHOL/HD-5.8 LDLcalc-116 [MASKED] 07:18AM BLOOD TSH-2.0 [MASKED] 05:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 05:27PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. He was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. 2. PSYCHIATRIC: Patient was admitted to inpatient psychiatry due to depression with passive suicidal ideation in the context of self-discontinuing his psychiatric medications approximately 2 weeks prior and psychosocial stressors. On admission interview, patient reported worsening depression in the context of the death of his brother 2 months prior, with associated poor sleep, decreased appetite with a [MASKED] lb weight loss in the past few weeks, decreased energy, and decreased concentration. Denied SI on admission, stating that he realized that suicide is a moral sin, and he no longer would not commit suicide for that reason. He was continued on his home gabapentin. Discussed decreasing [MASKED] with the patient. He was taking 30 mg BID. Continued Adderall at 10 mg BID in order to not precipitate withdrawal. During hospitalization, patient has also noted to be irritable, tangential, and hyper-verbal, concerning for an underlying bipolar disorder and current mixed state. He was started on Risperdal, which was titrated to 2 mg QHS. He was given hydroxyzine PRN and ramelteon PRN for sleep. The patient often reported to the team improved mood and sleep, however would also report irritability and "agitation." He was noted to be attending groups and social in the milieu. Obtained psychological testing, where patient endorsed depression and distress. There were also questions raising possibility of Cluster B personality traits. Although patient initially denied SI, he intermittently reported vague SI in the context of discharge planning. However, ultimately at discharge, patient was secured a bed at a CSS. He reported an improved mood and reported that he felt safe to discharge. He reported that he would be able to reach out for help if he felt poorly and would seek hospitalization if he felt unsafe. 3. SUBSTANCE USE DISORDERS: # Alcohol use disorder Patient reported a history of heavy alcohol use in the past. Reported being sober for the last month. Patient reported motivation to continue to abstain from alcohol use throughout hospitalization. # Opioid use disorder Patient was continued on suboxone [MASKED] daily, as patient reported that he had been taking less than suboxone [MASKED] BID that was prescribed in [MASKED]. He reported that he was trying to get off suboxone. Patient was encouraged to follow up with his outpatient provider for further adjustments in suboxone. 4. MEDICAL #)Right thumb cellulitis Patient reported that prior to admission, in order to "snap myself out of the depression," he grinded his thumb into a block of wood. He completed a course of cephalexin 500 mg PO Q6H for cellulitis. The cellulitis improved and patient reported no pain or discomfort at discharge. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient often attended these groups that focused on teaching patients various coping skills. He was noted to be pleasant and an active participant. When not in groups, he was social with peers in the milieu. There were no behavioral concerns requiring restraint or seclusion. # Homelessness Patient reported that he did not have stable housing after leaving his brothers house once his brother passed away. Patient often discussed housing issues with the team, although stated that housing was "not an issue" as he could always stay with friends. Social work assisted the patient with housing options, and he reported to the team that he completed an application for the [MASKED] in [MASKED]. The patient was discharged to a CSS placement. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: The team called and left a message for patient's outpatient psychiatrist, Dr. [MASKED] did not hear back. The patient declined to have the social worker contact his sister. #) Guardianship: N/A INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting risperidone, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to himself due to depression and SI. The patient is chronically at risk for self harm due to factors such as chronic mental illness, history of substance abuse, history of abuse, recent discharge from an inpatient psychiatric unit, male gender, Caucasian race, age and martial status. During hospitalization, patient reported motivation continue to abstain from alcohol. He reported improved mood. He is being discharged with protective factors that make him appropriate for outpatient care at this time, including help seeking nature, good relationship with his outpatient psychiatrist, good knowledge of resources available to him, no SI, strong religious beliefs, and future orientation with plans to follow up on housing applications and with his outpatient psychiatrist. Our Prognosis of this patient is guarded. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Gabapentin 800 mg PO TID 4. Simvastatin 20 mg PO QPM 5. Ranitidine 150 mg PO BID 6. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 7. Amphetamine-Dextroamphetamine 30 mg PO BID Discharge Medications: 1. HydrOXYzine 25 mg PO QHS:PRN anxiety/insomnia RX hydroxyzine HCl 25 mg 1 tablet by mouth at bedtime Disp #7 Tablet Refills:0 2. melatonin 5 mg oral QHS PRN RX melatonin 5 mg 1 tablet(s) by mouth at bedtime Disp #7 Tablet Refills:0 3. RisperiDONE 2 mg PO QHS mood disorder RX risperidone 2 mg 1 tablet(s) by mouth at bedtime Disp #7 Tablet Refills:0 4. Amphetamine-Dextroamphetamine 10 mg PO BID RX dextroamphetamine-amphetamine [Adderall] 10 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 5. Atenolol 100 mg PO DAILY RX atenolol 100 mg 1 tablet(s) by mouth Daily Disp #7 Tablet Refills:1 6. Gabapentin 800 mg PO BID RX gabapentin 800 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 7. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth Daily Disp #14 Tablet Refills:0 8. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY 9. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #28 Tablet Refills:0 10. Simvastatin 20 mg PO QPM RX simvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #14 Tablet Refills:0 Discharge Disposition: Extended Care Discharge Diagnosis: Major depressive disorder r/o BAD I mixed Discharge Condition: Vitals: T 98.0 BP 138/89 HR 97 RR 18 O2 98% Appearance: middle aged male, no apparent distress, wearing casual street clothes, good hygiene Behavior: calm, cooperative Mood and Affect: 'good' / euthymic Thought process: linear, goal directed Thought Content: Denies SI/HI, does not report AVH Judgment and Insight: fair/fair Discharge Instructions: You were hospitalized at [MASKED] for depression. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED]	[]	[ "I10", "E785", "G4700", "F419" ]	[ "F3160: Bipolar disorder, current episode mixed, unspecified", "R45851: Suicidal ideations", "F1120: Opioid dependence, uncomplicated", "L03011: Cellulitis of right finger", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "G4700: Insomnia, unspecified", "F419: Anxiety disorder, unspecified", "Z590: Homelessness" ]
10,040,664	21,185,129	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___ ___ Complaint: loop ileostomy Major Surgical or Invasive Procedure: Reversal of ileostomy. History of Present Illness: ___ w recently diagnosed sigmoid colon cancer presents to clinic to discuss surgical management. Pt underwent colonoscopy on ___ for BRBPR, which she reports she has had intermittently for months to years, also reports she has not had any BRBPR since the colonoscopy. This was pt's ___ colonoscopy. A 1 cm mass was identified ~1 cm from the anal verge. Pathology returned as invasive adenocarcinoma. A CT torso was performed ___ and did not find any evidence of distant disease. Past Medical History: PMH: FAMILIAL ADENOMATOUS POLYPOSIS RECTAL CANCER PSH: None on File Social History: ___ Family History: -No IBD or colorectal cancer. -Father: CAD, PVD, anxiety. -Mother: died of cervical cancer at age ___ -Has 7 brothers & sisters. One of her sisters has Grave's disease. Physical Exam: DISCHARGE PHYSICAL EXAM: VS: AVSS Gen: well appearing, NAD HEENT: no lymphadenopathy, moist mucous membranes Lungs: Respirations are unlabored on room air. Heart: Normal rate and regular rhythm. Abd: non-distended. Appropriately tender. No rebound or guarding. Incisions: The ostomy site is left open to heal by secondary intent with minimal serosanguinous drainage. Extremities: warm and well-perfused with no edema. Pertinent Results: ___ 06:42AM BLOOD WBC-8.2 RBC-4.83 Hgb-13.0* Hct-40.0 MCV-83 MCH-26.9 MCHC-32.5 RDW-16.1* RDWSD-48.6* Plt ___ ___ 07:25AM BLOOD Glucose-114* UreaN-12 Creat-0.9 Na-143 K-3.5 Cl-105 HCO___-21* AnGap-17 Brief Hospital Course: Mr ___ presented to ___ holding at ___ on ___ for an ileostomy takedown and reversal. He/She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was well controlled on oral pain medication with intravenous morphine for breakthrough CV: Vital signs were routinely monitored during the patient's length of stay and demonstrated no abnormalities. Pulm: The patient was encouraged to ambulate, sit and get out of bed, use the incentive spirometer, and had oxygen saturation levels monitored as indicated. GI: The patient was initially kept NPO after the procedure. The patient was later advanced to and tolerated a regular diet at time of discharge. The patient had increased number of bowel movements post-operatively and loperamide and psyllium were added to his medication regimin. He was discharged with instructions on how to titrate the medication himself if he needed to at home. On discharge he was having one small bowel movement every couple hours. GU: Patient had a Foley catheter that was removed at time of discharge. Urine output was monitored as indicated. At time of discharge, the patient was voiding without difficulty. ID: The patient's vital signs were monitored for signs of infection and fever. The patient was started on/continued on antibiotics as indicated. Heme: The patient had blood levels checked post operatively during the hospital course to monitor for signs of bleeding. The patient had vital signs, including heart rate and blood pressure, monitored throughout the hospital stay. On ___, the patient was discharged to home. At discharge, he/she was tolerating a regular diet, passing flatus, stooling, voiding, and ambulating independently. She will follow-up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Medications on Admission: Pysllium powder loperamide atorvastatin cetirizine citalopram fluticasone omeprazole oxybutynin topiramate Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity do not drink alcohol or drive a car while taking this medication RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 2. Psyllium Powder 1 PKT PO BID 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate do not take more than 3000mg of Tylenol in 24 hours or drink alcohol while taking 4. Atorvastatin 40 mg PO QPM 5. Cetirizine 10 mg PO DAILY 6. Citalopram 40 mg PO DAILY 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. LOPERamide 4 mg PO QID RX loperamide 2 mg 2 tablets by mouth four times a day Disp #100 Tablet Refills:0 9. Omeprazole 40 mg PO DAILY 10. Oxybutynin 10 mg PO BID 11. Topiramate (Topamax) 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Ileostomy status post total proctocolectomy with ileoanal pouch. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after an ileostomy takedown. You have recovered from this procedure well and you are now ready to return home. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected however, if you notice that you are passing bright red blood with bowel your please seek medical attention. If you are passing loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. It is also not uncommon after an ileostomy takedown to have frequent loose stools until you are taking more regular food however this should improve. The muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence however this should improve. If you do not show improvement in these symptoms within ___ days please call the office for advice. Occasionally, patients will need to take a medication to slow their bowel movements as their bodies adjust to the new normal without an ileostomy, you should consult with our office for advice. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have a small wound where the old ileostomy once was. This should be covered with a dry sterile gauze dressing. The wound no longer requires packing with gauze packing strip. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. Please apply a new gauze dressing after showering. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgical team. You may gradually increase your activity as tolerated but clear heavy exercise with your surgical team. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 3000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___	[ "Z432", "E785", "Z85048", "I10", "F329", "F419" ]	Allergies: Penicillins [MASKED] Complaint: loop ileostomy Major Surgical or Invasive Procedure: Reversal of ileostomy. History of Present Illness: [MASKED] w recently diagnosed sigmoid colon cancer presents to clinic to discuss surgical management. Pt underwent colonoscopy on [MASKED] for BRBPR, which she reports she has had intermittently for months to years, also reports she has not had any BRBPR since the colonoscopy. This was pt's [MASKED] colonoscopy. A 1 cm mass was identified ~1 cm from the anal verge. Pathology returned as invasive adenocarcinoma. A CT torso was performed [MASKED] and did not find any evidence of distant disease. Past Medical History: PMH: FAMILIAL ADENOMATOUS POLYPOSIS RECTAL CANCER PSH: None on File Social History: [MASKED] Family History: -No IBD or colorectal cancer. -Father: CAD, PVD, anxiety. -Mother: died of cervical cancer at age [MASKED] -Has 7 brothers & sisters. One of her sisters has Grave's disease. Physical Exam: DISCHARGE PHYSICAL EXAM: VS: AVSS Gen: well appearing, NAD HEENT: no lymphadenopathy, moist mucous membranes Lungs: Respirations are unlabored on room air. Heart: Normal rate and regular rhythm. Abd: non-distended. Appropriately tender. No rebound or guarding. Incisions: The ostomy site is left open to heal by secondary intent with minimal serosanguinous drainage. Extremities: warm and well-perfused with no edema. Pertinent Results: [MASKED] 06:42AM BLOOD WBC-8.2 RBC-4.83 Hgb-13.0* Hct-40.0 MCV-83 MCH-26.9 MCHC-32.5 RDW-16.1* RDWSD-48.6* Plt [MASKED] [MASKED] 07:25AM BLOOD Glucose-114* UreaN-12 Creat-0.9 Na-143 K-3.5 Cl-105 HCO -21* AnGap-17 Brief Hospital Course: Mr [MASKED] presented to [MASKED] holding at [MASKED] on [MASKED] for an ileostomy takedown and reversal. He/She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was well controlled on oral pain medication with intravenous morphine for breakthrough CV: Vital signs were routinely monitored during the patient's length of stay and demonstrated no abnormalities. Pulm: The patient was encouraged to ambulate, sit and get out of bed, use the incentive spirometer, and had oxygen saturation levels monitored as indicated. GI: The patient was initially kept NPO after the procedure. The patient was later advanced to and tolerated a regular diet at time of discharge. The patient had increased number of bowel movements post-operatively and loperamide and psyllium were added to his medication regimin. He was discharged with instructions on how to titrate the medication himself if he needed to at home. On discharge he was having one small bowel movement every couple hours. GU: Patient had a Foley catheter that was removed at time of discharge. Urine output was monitored as indicated. At time of discharge, the patient was voiding without difficulty. ID: The patient's vital signs were monitored for signs of infection and fever. The patient was started on/continued on antibiotics as indicated. Heme: The patient had blood levels checked post operatively during the hospital course to monitor for signs of bleeding. The patient had vital signs, including heart rate and blood pressure, monitored throughout the hospital stay. On [MASKED], the patient was discharged to home. At discharge, he/she was tolerating a regular diet, passing flatus, stooling, voiding, and ambulating independently. She will follow-up in the clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. Medications on Admission: Pysllium powder loperamide atorvastatin cetirizine citalopram fluticasone omeprazole oxybutynin topiramate Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity do not drink alcohol or drive a car while taking this medication RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 2. Psyllium Powder 1 PKT PO BID 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate do not take more than 3000mg of Tylenol in 24 hours or drink alcohol while taking 4. Atorvastatin 40 mg PO QPM 5. Cetirizine 10 mg PO DAILY 6. Citalopram 40 mg PO DAILY 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. LOPERamide 4 mg PO QID RX loperamide 2 mg 2 tablets by mouth four times a day Disp #100 Tablet Refills:0 9. Omeprazole 40 mg PO DAILY 10. Oxybutynin 10 mg PO BID 11. Topiramate (Topamax) 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Ileostomy status post total proctocolectomy with ileoanal pouch. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after an ileostomy takedown. You have recovered from this procedure well and you are now ready to return home. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected however, if you notice that you are passing bright red blood with bowel your please seek medical attention. If you are passing loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. It is also not uncommon after an ileostomy takedown to have frequent loose stools until you are taking more regular food however this should improve. The muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence however this should improve. If you do not show improvement in these symptoms within [MASKED] days please call the office for advice. Occasionally, patients will need to take a medication to slow their bowel movements as their bodies adjust to the new normal without an ileostomy, you should consult with our office for advice. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have a small wound where the old ileostomy once was. This should be covered with a dry sterile gauze dressing. The wound no longer requires packing with gauze packing strip. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. Please apply a new gauze dressing after showering. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgical team. You may gradually increase your activity as tolerated but clear heavy exercise with your surgical team. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 3000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED]	[]	[ "E785", "I10", "F329", "F419" ]	[ "Z432: Encounter for attention to ileostomy", "E785: Hyperlipidemia, unspecified", "Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]
10,040,664	21,799,092	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___ ___ Complaint: Incisional hernias x 2. Major Surgical or Invasive Procedure: HERNIORRHAPHY INCISIONAL X2 WITH MESH History of Present Illness: Mr. ___ underwent reversal of his ileostomy on ___ and was able to be discharged home after approximately 4 days. He had a much less eventful postoperative course then after his pouch procedure. He was sent home on Imodium and fiber supplementation for the expected liquid and frequent bowel movements. However, he has not been able to make his initial postoperative appointments in ___ cancer clinic because he was concerned about driving all the way to ___ given the frequency and looseness of his stools. He has been in frequent communication with my office including discussions with my nurse ___ regarding agents to slow down his bowel movements. He has been on Imodium and fiber we were considering adding Lomotil and recently I started him on Cyproheptadine with significant improvement. He is down from ___ bowel movements a day to perhaps ___. He is not having any accidents at night. In fact he is able to sleep through the night. He now reports that his bowel movements are roughly the consistency of pudding. His only other complaint is of perianal irritation and redness secondary to his frequent bowel movements. Past Medical History: PMH: FAMILIAL ADENOMATOUS POLYPOSIS RECTAL CANCER PSH: None on File Social History: ___ Family History: -No IBD or colorectal cancer. -Father: CAD, PVD, anxiety. -Mother: died of cervical cancer at age ___ -Has 7 brothers & sisters. One of her sisters has Grave's disease. Physical Exam: Gen: NAD CV: RRR Pulm: nonlabored breathing on room air Abd: soft, nontender, nondistended, dressings c/d/i Brief Hospital Course: Patient underwent incisional hernia repair x2 with mesh (ileostomy and umbilical port sites). Please see operative note for details. He tolerated the procedure well. Post operatively, he was voiding spontaneously, ambulating, pain well controlled, tolerating regular diet, vitals stable. He was safe and stable for discharge to home the same day. Appropriate instructions and follow up appointments were made. Medications on Admission: atorvastatin 40' citalopram 40 mg ' cyproheptadine 4 ''' fluticasone 50 mirtazapine 7.5' rizatriptan 10 mg prn topiramate 100 ' Imodium 2 ''' Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 3. Atorvastatin 40 mg PO QPM 4. Citalopram 40 mg PO DAILY 5. Cyproheptadine 4 mg PO Q8H 6. Fluticasone Propionate NASAL 2 SPRY NU BID 7. Mirtazapine 7.5 mg PO QHS 8. Topiramate (Topamax) 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Incisional Hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Followup Instructions: ___	[ "K432", "Z880", "Z85048", "Z79899", "I10" ]	Allergies: Penicillins [MASKED] Complaint: Incisional hernias x 2. Major Surgical or Invasive Procedure: HERNIORRHAPHY INCISIONAL X2 WITH MESH History of Present Illness: Mr. [MASKED] underwent reversal of his ileostomy on [MASKED] and was able to be discharged home after approximately 4 days. He had a much less eventful postoperative course then after his pouch procedure. He was sent home on Imodium and fiber supplementation for the expected liquid and frequent bowel movements. However, he has not been able to make his initial postoperative appointments in [MASKED] cancer clinic because he was concerned about driving all the way to [MASKED] given the frequency and looseness of his stools. He has been in frequent communication with my office including discussions with my nurse [MASKED] regarding agents to slow down his bowel movements. He has been on Imodium and fiber we were considering adding Lomotil and recently I started him on Cyproheptadine with significant improvement. He is down from [MASKED] bowel movements a day to perhaps [MASKED]. He is not having any accidents at night. In fact he is able to sleep through the night. He now reports that his bowel movements are roughly the consistency of pudding. His only other complaint is of perianal irritation and redness secondary to his frequent bowel movements. Past Medical History: PMH: FAMILIAL ADENOMATOUS POLYPOSIS RECTAL CANCER PSH: None on File Social History: [MASKED] Family History: -No IBD or colorectal cancer. -Father: CAD, PVD, anxiety. -Mother: died of cervical cancer at age [MASKED] -Has 7 brothers & sisters. One of her sisters has Grave's disease. Physical Exam: Gen: NAD CV: RRR Pulm: nonlabored breathing on room air Abd: soft, nontender, nondistended, dressings c/d/i Brief Hospital Course: Patient underwent incisional hernia repair x2 with mesh (ileostomy and umbilical port sites). Please see operative note for details. He tolerated the procedure well. Post operatively, he was voiding spontaneously, ambulating, pain well controlled, tolerating regular diet, vitals stable. He was safe and stable for discharge to home the same day. Appropriate instructions and follow up appointments were made. Medications on Admission: atorvastatin 40' citalopram 40 mg ' cyproheptadine 4 ''' fluticasone 50 mirtazapine 7.5' rizatriptan 10 mg prn topiramate 100 ' Imodium 2 ''' Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 3. Atorvastatin 40 mg PO QPM 4. Citalopram 40 mg PO DAILY 5. Cyproheptadine 4 mg PO Q8H 6. Fluticasone Propionate NASAL 2 SPRY NU BID 7. Mirtazapine 7.5 mg PO QHS 8. Topiramate (Topamax) 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Incisional Hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. Followup Instructions: [MASKED]	[]	[ "I10" ]	[ "K432: Incisional hernia without obstruction or gangrene", "Z880: Allergy status to penicillin", "Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus", "Z79899: Other long term (current) drug therapy", "I10: Essential (primary) hypertension" ]
10,040,664	28,611,665	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___ ___ Complaint: FAP Major Surgical or Invasive Procedure: Laparoscopic total proctocolectomy with ileal low rectal pouch anastomosis with proximal diverting ileostomy History of Present Illness: Referred to Dr. ___ surgical treatment of FAP. He was referred for genetic testing as an outpatient prior to surgery. Surgical arrangements were made by Dr. ___ surgery. Past Medical History: PMH: FAMILIAL ADENOMATOUS POLYPOSIS RECTAL CANCER PSH: None on File Social History: Employeed at ___ Married, supportive wife Physical ___: General: doing well, tolerating a regular diet, pain controlled, ambulating VSS Neruo: A&OX3 Cardio/Pulm: no chest pain or shortness of breath Abd: obese, soft, surgical incisions intact without signs of infection, ileostomy pink with liquid stool output ___: no lower extremity edema Pertinent Results: Admission ___ 07:10AM BLOOD WBC-9.3 RBC-3.85* Hgb-11.4* Hct-33.8* MCV-88 MCH-29.6 MCHC-33.7 RDW-13.8 RDWSD-44.0 Plt ___ ___ 07:10AM BLOOD Glucose-125* UreaN-15 Creat-1.0 Na-142 K-3.9 Cl-105 HCO3-22 AnGap-15 ___ 07:10AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.1 DIscharge ___ 07:35AM BLOOD WBC-8.3 RBC-3.86* Hgb-11.3* Hct-33.8* MCV-88 MCH-29.3 MCHC-33.4 RDW-13.2 RDWSD-41.8 Plt ___ ___ 07:00AM BLOOD Glucose-83 UreaN-14 Creat-1.0 Na-140 K-4.1 Cl-100 HCO3-22 AnGap-18* ___ 07:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.2 CT ___ 1. Marked distention of the stomach and entire small bowel proximal to the diverting ileostomy with transition point appearing at the ileostomy itself with dilated proximal loop and decompressed exiting loop of ileum consistent with small-bowel obstruction. No evidence of hypoenhancing bowel or free intraperitoneal air. 2. Hepatic steatosis. Brief Hospital Course: Mr. ___ is a ___ with a T2N0 rectal cancer in the setting of numerous polyps now tested positive for MUTYH mutation consistent with MAP who come in for a scheduled total laparascopic protocolectomy with ileoanal pouch and diverting ileostomy. He tolerated the procedure very well. After a brief and uneventful stay in the PACU, he was admitted to the floor for further management. His post-op course was initially complicated by post-op ileus, which resolved after nasogastric tube placement and then later high ileostomy output, which subsequently resolved. He was discharged home post-op day ___ in good condition with ___ services for ostomy care. At discharge, he was tolerating regular diet, appropriate ileostomy output, ambulating without assistance. Medications on Admission: atorvastatin 40 mg tablet' citalopram 40 mg tablet' dicyclomine 20 mg tablet''' fluticasone 50 mcg/actuation nasal spray '' hydrochlorothiazide 25 mg tablet' lisinopril 20 ' lorazepam 1 mg ' mirtazapine 7.5 mg ' omeprazole 40 mg ' oxybutynin chloride ER 10 '' rizatriptan 10 mg '-prn tamsulosin 0.4 '-3 days before syrgery topiramate 100 ' cetirizine 10 mg ' Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. LOPERamide 4 mg PO QID Titrate according to ostomy volume and consistency RX loperamide [Anti-Diarrhea] 2 mg 4 mg by mouth four times a day Disp #120 Tablet Refills:0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth ___ Disp #15 Tablet Refills:0 4. Psyllium Wafer 2 WAF PO TID 5. Atorvastatin 40 mg PO QPM 6. Cetirizine 10 mg PO DAILY 7. Citalopram 40 mg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 10. Hydrochlorothiazide 25 mg PO DAILY 11. LORazepam 1 mg PO QPM 12. Omeprazole 40 mg PO DAILY 13. Oxybutynin 10 mg PO BID 14. Topiramate (Topamax) 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PREOPERATIVE DIAGNOSIS: Familial adenomatous polyposis with MYH variation with a known rectal cancer. POSTOPERATIVE DIAGNOSIS: Familial adenomatous polyposis with MYH variation with a known rectal cancer. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. GEN: NAD HEENT: NCAT, EOMI CV: RRR PULM: normal excursion, no respiratory distress ABD: soft, NT/ND. ostomy with brown output and some gas, lap sites CDI EXT: no edema NEURO: grossly intact Discharge Instructions: Mr. ___, ___ were admitted to the hospital after a proctectomy with ileal pouch, anal anastomosis and diverting loop ileostomy for surgical management of your ulcerative colitis. ___ have recovered from this procedure well and ___ are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. ___ will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact ___ regarding these results they will contact ___ before this time. ___ have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. ___ may return home to finish your recovery. If ___ have any of the following symptoms please call the office for advice ___: fever greater than 101.5 increasing abdominal distension increasing abdominal pain nausea/vomiting inability to tolerate food or liquids prolonged loose stool extended constipation inability to urinate Incisions: ___ have small laparascopic incision sites with steri-strips in place. Those will eventually fall off on their own. This is healing well however it is important that ___ monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. ___ may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips), these will fall off over time, please do not remove them. Please no baths or swimming until cleared by the surgical team. It is expected that ___ may still have pain after surgery and this pain will gradually improved over the course of your stay here. ___ will especially have pain when changing positions and with movement. ___ should continue to take 2 Extra Strength Tylenol (___) for pain every 8 hours around the clock and ___ may also take Advil (Ibuprofen) 600mg every hours for 7 days. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while or Tylenol. Please take Advil with food. If these medications are not controlling your pain to a point where ___ can ambulate and preform minor tasks, ___ should take a dose of the narcotic pain medication oxycodone. Please take this only if needed for pain. Do not take with any other sedating medications or alcohol. Do not drive a car if taking narcotic pain medications. ___ may feel weak or "washed out" for up to 6 weeks after surgery. No heavy lifting greater than a gallon of milk for 3 weeks. ___ may climb stairs. ___ may go outside and walk, but avoid traveling long distances until ___ speak with your surgical team at your first follow-up visit. Your surgical team will clear ___ for heavier exercise and activity as the observe your progress at your follow-up appointment. ___ should only drive a car on your own if ___ are off narcotic pain medications and feel as if your reaction time is back to normal so ___ can react appropriately while driving. ___ have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. ___ must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1500cc or less than 500cc. If ___ find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if ___ notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If ___ notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. ___ may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to ___ by the ostomy nurses. ___ monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. ___ stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as ___ have been instructed by the wound/ostomy nurses. ___ will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. ___ will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until ___ are comfortable caring for it on your own. Thank ___ for allowing us to participate in your care! Our hope is that ___ will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___	[ "D126", "K9189", "K567", "C20", "I10", "E785", "E876", "Y838", "Y92230" ]	Allergies: Penicillins [MASKED] Complaint: FAP Major Surgical or Invasive Procedure: Laparoscopic total proctocolectomy with ileal low rectal pouch anastomosis with proximal diverting ileostomy History of Present Illness: Referred to Dr. [MASKED] surgical treatment of FAP. He was referred for genetic testing as an outpatient prior to surgery. Surgical arrangements were made by Dr. [MASKED] surgery. Past Medical History: PMH: FAMILIAL ADENOMATOUS POLYPOSIS RECTAL CANCER PSH: None on File Social History: Employeed at [MASKED] Married, supportive wife Physical [MASKED]: General: doing well, tolerating a regular diet, pain controlled, ambulating VSS Neruo: A&OX3 Cardio/Pulm: no chest pain or shortness of breath Abd: obese, soft, surgical incisions intact without signs of infection, ileostomy pink with liquid stool output [MASKED]: no lower extremity edema Pertinent Results: Admission [MASKED] 07:10AM BLOOD WBC-9.3 RBC-3.85* Hgb-11.4* Hct-33.8* MCV-88 MCH-29.6 MCHC-33.7 RDW-13.8 RDWSD-44.0 Plt [MASKED] [MASKED] 07:10AM BLOOD Glucose-125* UreaN-15 Creat-1.0 Na-142 K-3.9 Cl-105 HCO3-22 AnGap-15 [MASKED] 07:10AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.1 DIscharge [MASKED] 07:35AM BLOOD WBC-8.3 RBC-3.86* Hgb-11.3* Hct-33.8* MCV-88 MCH-29.3 MCHC-33.4 RDW-13.2 RDWSD-41.8 Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-83 UreaN-14 Creat-1.0 Na-140 K-4.1 Cl-100 HCO3-22 AnGap-18* [MASKED] 07:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.2 CT [MASKED] 1. Marked distention of the stomach and entire small bowel proximal to the diverting ileostomy with transition point appearing at the ileostomy itself with dilated proximal loop and decompressed exiting loop of ileum consistent with small-bowel obstruction. No evidence of hypoenhancing bowel or free intraperitoneal air. 2. Hepatic steatosis. Brief Hospital Course: Mr. [MASKED] is a [MASKED] with a T2N0 rectal cancer in the setting of numerous polyps now tested positive for MUTYH mutation consistent with MAP who come in for a scheduled total laparascopic protocolectomy with ileoanal pouch and diverting ileostomy. He tolerated the procedure very well. After a brief and uneventful stay in the PACU, he was admitted to the floor for further management. His post-op course was initially complicated by post-op ileus, which resolved after nasogastric tube placement and then later high ileostomy output, which subsequently resolved. He was discharged home post-op day [MASKED] in good condition with [MASKED] services for ostomy care. At discharge, he was tolerating regular diet, appropriate ileostomy output, ambulating without assistance. Medications on Admission: atorvastatin 40 mg tablet' citalopram 40 mg tablet' dicyclomine 20 mg tablet''' fluticasone 50 mcg/actuation nasal spray '' hydrochlorothiazide 25 mg tablet' lisinopril 20 ' lorazepam 1 mg ' mirtazapine 7.5 mg ' omeprazole 40 mg ' oxybutynin chloride ER 10 '' rizatriptan 10 mg '-prn tamsulosin 0.4 '-3 days before syrgery topiramate 100 ' cetirizine 10 mg ' Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. LOPERamide 4 mg PO QID Titrate according to ostomy volume and consistency RX loperamide [Anti-Diarrhea] 2 mg 4 mg by mouth four times a day Disp #120 Tablet Refills:0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg [MASKED] tablet(s) by mouth [MASKED] Disp #15 Tablet Refills:0 4. Psyllium Wafer 2 WAF PO TID 5. Atorvastatin 40 mg PO QPM 6. Cetirizine 10 mg PO DAILY 7. Citalopram 40 mg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 10. Hydrochlorothiazide 25 mg PO DAILY 11. LORazepam 1 mg PO QPM 12. Omeprazole 40 mg PO DAILY 13. Oxybutynin 10 mg PO BID 14. Topiramate (Topamax) 100 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PREOPERATIVE DIAGNOSIS: Familial adenomatous polyposis with MYH variation with a known rectal cancer. POSTOPERATIVE DIAGNOSIS: Familial adenomatous polyposis with MYH variation with a known rectal cancer. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. GEN: NAD HEENT: NCAT, EOMI CV: RRR PULM: normal excursion, no respiratory distress ABD: soft, NT/ND. ostomy with brown output and some gas, lap sites CDI EXT: no edema NEURO: grossly intact Discharge Instructions: Mr. [MASKED], [MASKED] were admitted to the hospital after a proctectomy with ileal pouch, anal anastomosis and diverting loop ileostomy for surgical management of your ulcerative colitis. [MASKED] have recovered from this procedure well and [MASKED] are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. [MASKED] will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact [MASKED] regarding these results they will contact [MASKED] before this time. [MASKED] have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. [MASKED] may return home to finish your recovery. If [MASKED] have any of the following symptoms please call the office for advice [MASKED]: fever greater than 101.5 increasing abdominal distension increasing abdominal pain nausea/vomiting inability to tolerate food or liquids prolonged loose stool extended constipation inability to urinate Incisions: [MASKED] have small laparascopic incision sites with steri-strips in place. Those will eventually fall off on their own. This is healing well however it is important that [MASKED] monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. [MASKED] may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips), these will fall off over time, please do not remove them. Please no baths or swimming until cleared by the surgical team. It is expected that [MASKED] may still have pain after surgery and this pain will gradually improved over the course of your stay here. [MASKED] will especially have pain when changing positions and with movement. [MASKED] should continue to take 2 Extra Strength Tylenol ([MASKED]) for pain every 8 hours around the clock and [MASKED] may also take Advil (Ibuprofen) 600mg every hours for 7 days. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while or Tylenol. Please take Advil with food. If these medications are not controlling your pain to a point where [MASKED] can ambulate and preform minor tasks, [MASKED] should take a dose of the narcotic pain medication oxycodone. Please take this only if needed for pain. Do not take with any other sedating medications or alcohol. Do not drive a car if taking narcotic pain medications. [MASKED] may feel weak or "washed out" for up to 6 weeks after surgery. No heavy lifting greater than a gallon of milk for 3 weeks. [MASKED] may climb stairs. [MASKED] may go outside and walk, but avoid traveling long distances until [MASKED] speak with your surgical team at your first follow-up visit. Your surgical team will clear [MASKED] for heavier exercise and activity as the observe your progress at your follow-up appointment. [MASKED] should only drive a car on your own if [MASKED] are off narcotic pain medications and feel as if your reaction time is back to normal so [MASKED] can react appropriately while driving. [MASKED] have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. [MASKED] must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1500cc or less than 500cc. If [MASKED] find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if [MASKED] notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If [MASKED] notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. [MASKED] may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to [MASKED] by the ostomy nurses. [MASKED] monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. [MASKED] stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as [MASKED] have been instructed by the wound/ostomy nurses. [MASKED] will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. [MASKED] will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until [MASKED] are comfortable caring for it on your own. Thank [MASKED] for allowing us to participate in your care! Our hope is that [MASKED] will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED]	[]	[ "I10", "E785", "Y92230" ]	[ "D126: Benign neoplasm of colon, unspecified", "K9189: Other postprocedural complications and disorders of digestive system", "K567: Ileus, unspecified", "C20: Malignant neoplasm of rectum", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E876: Hypokalemia", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,040,737	20,352,299	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) / Macrodantin / ampicillin Attending: ___. Chief Complaint: Right ankle fracture Major Surgical or Invasive Procedure: Open reduction internal fixation right ankle fracture History of Present Illness: ___ w/ R ankle fx s/p ORIF w/ Dr. ___ on ___. Past Medical History: ___: anxiety, bronchitis, ___ esophagus/GERD, hypothyroid PSH: dental surgery only, denies abdominal procedures Social History: ___ Family History: non contributory Physical Exam: Alert, oriented RLE splint clean dry intact Moving all toes Toes WWP SILT distally Pertinent Results: ___ 03:35PM GLUCOSE-135* UREA N-11 CREAT-0.7 SODIUM-145 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-30 ANION GAP-11 ___ 03:35PM estGFR-Using this ___ 03:35PM 25OH VitD-44 ___ 03:35PM WBC-6.9 RBC-3.77* HGB-10.7* HCT-32.9* MCV-87 MCH-28.4 MCHC-32.5 RDW-13.2 RDWSD-41.8 ___ 03:35PM PLT COUNT-290 ___ 03:35PM ___ PTT-26.3 ___ Brief Hospital Course: Mrs. ___ was directly admitted from clinic for surgery. She underwent ORIF of right ankle fracture on ___ with Dr. ___. She tolerated the procedure well. All of her home medications were resumed. She worked with ___ who determined that discharge to rehab was appropriate. She will be taking aspirin for 2 weeks for DVT prophylaxis. She received 2 doses of Ancef postoperatively. Her hospital course is otherwise uncomplicated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. QUEtiapine Fumarate 250 mg PO QHS 2. ClonazePAM 1 mg PO QHS 3. Estradiol 10 mg PO TWICE WEEKLY 4. Liothyronine Sodium 75 mcg PO DAILY 5. PARoxetine 37.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Aspirin 325 mg PO DAILY Duration: 2 Weeks 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Ondansetron 4 mg PO Q8H:PRN n/v 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #50 Tablet Refills:*0 6. Liothyronine Sodium 15 mcg PO DAILY 7. ClonazePAM 1 mg PO QHS 8. Estradiol 10 mg PO TWICE WEEKLY 9. PARoxetine 37.5 mg PO DAILY 10. QUEtiapine Fumarate 250 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right ankle fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Non weight bearing right lower extremity Please keep splint clean & dry at all times Please take aspirin for 2 weeks Follow up with Dr. ___ as scheduled ___ off of narcotics Physical Therapy: Physical therapy: non weight bearing right lower extremity, okay for hip / knee range of motion Treatments Frequency: Physical therapy: non weight bearing right lower extremity, okay for hip / knee range of motion Followup Instructions: ___	[ "S82851A", "E039", "K219", "K5900", "F419" ]	Allergies: Sulfa (Sulfonamide Antibiotics) / Macrodantin / ampicillin Chief Complaint: Right ankle fracture Major Surgical or Invasive Procedure: Open reduction internal fixation right ankle fracture History of Present Illness: [MASKED] w/ R ankle fx s/p ORIF w/ Dr. [MASKED] on [MASKED]. Past Medical History: [MASKED]: anxiety, bronchitis, [MASKED] esophagus/GERD, hypothyroid PSH: dental surgery only, denies abdominal procedures Social History: [MASKED] Family History: non contributory Physical Exam: Alert, oriented RLE splint clean dry intact Moving all toes Toes WWP SILT distally Pertinent Results: [MASKED] 03:35PM GLUCOSE-135* UREA N-11 CREAT-0.7 SODIUM-145 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-30 ANION GAP-11 [MASKED] 03:35PM estGFR-Using this [MASKED] 03:35PM 25OH VitD-44 [MASKED] 03:35PM WBC-6.9 RBC-3.77* HGB-10.7* HCT-32.9* MCV-87 MCH-28.4 MCHC-32.5 RDW-13.2 RDWSD-41.8 [MASKED] 03:35PM PLT COUNT-290 [MASKED] 03:35PM [MASKED] PTT-26.3 [MASKED] Brief Hospital Course: Mrs. [MASKED] was directly admitted from clinic for surgery. She underwent ORIF of right ankle fracture on [MASKED] with Dr. [MASKED]. She tolerated the procedure well. All of her home medications were resumed. She worked with [MASKED] who determined that discharge to rehab was appropriate. She will be taking aspirin for 2 weeks for DVT prophylaxis. She received 2 doses of Ancef postoperatively. Her hospital course is otherwise uncomplicated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. QUEtiapine Fumarate 250 mg PO QHS 2. ClonazePAM 1 mg PO QHS 3. Estradiol 10 mg PO TWICE WEEKLY 4. Liothyronine Sodium 75 mcg PO DAILY 5. PARoxetine 37.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Aspirin 325 mg PO DAILY Duration: 2 Weeks 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Ondansetron 4 mg PO Q8H:PRN n/v 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #50 Tablet Refills:*0 6. Liothyronine Sodium 15 mcg PO DAILY 7. ClonazePAM 1 mg PO QHS 8. Estradiol 10 mg PO TWICE WEEKLY 9. PARoxetine 37.5 mg PO DAILY 10. QUEtiapine Fumarate 250 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Right ankle fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Non weight bearing right lower extremity Please keep splint clean & dry at all times Please take aspirin for 2 weeks Follow up with Dr. [MASKED] as scheduled [MASKED] off of narcotics Physical Therapy: Physical therapy: non weight bearing right lower extremity, okay for hip / knee range of motion Treatments Frequency: Physical therapy: non weight bearing right lower extremity, okay for hip / knee range of motion Followup Instructions: [MASKED]	[]	[ "E039", "K219", "K5900", "F419" ]	[ "S82851A: Displaced trimalleolar fracture of right lower leg, initial encounter for closed fracture", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "K5900: Constipation, unspecified", "F419: Anxiety disorder, unspecified" ]
10,040,881	26,301,946	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Univasc Attending: ___. Chief Complaint: dehydration, failure to thrive Major Surgical or Invasive Procedure: ___ Omental biopsy History of Present Illness: Patient is a ___ with mood disorder NOS, primary hyperparathyroidism s/p resection, wet macular degeneration s/p laser photocoagulation (legally blind), who is referred from ___ with progressive functional and cognitive decline and findings of dehydration. History mostly obtained from ___ three daughters at bedside. Per daughters, patient was at her usual state of health until about 6 months ago when she began to slowly decline in her functional status. Previously she was ambulatory, conversational with family members and tolerating three meals a day. Over the past 6 months, she has become increasingly bedbound mostly due to lack of motivation, with very poor appetite (only taking 1 ensure daily often) with lack of interest in previously pleasurable activities including socializing with family and reading the news. Daughters also endorse underlying chronic social anxiety (refused to let repairmen in to fix her home of many years). Given this ongoing decline, PCP had conducted ___ MMSE in ___ and per report pt scored ___. Her decline has been associated with about 20lb weight loss, occasional diarrhea for past 3 months, and intermittent periods of acute confusion, disorientation and hallucinations (does not recognize family members, thinks she is talking to deceased family members). Daughters also think she often chokes and coughs after swallowing her food. Most recently seen in PCP office this week, basic labs, UA done which were per report unremarkable. Also given borderline SBP in ___ in office, PCP stopped ___ beta blocker. On ROS, endorsed left arm pain, otherwise denied fever, chills, shortness of breath. SHe had been up to date with mammograms and colonoscopies with no remarkable findings per report. Given above decline, patient was brought to ___, where basic labs were unremarkable. transferred to ___ bed shortage. In the ___, initial VS were: 99.4 86 132/64 18 93% RA CXR: No definite acute cardiopulmonary process. ___ labs were notable for trop negative x2 Transfer VS were: 98.1 74 131/58 16 95% RA Past Medical History: Mood disorder NOS Primary hyperparathyroidism s/p resection of adenoma Wet macular degeneration s/p laser photocoagulation Social History: ___ Family History: Family history of colon cancer Physical Exam: Admission Exam Gen: Elderly woman, cachectic, fatigued, sleepy but arousable, NAD, hard of hearing Eyes: EOMI, sclerae anicteric ENT: dry mucous membranes, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, NT, ND, BS+ MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx1. No facial droop. Discharge Exam Pertinent Results: -------------------- ___ -------------------- Sodium 141, potassium 4.2, chloride 100, carbon dioxide 23, glucose 81, BUN 54, creatinine 1.8, albumin 3.4, total protein 6.1, T. bili 0.4 alkaline phosphatase 93, ALT 26, AST 51 Troponin at 1425 on one ___ was less than 0.01 WBC 5.3, RBC 4.6, Hgb 14.2, HCT 40.9, bands 5%, PLT135 UA is yellow, cloudy ST 1.015, glucose negative, bilirubin negative, ketones negative, blood small, pH 5, protein negative, urobilinogen 0.2, nitrate negative, leuk esterase negative -------------------- ___ ___: -------------------- ___ 08:05PM cTropnT-<0.01 ___ 12:06PM GLUCOSE-83 ___ 12:06PM UREA N-62* CREAT-2.2# SODIUM-140 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-21 ANION GAP-25* ___ 12:06PM ALT(SGPT)-29 AST(SGOT)-53* ALK PHOS-96 TOT BILI-0.3 ___ 12:06PM CALCIUM-9.9 ___ 12:06PM WBC-5.7 RBC-4.70 HGB-14.2 HCT-42.7 MCV-91 MCH-30.2 MCHC-33.3 RDW-15.2 RDWSD-51.0* ___ 12:06PM PLT COUNT-161 ___ 12:06PM URINE RBC-2 WBC-9* BACTERIA-FEW YEAST-NONE EPI-1 -------------------- IMAGING: -------------------- CT torso with contrast 1. Extensive mesenteric, omental, retroperitoneal, and pelvic side wall soft tissue mass/nodal tissue highly suspicious for lymphoma. 2. Wall thickening of the cecum which is also suspicious for lymphoma involvement. 3. 11 mm splenic hypodensity, statistically a cyst or hemangioma but given clinical context, attention on follow-up imaging is warranted. 4. 5.3 x 3.8 cm left adnexal cystic lesion. This is abnormal for a postmenopausal woman. Gynecologic consultation is recommended. 5. No supraclavicular, axillary or mediastinal adenopathy. No suspicious pulmonary nodules or masses. 6. Mild to moderate centrilobular emphysematous changes with associated diffuse bronchial wall thickening suggests smoking related changes. -------------------- PATHOLOGY -------------------- ___ Pathology Tissue: immunophenotyping-peripheral -- PENDING ___ Cytogenetics Tissue: OMENTUM -- FINDINGS: No mitotic cells were found in the culture set up from this sample. CYTOGENETIC DIAGNOSIS: Undetermined. INTERPRETATION/COMMENT: Chromosome analysis was not possible because the culture set up from this omentum biopsy did not produce mitotic cells. However, FISH of interphase cells was positive for the IGH/BCL2 gene rearrangement and rearrangement of the MYC gene (see below). FISH: POSITIVE for IGH/BCL2 and MYC REARRANGEMENT. Numerous interphase omentum cells had probe signal patterns consistent with the IGH/BCL2 gene rearrangement and rearrangement of the MYC gene. There was no evidence of a BCL6 gene rearrangement. These findings are consistent with a "double hit" high grade diffuse large B-cell lymphoma of germinal center origin. ___ Cytology TOUCH PREP OF CORE -- DIAGNOSIS: Omentum, right, touch prep of core biopsy: NONDIAGNOSTIC. - Bland-appearing mesothelial cells, see note. Note: See concurrent core biopsy report (___) , flow cytometry report (___) and cytogenetics report (___-___) for further characterization. ___ Pathology Tissue: OMENTUM, BIOPSY -- DIAGNOSIS: HIGH GRADE B-CELL LYMPHOMA WITH MYC AND BCL2 TRANSLOCATIONS, SEE NOTE. Note: Section of core needle biopsy material demonstrates a sheet-like distribution of medium-sized lymphoid cells with admixed fibroadipose tissue. The medium sized monomorphic appearing lymphoid cells demonstrate a high nuclear to cytoplasmic ration, large irregular nuclei, and prominent nucleoli. Frequent mitotic figures as well apoptotic bodies are present. Areas of overt necrosis are not identified. There are small foci of small, mature appearing lymphocytes admixed with fibroadipose tissue. By immunohistochemistry CD20 highlights B-cells representing the vast majority of the lymphoid population, although some areas are dimmer than others. CD3 and CD5 highlight T-cells occupying a very minor subset of the neoplastic infiltrate but highlight the small foci of mature appearing lymphocytes. CD10 is positive in the lymphoid infiltrate while BCL6 is negative. By ___ classifiers, this lymphoma is best classified as a germinal center type (GC). BCL2 highlights the entirety of the lymphocytes. CD21, BCL1, CD34, and TdT are negative. By Ki-67 (MIB1) immunostaining, the proliferation index approaches 100%. By cytogenetic analysis (see separate report CY17-130) fluorescence in-situ hybridization (FISH) studies revealed translocations of MYC and BCL2 genes. Taken together, the morphologic, immunophenotypic, and cytogenetic findings are diagnostic of a high grade B-cell lymphoma, with MYC and BCL2 translocations. Lymphomas such as this were formerly referred to as double-hit lymphomas. Correlation with clinical, flowcytometric ___ and ___ and other laboratory findings is recommended. ___ Pathology Tissue: immunophenotyping right -- PENDING -------------------- LABS CLOSEST TO DISCHARGE -- before stopping checking -------------------- ___ 08:10AM BLOOD WBC-6.0 RBC-3.49* Hgb-10.5* Hct-31.7* MCV-91 MCH-30.1 MCHC-33.1 RDW-15.7* RDWSD-52.6* Plt ___ ___ 03:48PM BLOOD Hct-31.0* ___ 08:10AM BLOOD ___ PTT-40.7* ___ ___ 08:10AM BLOOD Glucose-58* UreaN-28* Creat-1.4* Na-142 K-4.9 Cl-96 HCO3-18* AnGap-33* ___ 08:10AM BLOOD LD(LDH)-1795* ___ 08:10AM BLOOD Calcium-9.3 Phos-5.2* Mg-1.9 UricAcd-17.2* Brief Hospital Course: ___ woman with PMHx including depression, primary hyperparathyroidism s/p resection, wet macular degeneration s/p laser photocoagulation (legally blind), presenting with progressive functional and cognitive decline and findings of dehydration, now found to have a high grade lymphoma, transitioning to hospice. # Diffuse retroperitoneal/abdominal lymphadenopathy, with wall thickening of the cecum, an 11 mm splenic hypodensity, and a left adnexal cystic lesion - an omental biopsy was performed, showing a high-grade B-cell lymphoma - after discussion with Oncology, the family (since the patient lacked capacity, and her health care proxy, daughter ___, was invoked) elected to take a palliative/hospice approach - she was referred to hospice on ___ and discharged home ___ # Hyperuricemia, and markedly elevated LDH - thought secondary to lymphoma, however given goals of care, will not plan to check any more labs - plan to stop allopurinol on discharge # Small R rectus sheath hematoma with mild acute blood loss anemia associated with omental biopsy - was kept off anticoagulants, seemed to stabilize prior to discharge based on exam and Hcts # Failure to thrive, dehydration, ___, and hypomagnesemia - attributed to the above, improved with fluids # Cognitive decline -- based on hx suspect dementia with superimposed delirium - appreciate prior Geriatrics consult who recommended starting methylphenidate at 2.5mg qAM, however the family felt she was getting over stimulated with this, so the dose was decreased to 1.25mg daily -- further reduction or spacing/stopping this medication may be needed # Mild pain - L elbow, low back - given APAP and oxycodone PRN - see below re: why she's not on a bowel regimen # Post prandial diarrhea - given starting oxycodone, have avoided prescribing a bowel regimen as this may help slow her down - if her pain requirements increase, she may benefit from laxatives # Mild thrombocytopenia - suspect related to the above, again no more monitoring # Emphysema seen on CT chest - no current respiratory symptoms - defer further evaluation or treatment for now given the above # Other - her home acyclovir, amlodipine, aspirin, docusate, losartan, eyedrops, and multivitamin were held # Advance care planning - HCP: Daughter as per web OMR, no scanned form on file - Care preferences: see ___ Oncology note for details of that conversation -- based on transition to a comfort approach, is DNAR/DNI with transition to home hospice on ___ - completed a MOLST on ___ indicating numerous limitations on life-sustaining treatment Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Losartan Potassium 100 mg PO DAILY 3. Acyclovir 400 mg PO BID:PRN herpetic eye disease 4. Lotemax (loteprednol etabonate) 0.5 % ophthalmic as needed 5. Aspirin 81 mg PO DAILY 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Multivitamins 1 TAB PO DAILY 8. Acetaminophen Dose is Unknown PO Q6H:PRN Pain - Mild Discharge Medications: 1. MethylPHENIDATE (Ritalin) 1.25 mg PO QAM RX methylphenidate 2.5 mg 0.5 (One half) tablet(s) by mouth DAILY Disp #15 Tablet Refills:0 2. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4H:PRN Disp #20 Tablet Refills:0 3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Lotemax (loteprednol etabonate) 0.5 % ophthalmic as needed Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # High grade lymphoma in the abdomen Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - With assistance. Discharge Instructions: You were admitted with dehydration and feeling unwell. We found that you have a serious terminal illness, and after discussion with our experts, we decided with you that discharge home on hospice was the right plan. Followup Instructions: ___	[ "C8593", "G9341", "N179", "R64", "E46", "G3109", "F05", "D62", "L7632", "Z681", "D696", "E8342", "E860", "H548", "H9190", "I10", "F0280", "H353290", "F329", "E210", "M25522", "M545", "J439", "R197", "Z66", "R627", "E790", "Y848", "Y92230", "Z87891" ]	Allergies: Univasc Chief Complaint: dehydration, failure to thrive Major Surgical or Invasive Procedure: [MASKED] Omental biopsy History of Present Illness: Patient is a [MASKED] with mood disorder NOS, primary hyperparathyroidism s/p resection, wet macular degeneration s/p laser photocoagulation (legally blind), who is referred from [MASKED] with progressive functional and cognitive decline and findings of dehydration. History mostly obtained from [MASKED] three daughters at bedside. Per daughters, patient was at her usual state of health until about 6 months ago when she began to slowly decline in her functional status. Previously she was ambulatory, conversational with family members and tolerating three meals a day. Over the past 6 months, she has become increasingly bedbound mostly due to lack of motivation, with very poor appetite (only taking 1 ensure daily often) with lack of interest in previously pleasurable activities including socializing with family and reading the news. Daughters also endorse underlying chronic social anxiety (refused to let repairmen in to fix her home of many years). Given this ongoing decline, PCP had conducted [MASKED] MMSE in [MASKED] and per report pt scored [MASKED]. Her decline has been associated with about 20lb weight loss, occasional diarrhea for past 3 months, and intermittent periods of acute confusion, disorientation and hallucinations (does not recognize family members, thinks she is talking to deceased family members). Daughters also think she often chokes and coughs after swallowing her food. Most recently seen in PCP office this week, basic labs, UA done which were per report unremarkable. Also given borderline SBP in [MASKED] in office, PCP stopped [MASKED] beta blocker. On ROS, endorsed left arm pain, otherwise denied fever, chills, shortness of breath. SHe had been up to date with mammograms and colonoscopies with no remarkable findings per report. Given above decline, patient was brought to [MASKED], where basic labs were unremarkable. transferred to [MASKED] bed shortage. In the [MASKED], initial VS were: 99.4 86 132/64 18 93% RA CXR: No definite acute cardiopulmonary process. [MASKED] labs were notable for trop negative x2 Transfer VS were: 98.1 74 131/58 16 95% RA Past Medical History: Mood disorder NOS Primary hyperparathyroidism s/p resection of adenoma Wet macular degeneration s/p laser photocoagulation Social History: [MASKED] Family History: Family history of colon cancer Physical Exam: Admission Exam Gen: Elderly woman, cachectic, fatigued, sleepy but arousable, NAD, hard of hearing Eyes: EOMI, sclerae anicteric ENT: dry mucous membranes, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA [MASKED]. GI: soft, NT, ND, BS+ MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx1. No facial droop. Discharge Exam Pertinent Results: -------------------- [MASKED] -------------------- Sodium 141, potassium 4.2, chloride 100, carbon dioxide 23, glucose 81, BUN 54, creatinine 1.8, albumin 3.4, total protein 6.1, T. bili 0.4 alkaline phosphatase 93, ALT 26, AST 51 Troponin at 1425 on one [MASKED] was less than 0.01 WBC 5.3, RBC 4.6, Hgb 14.2, HCT 40.9, bands 5%, PLT135 UA is yellow, cloudy ST 1.015, glucose negative, bilirubin negative, ketones negative, blood small, pH 5, protein negative, urobilinogen 0.2, nitrate negative, leuk esterase negative -------------------- [MASKED] [MASKED]: -------------------- [MASKED] 08:05PM cTropnT-<0.01 [MASKED] 12:06PM GLUCOSE-83 [MASKED] 12:06PM UREA N-62* CREAT-2.2# SODIUM-140 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-21 ANION GAP-25* [MASKED] 12:06PM ALT(SGPT)-29 AST(SGOT)-53* ALK PHOS-96 TOT BILI-0.3 [MASKED] 12:06PM CALCIUM-9.9 [MASKED] 12:06PM WBC-5.7 RBC-4.70 HGB-14.2 HCT-42.7 MCV-91 MCH-30.2 MCHC-33.3 RDW-15.2 RDWSD-51.0* [MASKED] 12:06PM PLT COUNT-161 [MASKED] 12:06PM URINE RBC-2 WBC-9* BACTERIA-FEW YEAST-NONE EPI-1 -------------------- IMAGING: -------------------- CT torso with contrast 1. Extensive mesenteric, omental, retroperitoneal, and pelvic side wall soft tissue mass/nodal tissue highly suspicious for lymphoma. 2. Wall thickening of the cecum which is also suspicious for lymphoma involvement. 3. 11 mm splenic hypodensity, statistically a cyst or hemangioma but given clinical context, attention on follow-up imaging is warranted. 4. 5.3 x 3.8 cm left adnexal cystic lesion. This is abnormal for a postmenopausal woman. Gynecologic consultation is recommended. 5. No supraclavicular, axillary or mediastinal adenopathy. No suspicious pulmonary nodules or masses. 6. Mild to moderate centrilobular emphysematous changes with associated diffuse bronchial wall thickening suggests smoking related changes. -------------------- PATHOLOGY -------------------- [MASKED] Pathology Tissue: immunophenotyping-peripheral -- PENDING [MASKED] Cytogenetics Tissue: OMENTUM -- FINDINGS: No mitotic cells were found in the culture set up from this sample. CYTOGENETIC DIAGNOSIS: Undetermined. INTERPRETATION/COMMENT: Chromosome analysis was not possible because the culture set up from this omentum biopsy did not produce mitotic cells. However, FISH of interphase cells was positive for the IGH/BCL2 gene rearrangement and rearrangement of the MYC gene (see below). FISH: POSITIVE for IGH/BCL2 and MYC REARRANGEMENT. Numerous interphase omentum cells had probe signal patterns consistent with the IGH/BCL2 gene rearrangement and rearrangement of the MYC gene. There was no evidence of a BCL6 gene rearrangement. These findings are consistent with a "double hit" high grade diffuse large B-cell lymphoma of germinal center origin. [MASKED] Cytology TOUCH PREP OF CORE -- DIAGNOSIS: Omentum, right, touch prep of core biopsy: NONDIAGNOSTIC. - Bland-appearing mesothelial cells, see note. Note: See concurrent core biopsy report ([MASKED]) , flow cytometry report ([MASKED]) and cytogenetics report ([MASKED]-[MASKED]) for further characterization. [MASKED] Pathology Tissue: OMENTUM, BIOPSY -- DIAGNOSIS: HIGH GRADE B-CELL LYMPHOMA WITH MYC AND BCL2 TRANSLOCATIONS, SEE NOTE. Note: Section of core needle biopsy material demonstrates a sheet-like distribution of medium-sized lymphoid cells with admixed fibroadipose tissue. The medium sized monomorphic appearing lymphoid cells demonstrate a high nuclear to cytoplasmic ration, large irregular nuclei, and prominent nucleoli. Frequent mitotic figures as well apoptotic bodies are present. Areas of overt necrosis are not identified. There are small foci of small, mature appearing lymphocytes admixed with fibroadipose tissue. By immunohistochemistry CD20 highlights B-cells representing the vast majority of the lymphoid population, although some areas are dimmer than others. CD3 and CD5 highlight T-cells occupying a very minor subset of the neoplastic infiltrate but highlight the small foci of mature appearing lymphocytes. CD10 is positive in the lymphoid infiltrate while BCL6 is negative. By [MASKED] classifiers, this lymphoma is best classified as a germinal center type (GC). BCL2 highlights the entirety of the lymphocytes. CD21, BCL1, CD34, and TdT are negative. By Ki-67 (MIB1) immunostaining, the proliferation index approaches 100%. By cytogenetic analysis (see separate report CY17-130) fluorescence in-situ hybridization (FISH) studies revealed translocations of MYC and BCL2 genes. Taken together, the morphologic, immunophenotypic, and cytogenetic findings are diagnostic of a high grade B-cell lymphoma, with MYC and BCL2 translocations. Lymphomas such as this were formerly referred to as double-hit lymphomas. Correlation with clinical, flowcytometric [MASKED] and [MASKED] and other laboratory findings is recommended. [MASKED] Pathology Tissue: immunophenotyping right -- PENDING -------------------- LABS CLOSEST TO DISCHARGE -- before stopping checking -------------------- [MASKED] 08:10AM BLOOD WBC-6.0 RBC-3.49* Hgb-10.5* Hct-31.7* MCV-91 MCH-30.1 MCHC-33.1 RDW-15.7* RDWSD-52.6* Plt [MASKED] [MASKED] 03:48PM BLOOD Hct-31.0* [MASKED] 08:10AM BLOOD [MASKED] PTT-40.7* [MASKED] [MASKED] 08:10AM BLOOD Glucose-58* UreaN-28* Creat-1.4* Na-142 K-4.9 Cl-96 HCO3-18* AnGap-33* [MASKED] 08:10AM BLOOD LD(LDH)-1795* [MASKED] 08:10AM BLOOD Calcium-9.3 Phos-5.2* Mg-1.9 UricAcd-17.2* Brief Hospital Course: [MASKED] woman with PMHx including depression, primary hyperparathyroidism s/p resection, wet macular degeneration s/p laser photocoagulation (legally blind), presenting with progressive functional and cognitive decline and findings of dehydration, now found to have a high grade lymphoma, transitioning to hospice. # Diffuse retroperitoneal/abdominal lymphadenopathy, with wall thickening of the cecum, an 11 mm splenic hypodensity, and a left adnexal cystic lesion - an omental biopsy was performed, showing a high-grade B-cell lymphoma - after discussion with Oncology, the family (since the patient lacked capacity, and her health care proxy, daughter [MASKED], was invoked) elected to take a palliative/hospice approach - she was referred to hospice on [MASKED] and discharged home [MASKED] # Hyperuricemia, and markedly elevated LDH - thought secondary to lymphoma, however given goals of care, will not plan to check any more labs - plan to stop allopurinol on discharge # Small R rectus sheath hematoma with mild acute blood loss anemia associated with omental biopsy - was kept off anticoagulants, seemed to stabilize prior to discharge based on exam and Hcts # Failure to thrive, dehydration, [MASKED], and hypomagnesemia - attributed to the above, improved with fluids # Cognitive decline -- based on hx suspect dementia with superimposed delirium - appreciate prior Geriatrics consult who recommended starting methylphenidate at 2.5mg qAM, however the family felt she was getting over stimulated with this, so the dose was decreased to 1.25mg daily -- further reduction or spacing/stopping this medication may be needed # Mild pain - L elbow, low back - given APAP and oxycodone PRN - see below re: why she's not on a bowel regimen # Post prandial diarrhea - given starting oxycodone, have avoided prescribing a bowel regimen as this may help slow her down - if her pain requirements increase, she may benefit from laxatives # Mild thrombocytopenia - suspect related to the above, again no more monitoring # Emphysema seen on CT chest - no current respiratory symptoms - defer further evaluation or treatment for now given the above # Other - her home acyclovir, amlodipine, aspirin, docusate, losartan, eyedrops, and multivitamin were held # Advance care planning - HCP: Daughter as per web OMR, no scanned form on file - Care preferences: see [MASKED] Oncology note for details of that conversation -- based on transition to a comfort approach, is DNAR/DNI with transition to home hospice on [MASKED] - completed a MOLST on [MASKED] indicating numerous limitations on life-sustaining treatment Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Losartan Potassium 100 mg PO DAILY 3. Acyclovir 400 mg PO BID:PRN herpetic eye disease 4. Lotemax (loteprednol etabonate) 0.5 % ophthalmic as needed 5. Aspirin 81 mg PO DAILY 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Multivitamins 1 TAB PO DAILY 8. Acetaminophen Dose is Unknown PO Q6H:PRN Pain - Mild Discharge Medications: 1. MethylPHENIDATE (Ritalin) 1.25 mg PO QAM RX methylphenidate 2.5 mg 0.5 (One half) tablet(s) by mouth DAILY Disp #15 Tablet Refills:0 2. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4H:PRN Disp #20 Tablet Refills:0 3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Lotemax (loteprednol etabonate) 0.5 % ophthalmic as needed Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: # High grade lymphoma in the abdomen Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - With assistance. Discharge Instructions: You were admitted with dehydration and feeling unwell. We found that you have a serious terminal illness, and after discussion with our experts, we decided with you that discharge home on hospice was the right plan. Followup Instructions: [MASKED]	[]	[ "N179", "D62", "D696", "I10", "F329", "Z66", "Y92230", "Z87891" ]	[ "C8593: Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes", "G9341: Metabolic encephalopathy", "N179: Acute kidney failure, unspecified", "R64: Cachexia", "E46: Unspecified protein-calorie malnutrition", "G3109: Other frontotemporal dementia", "F05: Delirium due to known physiological condition", "D62: Acute posthemorrhagic anemia", "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "Z681: Body mass index [BMI] 19.9 or less, adult", "D696: Thrombocytopenia, unspecified", "E8342: Hypomagnesemia", "E860: Dehydration", "H548: Legal blindness, as defined in USA", "H9190: Unspecified hearing loss, unspecified ear", "I10: Essential (primary) hypertension", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "H353290: Exudative age-related macular degeneration, unspecified eye, stage unspecified", "F329: Major depressive disorder, single episode, unspecified", "E210: Primary hyperparathyroidism", "M25522: Pain in left elbow", "M545: Low back pain", "J439: Emphysema, unspecified", "R197: Diarrhea, unspecified", "Z66: Do not resuscitate", "R627: Adult failure to thrive", "E790: Hyperuricemia without signs of inflammatory arthritis and tophaceous disease", "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", "Z87891: Personal history of nicotine dependence" ]
10,040,952	29,222,196	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: occipital headache and syncope found to have chiari malformation Major Surgical or Invasive Procedure: ___ s/p suboccipital craniotomy for chiari malformation, C1 laminectomy History of Present Illness: ___ M who initially presented to ___ clinic after the patient had been getting a hair cut by his girlfriend, when he tilted his head backwards and forward and developed excruciating occipital headache, which was briefly associated with nausea. He then developed dizziness and passed out. He has struck the right orbital area. There was loss of consciousness for approximately ___ seconds. There was no seizure notified, tongue biting or loss of bladder control. The patient recovered and the next day was referred to ED. CT revealed a Chiari malformation and he was recommended to have an MRI. He presents today for suboccipital craniotomy for chiari malformation and C1 laminectomy. Past Medical History: asthma, back pain Social History: ___ Family History: mother with recent stroke Physical Exam: ON DISCHARGE: Tm: 99.5, HR: 66-95, BP: 115-125/55-70, RR: ___, SpO2: 97-98% RA Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 4-3mm bilat EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. Sensation: Intact to light touch. Wound: Suboccipital crani dressing removed. Incision well approximated and closed with sutures. No drainage or erythema. Pertinent Results: Please see OMR for pertinent lab and imaging results. Brief Hospital Course: #Chiari malformation Patient presents on ___ for elective suboccipital craniotomy for chiari malformation and C1 laminectomy. The case was uncomplicated, see OMR for detailed operative report. He was extubated in the OR and transferred to PACU for post-anesthesia monitoring. He remained hemodynamically and neurologically stable and was transferred to the ___ for ongoing neurologic monitoring. His A-Line and Foley were removed on POD1. He ambulated with nursing on POD 1 and was independent on POD 2. Patient initially who had nausea postoperatively which resulted with antiemetics and scope patch. By POD 2, patient's nausea was improved, patient was reporting adequate pain control, and he was ready to for discharge home. Patient was discharged home on ___ with prescriptions and plan for follow-up in ___ clinic. Medications on Admission: albuterol PRN Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms RX cyclobenzaprine 10 mg 1 tablet(s) by mouth Q8hr Disp #5 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth Q6hr Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Chiari malformation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Suboccipital Craniotomy for decompression Chiari malformation and Spine Surgery without Fusion Surgery Your dressing came off on the second day after surgery. Your incision is closed with sutures. You will need suture removal. Please keep your incision dry until suture removal. Do not apply any lotions or creams to the site. Please avoid swimming for two weeks after suture/staple removal. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit New weakness or changes in sensation in your arms or legs. Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___	[ "G935", "Z87891", "J45909", "M549", "R110" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: occipital headache and syncope found to have chiari malformation Major Surgical or Invasive Procedure: [MASKED] s/p suboccipital craniotomy for chiari malformation, C1 laminectomy History of Present Illness: [MASKED] M who initially presented to [MASKED] clinic after the patient had been getting a hair cut by his girlfriend, when he tilted his head backwards and forward and developed excruciating occipital headache, which was briefly associated with nausea. He then developed dizziness and passed out. He has struck the right orbital area. There was loss of consciousness for approximately [MASKED] seconds. There was no seizure notified, tongue biting or loss of bladder control. The patient recovered and the next day was referred to ED. CT revealed a Chiari malformation and he was recommended to have an MRI. He presents today for suboccipital craniotomy for chiari malformation and C1 laminectomy. Past Medical History: asthma, back pain Social History: [MASKED] Family History: mother with recent stroke Physical Exam: ON DISCHARGE: Tm: 99.5, HR: 66-95, BP: 115-125/55-70, RR: [MASKED], SpO2: 97-98% RA Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 4-3mm bilat EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [MASKED] throughout. Sensation: Intact to light touch. Wound: Suboccipital crani dressing removed. Incision well approximated and closed with sutures. No drainage or erythema. Pertinent Results: Please see OMR for pertinent lab and imaging results. Brief Hospital Course: #Chiari malformation Patient presents on [MASKED] for elective suboccipital craniotomy for chiari malformation and C1 laminectomy. The case was uncomplicated, see OMR for detailed operative report. He was extubated in the OR and transferred to PACU for post-anesthesia monitoring. He remained hemodynamically and neurologically stable and was transferred to the [MASKED] for ongoing neurologic monitoring. His A-Line and Foley were removed on POD1. He ambulated with nursing on POD 1 and was independent on POD 2. Patient initially who had nausea postoperatively which resulted with antiemetics and scope patch. By POD 2, patient's nausea was improved, patient was reporting adequate pain control, and he was ready to for discharge home. Patient was discharged home on [MASKED] with prescriptions and plan for follow-up in [MASKED] clinic. Medications on Admission: albuterol PRN Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms RX cyclobenzaprine 10 mg 1 tablet(s) by mouth Q8hr Disp #5 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg [MASKED] tablet(s) by mouth Q6hr Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Chiari malformation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Suboccipital Craniotomy for decompression Chiari malformation and Spine Surgery without Fusion Surgery Your dressing came off on the second day after surgery. Your incision is closed with sutures. You will need suture removal. Please keep your incision dry until suture removal. Do not apply any lotions or creams to the site. Please avoid swimming for two weeks after suture/staple removal. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. [MASKED] try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at [MASKED] for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit New weakness or changes in sensation in your arms or legs. Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call [MASKED] and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: [MASKED]	[]	[ "Z87891", "J45909" ]	[ "G935: Compression of brain", "Z87891: Personal history of nicotine dependence", "J45909: Unspecified asthma, uncomplicated", "M549: Dorsalgia, unspecified", "R110: Nausea" ]
10,040,984	25,978,343	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Elective reversal of colostomy Major Surgical or Invasive Procedure: Colostomy reversal History of Present Illness: Mr. ___ is an ___ man with a history of cirrhosis, incarcerated hernia, and colonic perforation s/p resection and end colostomy, now undergoing colostomy reversal. Initially had ex-lap with bowel resection and end colostomy on ___ for incarcerated inguinal hernia, perforation of incarcerated colon by foreign body (toothpick), and peritonitis. Underwent colostomy reversal this admission, complicated by 1.5L blood loss likely from mesentery. Past Medical History: - Cirrhosis: Childs A. C/b portal HTN, splenomegaly, varices seen on screening EGD, no history of variceal bleeding. Believed to be secondary to EtOH. - Liver lesion - TIA/CVA: 10 months ago, no residual effects - Epilepsy - HTN - GERD - Diverticulosis - Thrombocytosis: CALR+ mutation, no increased risk of thrombosis - Prostate cancer s/p prostatectomy ___ - Hip fracture - L ___, R ___ - Incarcerated hernia with perforation s/p resection ___ Social History: ___ Family History: Father and brother had prostate cancer. No strong family history of other cancers, cardiovascular disease, or diabetes. Physical Exam: ADMISSION EXAM: VITALS: T 97.9F HR 65 BP 117/59 RR 14 SpO2 100% 3L via NC GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, mucus membranes 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, rubs, gallops ABD: soft, mildly tender to palpation, distended and tympanic. Minimal bowel sounds, no rebound tenderness or guarding, no organomegaly GU: Foley in place. Scant rectal bleeding. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Scattered ecchymoses on upper extremities. No rashes. NEURO: A&Ox3, no asterixis, moving all extremities spontaneously ACCESS: PIVs Pertinent Results: ___ 07:30AM BLOOD WBC-8.2 RBC-3.03* Hgb-9.0* Hct-26.7* MCV-88 MCH-29.7 MCHC-33.7 RDW-14.8 RDWSD-47.0* Plt ___ ___ 08:04AM BLOOD WBC-6.8 RBC-2.57* Hgb-7.6* Hct-22.6* MCV-88 MCH-29.6 MCHC-33.6 RDW-14.9 RDWSD-47.5* Plt ___ ___ 03:00PM BLOOD Hct-21.9* ___ 06:57AM BLOOD WBC-8.1 RBC-2.66* Hgb-8.0* Hct-23.3* MCV-88 MCH-30.1 MCHC-34.3 RDW-15.1 RDWSD-48.6* Plt ___ ___ 12:04PM BLOOD WBC-7.5 RBC-2.62* Hgb-7.8* Hct-23.0* MCV-88 MCH-29.8 MCHC-33.9 RDW-15.4 RDWSD-49.9* Plt ___ ___ 10:43PM BLOOD WBC-8.3 RBC-2.62* Hgb-7.9* Hct-22.9* MCV-87 MCH-30.2 MCHC-34.5 RDW-15.5 RDWSD-48.8* Plt ___ ___ 05:30PM BLOOD WBC-11.4* RBC-2.92* Hgb-8.6* Hct-25.6* MCV-88 MCH-29.5 MCHC-33.6 RDW-15.1 RDWSD-47.8* Plt ___ ___ 11:31AM BLOOD WBC-11.3* RBC-2.39* Hgb-7.2* Hct-21.3* MCV-89 MCH-30.1 MCHC-33.8 RDW-14.6 RDWSD-47.8* Plt ___ ___ 04:07AM BLOOD WBC-14.9* RBC-2.68* Hgb-7.9* Hct-24.4* MCV-91 MCH-29.5 MCHC-32.4 RDW-14.6 RDWSD-48.1* Plt ___ ___ 09:21PM BLOOD WBC-14.4* RBC-2.64* Hgb-7.9* Hct-23.8* MCV-90 MCH-29.9 MCHC-33.2 RDW-14.8 RDWSD-48.8* Plt ___ ___ 03:33PM BLOOD WBC-18.7# RBC-3.08 Hgb-9.2* Hct-28.6* MCV-93 MCH-29.9 MCHC-32.2 RDW-13.7 RDWSD-45.9 Plt ___ ___ 08:04AM BLOOD ___ PTT-35.6 ___ ___ 06:57AM BLOOD ___ PTT-32.1 ___ ___ 12:04PM BLOOD ___ PTT-32.5 ___ ___ 04:51AM BLOOD ___ PTT-34.1 ___ ___ 05:05PM BLOOD ___ PTT-32.8 ___ ___ 11:31AM BLOOD ___ PTT-32.1 ___ ___ 04:07AM BLOOD ___ PTT-29.8 ___ ___ 09:21PM BLOOD ___ PTT-32.4 ___ ___ 03:33PM BLOOD ___ PTT-31.5 ___ ___ 07:30AM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-140 K-3.8 Cl-105 HCO3-24 AnGap-11 ___ 08:04AM BLOOD Glucose-107* UreaN-12 Creat-1.0 Na-141 K-4.0 Cl-106 HCO3-24 AnGap-11 ___ 06:57AM BLOOD Glucose-128* UreaN-13 Creat-1.1 Na-141 K-4.0 Cl-106 HCO3-24 AnGap-11 ___ 04:51AM BLOOD Glucose-135* UreaN-15 Creat-1.1 Na-139 K-4.0 Cl-107 HCO3-23 AnGap-9 ___ 10:43PM BLOOD Glucose-123* UreaN-22* Creat-1.1 Na-142 K-4.7 Cl-108 HCO3-22 AnGap-12 ___ 05:05PM BLOOD Glucose-120* UreaN-23* Creat-1.1 Na-142 K-4.1 Cl-107 HCO3-22 AnGap-13 ___ 11:31AM BLOOD Glucose-122* UreaN-25* Creat-1.2 Na-139 K-4.1 Cl-106 HCO3-23 AnGap-10 ___ 04:07AM BLOOD Glucose-181* UreaN-25* Creat-1.2 Na-140 K-4.2 Cl-107 HCO3-22 AnGap-11 ___ 06:57AM BLOOD ALT-5 AST-22 AlkPhos-66 TotBili-0.4 ___ 04:51AM BLOOD ALT-10 AST-25 AlkPhos-59 TotBili-0.3 ___ 10:43PM BLOOD ALT-10 AST-28 AlkPhos-60 TotBili-0.5 ___ 03:33PM BLOOD ALT-22 AST-27 AlkPhos-98 TotBili-0.5 ___ 07:30AM BLOOD Calcium-7.7* Phos-1.9* Mg-2.0 ___ 08:04AM BLOOD Calcium-7.7* Phos-2.3* Mg-2.0 ___ 04:51AM BLOOD Calcium-7.4* Phos-1.6* Mg-1.8 ___ 10:43PM BLOOD Calcium-7.6* Phos-2.3* Mg-1.7 ___ 05:05PM BLOOD Calcium-7.8* Phos-2.5* Mg-1.9 ___ 11:31AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.8 ___ 04:07AM BLOOD Calcium-7.2* Phos-3.3 Mg-1.8 ___ 03:33PM BLOOD Albumin-3.9 Calcium-8.2* Phos-4.5 Mg-2.___uring Mr. ___ reversal surgery, significant blood loss was noted in the RUQ. Hemostasis was achieved, but the source was unclear, possibly damaged mesentery. Total blood loss was 1.5L, pt received 2U of blood and 2U FFP in the OR and PACU. He looked clinically well in PACU and was transferred to ICU for hemodynamic monitoring. On arrival to the MICU, Mr. ___ complained of minor abdominal soreness without significant pain, an upset stomach, and nausea. He denied headache, shortness of breath, fatigue, weakness, and chest pain. His H&H remained stable except for dilutional changes, and his vitals were monitored for signs of bleeding or hypovolemia. He was started on antibiotics per colorectal surgery team. His nausea and ileus were addressed with metoclopramide and ondansetron. After being deemed stable from a hemodynamic standpoint, he was transferred to the surgical floor. After transfer to the inpatient unit on ___, Mr. ___ continued to pass old blood. On over two days this changed to non bloody loose stool. He was given a unit of blood on the floor on ___. His wounds were all stable. He continued to have takedown site dressing changes. His was hemodynamically stable and his hematocrit continued to increase. He did have an elevated INR likely related to his baseline liver dysfunction and he was given Vitamin K. He tolerated a regular diet. Pain control was achieved with Tylenol. He worked with physical therapy who recommended services for home however, the patient refused home physical therapy services as well as outpatient services. Medications on Admission: 1. Furosemide 10 mg PO DAILY 2. LevETIRAcetam 250 mg PO BID 3. Metoprolol Tartrate 12.5 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 6. Aspirin 81 mg PO DAILY 7. Vitamin D 800 UNIT PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Ranitidine 150 mg PO QHS 10. Spironolactone 25 mg PO DAILY Discharge Medications: 1. Psyllium Wafer 1 WAF PO BID RX psyllium [Metamucil (sugar)] 1.7 g 1 wafer(s) by mouth twice a day Disp #60 Wafer Refills:*0 2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild Duration: 5 Days do not continue more than 5 days, do not drink alcohol, do not take more than 2000mg in 24 hrs 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID ok to restart if constipated 5. Furosemide 10 mg PO DAILY 6. LevETIRAcetam 250 mg PO BID 7. Metoprolol Tartrate 12.5 mg PO DAILY do not start until ___ 8. Multivitamins 1 TAB PO DAILY 9. Ranitidine 150 mg PO QHS 10. Spironolactone 25 mg PO DAILY 11. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: colostomy reversal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after an ileostomy takedown. You had some bleeding after the procedure however this has stabilized and You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected however, if you notice that you are passing bright red blood with bowel your please seek medical attention. If you are passing loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. It is also not uncommon after an ileostomy takedown to have frequent loose stools until you are taking more regular food however this should improve. The muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence however this should improve. If you do not show improvement in these symptoms within ___ days please call the office for advice. Occasionally, patients will need to take a medication to slow their bowel movements as their bodies adjust to the new normal without an ileostomy, you should consult with our office for advice. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have a small wound where the old ileostomy once was. This should be covered with a dry sterile gauze dressing. The wound no longer requires packing with gauze packing strip. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. Please apply a new gauze dressing after showering. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgical team. You may gradually increase your activity as tolerated but clear heavy exercise with your surgical team. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 3000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___	[ "Z433", "K9171", "D684", "K766", "D62", "K913", "K660", "K7030", "G40909", "I10", "K219", "F1021", "Y838", "Y92234", "Z8546", "Z8673", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions [MASKED] Complaint: Elective reversal of colostomy Major Surgical or Invasive Procedure: Colostomy reversal History of Present Illness: Mr. [MASKED] is an [MASKED] man with a history of cirrhosis, incarcerated hernia, and colonic perforation s/p resection and end colostomy, now undergoing colostomy reversal. Initially had ex-lap with bowel resection and end colostomy on [MASKED] for incarcerated inguinal hernia, perforation of incarcerated colon by foreign body (toothpick), and peritonitis. Underwent colostomy reversal this admission, complicated by 1.5L blood loss likely from mesentery. Past Medical History: - Cirrhosis: Childs A. C/b portal HTN, splenomegaly, varices seen on screening EGD, no history of variceal bleeding. Believed to be secondary to EtOH. - Liver lesion - TIA/CVA: 10 months ago, no residual effects - Epilepsy - HTN - GERD - Diverticulosis - Thrombocytosis: CALR+ mutation, no increased risk of thrombosis - Prostate cancer s/p prostatectomy [MASKED] - Hip fracture - L [MASKED], R [MASKED] - Incarcerated hernia with perforation s/p resection [MASKED] Social History: [MASKED] Family History: Father and brother had prostate cancer. No strong family history of other cancers, cardiovascular disease, or diabetes. Physical Exam: ADMISSION EXAM: VITALS: T 97.9F HR 65 BP 117/59 RR 14 SpO2 100% 3L via NC GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, mucus membranes 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, rubs, gallops ABD: soft, mildly tender to palpation, distended and tympanic. Minimal bowel sounds, no rebound tenderness or guarding, no organomegaly GU: Foley in place. Scant rectal bleeding. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Scattered ecchymoses on upper extremities. No rashes. NEURO: A&Ox3, no asterixis, moving all extremities spontaneously ACCESS: PIVs Pertinent Results: [MASKED] 07:30AM BLOOD WBC-8.2 RBC-3.03* Hgb-9.0* Hct-26.7* MCV-88 MCH-29.7 MCHC-33.7 RDW-14.8 RDWSD-47.0* Plt [MASKED] [MASKED] 08:04AM BLOOD WBC-6.8 RBC-2.57* Hgb-7.6* Hct-22.6* MCV-88 MCH-29.6 MCHC-33.6 RDW-14.9 RDWSD-47.5* Plt [MASKED] [MASKED] 03:00PM BLOOD Hct-21.9* [MASKED] 06:57AM BLOOD WBC-8.1 RBC-2.66* Hgb-8.0* Hct-23.3* MCV-88 MCH-30.1 MCHC-34.3 RDW-15.1 RDWSD-48.6* Plt [MASKED] [MASKED] 12:04PM BLOOD WBC-7.5 RBC-2.62* Hgb-7.8* Hct-23.0* MCV-88 MCH-29.8 MCHC-33.9 RDW-15.4 RDWSD-49.9* Plt [MASKED] [MASKED] 10:43PM BLOOD WBC-8.3 RBC-2.62* Hgb-7.9* Hct-22.9* MCV-87 MCH-30.2 MCHC-34.5 RDW-15.5 RDWSD-48.8* Plt [MASKED] [MASKED] 05:30PM BLOOD WBC-11.4* RBC-2.92* Hgb-8.6* Hct-25.6* MCV-88 MCH-29.5 MCHC-33.6 RDW-15.1 RDWSD-47.8* Plt [MASKED] [MASKED] 11:31AM BLOOD WBC-11.3* RBC-2.39* Hgb-7.2* Hct-21.3* MCV-89 MCH-30.1 MCHC-33.8 RDW-14.6 RDWSD-47.8* Plt [MASKED] [MASKED] 04:07AM BLOOD WBC-14.9* RBC-2.68* Hgb-7.9* Hct-24.4* MCV-91 MCH-29.5 MCHC-32.4 RDW-14.6 RDWSD-48.1* Plt [MASKED] [MASKED] 09:21PM BLOOD WBC-14.4* RBC-2.64* Hgb-7.9* Hct-23.8* MCV-90 MCH-29.9 MCHC-33.2 RDW-14.8 RDWSD-48.8* Plt [MASKED] [MASKED] 03:33PM BLOOD WBC-18.7# RBC-3.08 Hgb-9.2* Hct-28.6* MCV-93 MCH-29.9 MCHC-32.2 RDW-13.7 RDWSD-45.9 Plt [MASKED] [MASKED] 08:04AM BLOOD [MASKED] PTT-35.6 [MASKED] [MASKED] 06:57AM BLOOD [MASKED] PTT-32.1 [MASKED] [MASKED] 12:04PM BLOOD [MASKED] PTT-32.5 [MASKED] [MASKED] 04:51AM BLOOD [MASKED] PTT-34.1 [MASKED] [MASKED] 05:05PM BLOOD [MASKED] PTT-32.8 [MASKED] [MASKED] 11:31AM BLOOD [MASKED] PTT-32.1 [MASKED] [MASKED] 04:07AM BLOOD [MASKED] PTT-29.8 [MASKED] [MASKED] 09:21PM BLOOD [MASKED] PTT-32.4 [MASKED] [MASKED] 03:33PM BLOOD [MASKED] PTT-31.5 [MASKED] [MASKED] 07:30AM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-140 K-3.8 Cl-105 HCO3-24 AnGap-11 [MASKED] 08:04AM BLOOD Glucose-107* UreaN-12 Creat-1.0 Na-141 K-4.0 Cl-106 HCO3-24 AnGap-11 [MASKED] 06:57AM BLOOD Glucose-128* UreaN-13 Creat-1.1 Na-141 K-4.0 Cl-106 HCO3-24 AnGap-11 [MASKED] 04:51AM BLOOD Glucose-135* UreaN-15 Creat-1.1 Na-139 K-4.0 Cl-107 HCO3-23 AnGap-9 [MASKED] 10:43PM BLOOD Glucose-123* UreaN-22* Creat-1.1 Na-142 K-4.7 Cl-108 HCO3-22 AnGap-12 [MASKED] 05:05PM BLOOD Glucose-120* UreaN-23* Creat-1.1 Na-142 K-4.1 Cl-107 HCO3-22 AnGap-13 [MASKED] 11:31AM BLOOD Glucose-122* UreaN-25* Creat-1.2 Na-139 K-4.1 Cl-106 HCO3-23 AnGap-10 [MASKED] 04:07AM BLOOD Glucose-181* UreaN-25* Creat-1.2 Na-140 K-4.2 Cl-107 HCO3-22 AnGap-11 [MASKED] 06:57AM BLOOD ALT-5 AST-22 AlkPhos-66 TotBili-0.4 [MASKED] 04:51AM BLOOD ALT-10 AST-25 AlkPhos-59 TotBili-0.3 [MASKED] 10:43PM BLOOD ALT-10 AST-28 AlkPhos-60 TotBili-0.5 [MASKED] 03:33PM BLOOD ALT-22 AST-27 AlkPhos-98 TotBili-0.5 [MASKED] 07:30AM BLOOD Calcium-7.7* Phos-1.9* Mg-2.0 [MASKED] 08:04AM BLOOD Calcium-7.7* Phos-2.3* Mg-2.0 [MASKED] 04:51AM BLOOD Calcium-7.4* Phos-1.6* Mg-1.8 [MASKED] 10:43PM BLOOD Calcium-7.6* Phos-2.3* Mg-1.7 [MASKED] 05:05PM BLOOD Calcium-7.8* Phos-2.5* Mg-1.9 [MASKED] 11:31AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.8 [MASKED] 04:07AM BLOOD Calcium-7.2* Phos-3.3 Mg-1.8 [MASKED] 03:33PM BLOOD Albumin-3.9 Calcium-8.2* Phos-4.5 Mg-2. uring Mr. [MASKED] reversal surgery, significant blood loss was noted in the RUQ. Hemostasis was achieved, but the source was unclear, possibly damaged mesentery. Total blood loss was 1.5L, pt received 2U of blood and 2U FFP in the OR and PACU. He looked clinically well in PACU and was transferred to ICU for hemodynamic monitoring. On arrival to the MICU, Mr. [MASKED] complained of minor abdominal soreness without significant pain, an upset stomach, and nausea. He denied headache, shortness of breath, fatigue, weakness, and chest pain. His H&H remained stable except for dilutional changes, and his vitals were monitored for signs of bleeding or hypovolemia. He was started on antibiotics per colorectal surgery team. His nausea and ileus were addressed with metoclopramide and ondansetron. After being deemed stable from a hemodynamic standpoint, he was transferred to the surgical floor. After transfer to the inpatient unit on [MASKED], Mr. [MASKED] continued to pass old blood. On over two days this changed to non bloody loose stool. He was given a unit of blood on the floor on [MASKED]. His wounds were all stable. He continued to have takedown site dressing changes. His was hemodynamically stable and his hematocrit continued to increase. He did have an elevated INR likely related to his baseline liver dysfunction and he was given Vitamin K. He tolerated a regular diet. Pain control was achieved with Tylenol. He worked with physical therapy who recommended services for home however, the patient refused home physical therapy services as well as outpatient services. Medications on Admission: 1. Furosemide 10 mg PO DAILY 2. LevETIRAcetam 250 mg PO BID 3. Metoprolol Tartrate 12.5 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 6. Aspirin 81 mg PO DAILY 7. Vitamin D 800 UNIT PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Ranitidine 150 mg PO QHS 10. Spironolactone 25 mg PO DAILY Discharge Medications: 1. Psyllium Wafer 1 WAF PO BID RX psyllium [Metamucil (sugar)] 1.7 g 1 wafer(s) by mouth twice a day Disp #60 Wafer Refills:*0 2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild Duration: 5 Days do not continue more than 5 days, do not drink alcohol, do not take more than 2000mg in 24 hrs 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID ok to restart if constipated 5. Furosemide 10 mg PO DAILY 6. LevETIRAcetam 250 mg PO BID 7. Metoprolol Tartrate 12.5 mg PO DAILY do not start until [MASKED] 8. Multivitamins 1 TAB PO DAILY 9. Ranitidine 150 mg PO QHS 10. Spironolactone 25 mg PO DAILY 11. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: colostomy reversal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after an ileostomy takedown. You had some bleeding after the procedure however this has stabilized and You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected however, if you notice that you are passing bright red blood with bowel your please seek medical attention. If you are passing loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. It is also not uncommon after an ileostomy takedown to have frequent loose stools until you are taking more regular food however this should improve. The muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence however this should improve. If you do not show improvement in these symptoms within [MASKED] days please call the office for advice. Occasionally, patients will need to take a medication to slow their bowel movements as their bodies adjust to the new normal without an ileostomy, you should consult with our office for advice. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have a small wound where the old ileostomy once was. This should be covered with a dry sterile gauze dressing. The wound no longer requires packing with gauze packing strip. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. Please apply a new gauze dressing after showering. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgical team. You may gradually increase your activity as tolerated but clear heavy exercise with your surgical team. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 3000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED]	[]	[ "D62", "I10", "K219", "Z8673", "Z87891" ]	[ "Z433: Encounter for attention to colostomy", "K9171: Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure", "D684: Acquired coagulation factor deficiency", "K766: Portal hypertension", "D62: Acute posthemorrhagic anemia", "K913: Postprocedural intestinal obstruction", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "K7030: Alcoholic cirrhosis of liver without ascites", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "F1021: Alcohol dependence, in remission", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z8546: Personal history of malignant neoplasm of prostate", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence" ]
10,040,984	29,975,777	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Incarcerated inguinal hernia and perforation of incarcerated sigmoid colon with foreign body (toothpick). Major Surgical or Invasive Procedure: ___ 1. Exploratory laparotomy with sigmoid colectomy and ___ procedure. 2. Abdominal washout. 3. Reduction of incarcerated left inguinal hernia with Bassini-type repair. History of Present Illness: Per Dr. ___ note as follows: ___ man with known cirrhosis who presents with a two-day history of incarceration of a known left inguinal hernia. He also has not passed any flatus and is quite sick with an elevated white count and redness over the hernia. He is brought urgently to the operating room. Past Medical History: - prostate CA s/p prostatectomy in ___ - Saw a hematologist (Dr. ___ in ___ for a "blood disorder" a few years ago, might have been related to his liver disease - GERD - ETOH Abuse (per pt and wife quit ___ years ago) - s/p L hip ORIF (pt fell and broke right hip while withdrawing from EtOH a number of years ago) - "liver disease," unclear if pt had actually been diagnosed with cirrhosis Social History: ___ Family History: No FH of CAD or CA. A grandparent had DM. Physical Exam: ___ 80 HR 136/81 RR18 98% RA Gen: affable, elderly appearing gentleman CV: RRR no obvious MRG Pulm: post CTAB, anterior minor wheezes Abd: soft, non tender non distend no guarding or rebound, infra umbilical midline incision well healed no obvious facial defects Left scrotm large, tender, non reducible with erythematous skin. No ___ edema b/l Labs: 141 ___ 4.4 21 1.3 estGFR: 53 ALT: 42 AP: 136 Tbili: 1.4 Alb: 3.5 AST: 32 Lip: 19 11.0 23.1 500 32.3 Coags: pending CXR: outside facility ___ without evidence of acute process EKG: pending OSH ___: WBC 27k Plts 644k Cr 1.44 Tb 1.7 lactic acid ___ Pertinent Results: Admission labs: ___ 04:07PM BLOOD WBC-23.1# RBC-3.49 Hgb-11.0# Hct-32.3 MCV-93 MCH-31.5 MCHC-34.1 RDW-13.9 RDWSD-47.1* Plt ___ ___ 04:07PM BLOOD Glucose-106* UreaN-30* Creat-1.3* Na-141 K-4.4 Cl-107 HCO3-21* AnGap-17 ___ 04:07PM BLOOD ALT-42* AST-32 AlkPhos-136* TotBili-1.4 ___ 11:59PM BLOOD Calcium-7.6* Phos-4.7* Mg-1.7 ___ 04:07PM BLOOD Albumin-3.5 Discharge labs: ___ 06:14AM BLOOD WBC-8.3 RBC-3.37* Hgb-10.0* Hct-30.8* MCV-91 MCH-29.7 MCHC-32.5 RDW-14.4 RDWSD-47.3* Plt ___ ___ 04:53AM BLOOD ___ PTT-27.8 ___ ___ 06:14AM BLOOD Glucose-130* UreaN-43* Creat-1.8* Na-135 K-4.8 Cl-100 HCO3-22 AnGap-18 ___ 06:14AM BLOOD ALT-60* AST-50* AlkPhos-368* TotBili-0.5 ___ 06:14AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.3 Brief Hospital Course: On ___, he underwent exploratory laparotomy with sigmoid colectomy and ___ procedure for perforation of incarcerated sigmoid colon with foreign body (tooth pick), abdominal washout and reduction of incarcerated left inguinal hernia with Bassini-type repair. Other finders were peritonitis and cirrhosis. Surgeon was Dr. ___. Please refer to operative note for complete details. Postop,urine output was low and IV fluid bolus was given with improvement. He had a short run of VTach with normal EKG. Metoprolol was given for tachycardia on ___. Overnnight on ___, he had several rhythms (Tachy w/ new LBBB, inverted T waves). Cardiology was consulted. Cardiology was consulted and recommended ???? Cardiac enzymes were normal and lytes were repleted. The NG was removed on ___. He was started on sips and was passing gas and stool thru ostomy on ___. Diet was advanced to a regular diet. Dilaudid PCA was changed to oral dilaudid. On ___, O2 desaturated to 80%. CXR was done showing stable left opacity and right upper opacity. Lasix was started for pulmonary edema. Heart rate was tachy with a new LBBB, inverted T waves. Cardiology was consulted, troponin/ck cycled (wnl),and lytes replaced. Metoprolol was started for rate control. TTE was grossly unremarkable. On ___, he had ascites leaking through the incision as well as parastomal. Albumin and Lasix doses were given. Zosyn was started while ascites leaking. On ___, Liver U/S demonstrated cirrhosis, secondary evidence of portal HTN, and no thrombus. LFTs increased mildly from admission and remained in the same range. Cardiac enzymes were cycled and negative. Metoprolol was given with better control of heart rate. He had some SVT initermittently on walks down hallway without symptoms. Lasix and Spironolactone were decreased a couple times for creatinine increase to 1.8 on ___ from 1.3-1.5. Creatinine remained at 1.8 Weight was 64kg (admission 74kg). A Prevena wound vac was applied to the incision to control the ascites leak with good response. Prevena vac was removed on ___. Incision remained clean and dry. Staples were left in place to be removed by Dr. ___ in follow up appointment. Zosyn was changed to Augmenting on ___ then discontinued on ___ when he was discharged to rehab ___). He remained afebrile. Nutritional intake was poor despite nutritional supplements. Kcal count was low (325) and a feeding tube was placed. Osmolite 1.5 was started and rate increased to goal of 60ml/hour continuous. He tolerated this just fine. ___ evaluated and worked with him noting deconditioning and weakness. Rehab was recommended. ___ in ___ offered a bed and he was discharged in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. LevETIRAcetam 250 mg PO BID 3. Omeprazole Dose is Unknown PO DAILY 4. Aspirin Dose is Unknown PO Frequency is Unknown 5. Vitamin D 800 UNIT PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Ranitidine 150 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Acetylcysteine 20% ___ mL NEB Q4H:PRN thick secretions 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 5. Furosemide 10 mg PO DAILY 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 7. Glucose Gel 15 g PO PRN hypoglycemia protocol 8. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Wheezing 10. Metoprolol Tartrate 12.5 mg PO Q6H Hold for SBP <95 Hold for HR <60 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Senna 8.6 mg PO BID:PRN constipation 13. Spironolactone 25 mg PO DAILY 14. TraMADol 25 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 15. Aspirin 81 mg PO DAILY 16. Docusate Sodium 100 mg PO BID hold for loose stool 17. LevETIRAcetam 250 mg PO BID 18. Ranitidine 150 mg PO QHS 19. HELD- Vitamin D 800 UNIT PO DAILY This medication was held. Do not restart Vitamin D until discussed with PCP ___: Extended Care Facility: ___ Discharge Diagnosis: Incarcerated inguinal hernia. Perforation of incarcerated sigmoid colon with foreign body (toothpick) Peritonitis Cirrhosis ETOH Cirrhosis SVT 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 will be transferring to ___ Rehab in ___ Please call Dr. ___ office at ___ for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, discoloration of stoma, constipation, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, or any other concerning symptoms. You may shower, but no tub baths No heavy lifting/straining (nothing heavier than 10 pounds) Tube feedings have been started for malnutrition. Followup Instructions: ___	[ "K4030", "K659", "I472", "J811", "E46", "T184XXA", "K7031", "K766", "I8510", "S36593A", "E512", "K219", "F17210", "I10", "Z8673", "I447", "Z8546", "Z96643", "Y929", "Z6823" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Incarcerated inguinal hernia and perforation of incarcerated sigmoid colon with foreign body (toothpick). Major Surgical or Invasive Procedure: [MASKED] 1. Exploratory laparotomy with sigmoid colectomy and [MASKED] procedure. 2. Abdominal washout. 3. Reduction of incarcerated left inguinal hernia with Bassini-type repair. History of Present Illness: Per Dr. [MASKED] note as follows: [MASKED] man with known cirrhosis who presents with a two-day history of incarceration of a known left inguinal hernia. He also has not passed any flatus and is quite sick with an elevated white count and redness over the hernia. He is brought urgently to the operating room. Past Medical History: - prostate CA s/p prostatectomy in [MASKED] - Saw a hematologist (Dr. [MASKED] in [MASKED] for a "blood disorder" a few years ago, might have been related to his liver disease - GERD - ETOH Abuse (per pt and wife quit [MASKED] years ago) - s/p L hip ORIF (pt fell and broke right hip while withdrawing from EtOH a number of years ago) - "liver disease," unclear if pt had actually been diagnosed with cirrhosis Social History: [MASKED] Family History: No FH of CAD or CA. A grandparent had DM. Physical Exam: [MASKED] 80 HR 136/81 RR18 98% RA Gen: affable, elderly appearing gentleman CV: RRR no obvious MRG Pulm: post CTAB, anterior minor wheezes Abd: soft, non tender non distend no guarding or rebound, infra umbilical midline incision well healed no obvious facial defects Left scrotm large, tender, non reducible with erythematous skin. No [MASKED] edema b/l Labs: 141 [MASKED] 4.4 21 1.3 estGFR: 53 ALT: 42 AP: 136 Tbili: 1.4 Alb: 3.5 AST: 32 Lip: 19 11.0 23.1 500 32.3 Coags: pending CXR: outside facility [MASKED] without evidence of acute process EKG: pending OSH [MASKED]: WBC 27k Plts 644k Cr 1.44 Tb 1.7 lactic acid [MASKED] Pertinent Results: Admission labs: [MASKED] 04:07PM BLOOD WBC-23.1# RBC-3.49 Hgb-11.0# Hct-32.3 MCV-93 MCH-31.5 MCHC-34.1 RDW-13.9 RDWSD-47.1* Plt [MASKED] [MASKED] 04:07PM BLOOD Glucose-106* UreaN-30* Creat-1.3* Na-141 K-4.4 Cl-107 HCO3-21* AnGap-17 [MASKED] 04:07PM BLOOD ALT-42* AST-32 AlkPhos-136* TotBili-1.4 [MASKED] 11:59PM BLOOD Calcium-7.6* Phos-4.7* Mg-1.7 [MASKED] 04:07PM BLOOD Albumin-3.5 Discharge labs: [MASKED] 06:14AM BLOOD WBC-8.3 RBC-3.37* Hgb-10.0* Hct-30.8* MCV-91 MCH-29.7 MCHC-32.5 RDW-14.4 RDWSD-47.3* Plt [MASKED] [MASKED] 04:53AM BLOOD [MASKED] PTT-27.8 [MASKED] [MASKED] 06:14AM BLOOD Glucose-130* UreaN-43* Creat-1.8* Na-135 K-4.8 Cl-100 HCO3-22 AnGap-18 [MASKED] 06:14AM BLOOD ALT-60* AST-50* AlkPhos-368* TotBili-0.5 [MASKED] 06:14AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.3 Brief Hospital Course: On [MASKED], he underwent exploratory laparotomy with sigmoid colectomy and [MASKED] procedure for perforation of incarcerated sigmoid colon with foreign body (tooth pick), abdominal washout and reduction of incarcerated left inguinal hernia with Bassini-type repair. Other finders were peritonitis and cirrhosis. Surgeon was Dr. [MASKED]. Please refer to operative note for complete details. Postop,urine output was low and IV fluid bolus was given with improvement. He had a short run of VTach with normal EKG. Metoprolol was given for tachycardia on [MASKED]. Overnnight on [MASKED], he had several rhythms (Tachy w/ new LBBB, inverted T waves). Cardiology was consulted. Cardiology was consulted and recommended ???? Cardiac enzymes were normal and lytes were repleted. The NG was removed on [MASKED]. He was started on sips and was passing gas and stool thru ostomy on [MASKED]. Diet was advanced to a regular diet. Dilaudid PCA was changed to oral dilaudid. On [MASKED], O2 desaturated to 80%. CXR was done showing stable left opacity and right upper opacity. Lasix was started for pulmonary edema. Heart rate was tachy with a new LBBB, inverted T waves. Cardiology was consulted, troponin/ck cycled (wnl),and lytes replaced. Metoprolol was started for rate control. TTE was grossly unremarkable. On [MASKED], he had ascites leaking through the incision as well as parastomal. Albumin and Lasix doses were given. Zosyn was started while ascites leaking. On [MASKED], Liver U/S demonstrated cirrhosis, secondary evidence of portal HTN, and no thrombus. LFTs increased mildly from admission and remained in the same range. Cardiac enzymes were cycled and negative. Metoprolol was given with better control of heart rate. He had some SVT initermittently on walks down hallway without symptoms. Lasix and Spironolactone were decreased a couple times for creatinine increase to 1.8 on [MASKED] from 1.3-1.5. Creatinine remained at 1.8 Weight was 64kg (admission 74kg). A Prevena wound vac was applied to the incision to control the ascites leak with good response. Prevena vac was removed on [MASKED]. Incision remained clean and dry. Staples were left in place to be removed by Dr. [MASKED] in follow up appointment. Zosyn was changed to Augmenting on [MASKED] then discontinued on [MASKED] when he was discharged to rehab [MASKED]). He remained afebrile. Nutritional intake was poor despite nutritional supplements. Kcal count was low (325) and a feeding tube was placed. Osmolite 1.5 was started and rate increased to goal of 60ml/hour continuous. He tolerated this just fine. [MASKED] evaluated and worked with him noting deconditioning and weakness. Rehab was recommended. [MASKED] in [MASKED] offered a bed and he was discharged in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. LevETIRAcetam 250 mg PO BID 3. Omeprazole Dose is Unknown PO DAILY 4. Aspirin Dose is Unknown PO Frequency is Unknown 5. Vitamin D 800 UNIT PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Ranitidine 150 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Acetylcysteine 20% [MASKED] mL NEB Q4H:PRN thick secretions 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 5. Furosemide 10 mg PO DAILY 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 7. Glucose Gel 15 g PO PRN hypoglycemia protocol 8. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Wheezing 10. Metoprolol Tartrate 12.5 mg PO Q6H Hold for SBP <95 Hold for HR <60 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Senna 8.6 mg PO BID:PRN constipation 13. Spironolactone 25 mg PO DAILY 14. TraMADol 25 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 15. Aspirin 81 mg PO DAILY 16. Docusate Sodium 100 mg PO BID hold for loose stool 17. LevETIRAcetam 250 mg PO BID 18. Ranitidine 150 mg PO QHS 19. HELD- Vitamin D 800 UNIT PO DAILY This medication was held. Do not restart Vitamin D until discussed with PCP [MASKED]: Extended Care Facility: [MASKED] Discharge Diagnosis: Incarcerated inguinal hernia. Perforation of incarcerated sigmoid colon with foreign body (toothpick) Peritonitis Cirrhosis ETOH Cirrhosis SVT 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 will be transferring to [MASKED] Rehab in [MASKED] Please call Dr. [MASKED] office at [MASKED] for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, discoloration of stoma, constipation, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, or any other concerning symptoms. You may shower, but no tub baths No heavy lifting/straining (nothing heavier than 10 pounds) Tube feedings have been started for malnutrition. Followup Instructions: [MASKED]	[]	[ "K219", "F17210", "I10", "Z8673", "Y929" ]	[ "K4030: Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent", "K659: Peritonitis, unspecified", "I472: Ventricular tachycardia", "J811: Chronic pulmonary edema", "E46: Unspecified protein-calorie malnutrition", "T184XXA: Foreign body in colon, initial encounter", "K7031: Alcoholic cirrhosis of liver with ascites", "K766: Portal hypertension", "I8510: Secondary esophageal varices without bleeding", "S36593A: Other injury of sigmoid colon, initial encounter", "E512: Wernicke's encephalopathy", "K219: Gastro-esophageal reflux disease without esophagitis", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I447: Left bundle-branch block, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z96643: Presence of artificial hip joint, bilateral", "Y929: Unspecified place or not applicable", "Z6823: Body mass index [BMI] 23.0-23.9, adult" ]
10,041,312	25,060,515	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: codeine / erythromycin base / cephalasporin / Motrin Attending: ___. Chief Complaint: left lower extremity rest pain Major Surgical or Invasive Procedure: ___: diagnostic angiogram, LLE ___: Left iliofemoral thromboendarterectomy, external iliac artery stent History of Present Illness: Ms. ___ is an ___ years old woman with history of COPD- not on home O2, CHF (EF 40%), CKDIII, CAD, HTN, HLD who refers having left lower extremity pain since ___ this year. She refers it started as a throbbing pain when walking but has progressed to rest pain for the past two weeks. She denies weakness, nausea, vomit, fever, chills, chest pain or shortness of breath.Vital Signs sheet entries for ___: Weight: 210.10 (Standing Scale) (Entered in Nursing IPA). Height: 61 (Patient Reported) (Entered in Nursing IPA). BMI: 39.7. The patient refers she did not pursue further workup for her leg pain initially because she was having acute cholecystitis and had been in and out of the hospital for that reason. Her acute cholecystitis finally resolved around ___ (cholecystectomy) and since the leg pain was still there and now was present at rest she consulted Dr. ___ recommended further workup with angiogram and possible angioplasty. Past Medical History: PAST MEDICAL HISTORY COPD- not on home O2 CHF (EF 40%) CKDIII CAD HTN HLD Cognitive dysfunction Obesity GERD Hypercoagulable state-family unsure-no history of clots OA Asthma Gastric polyps Diverticulosis PAST SURGICAL HISTORY Laparoscopic cholecystectomy (___) Right shoulder, knee, hip surgery Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam VITAL SIGNS: Temp: 98.0, HR: 66, BP: 130/78, RR: 14, O2Sat:95%RA GENERAL: AAOx3 NAD HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no LAD CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G CAROTIDS: 2+, No bruits or JVD PULSES: Femoral/Popliteal/Dorsalis pedis/Posterior tibial LLE: -/-/-/- RLE: -/-/D/D PULMONARY: CTA ___, No crackles or rhonchi GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or peritoneal signs. +BSx4 EXT/MS/SKIN: Feet warm. NEUROLOGICAL: Reflexes, strength, and sensation grossly intact Discharge Physical Exam Vitals: Tm:98.2 Tc:97.8 HR:91 BP:119/71 RR:18 O2:95% 1L Gen: NAD CV: RRR Pulm: no respiratory distress Abd: soft, NTND Wound: left groin c/d/I Ext: warm bilaterally, + trace edema Pulses: dopplerable DP and ___ pulses bilaterally Brief Hospital Course: Ms. ___ presented to ___ on ___ with worsening pain in her left leg. She was anticoagulated with a heparin drip and taken to the Operating Room on ___ where she underwent diagnostic angiogram which showed occlusion of the left common femoral artery and left posterior tibial artery. She returned to the Operating Room on ___ where she underwent Left iliofemoral thromboendarterectomy with left greater saphenous vein patch angioplasty and Placement of a 7 x 80 mm Complete stent in the left external iliac artery post dilated with a 6 mm balloon. For full details of the procedure, please refer to the separately dictated Operative Report. She was extubated and returned to the PACU in stable condition. After satisfactory recovery from anesthesia, she was transferred to the surgical floor for further monitoring. She was continued on her home Aspirin 81 mg daily and started on Plavix 75 mg daily for 30 days post-operatively. Cardiology was consulted to pre-operative risk stratification and optimization and made recommendations regarding ongoing diuresis. Per their recommendations, her daily maintenance dose of Lasix was increased to 80 mg. They also recommended that patient have outpatient work up of obstructive sleep apnea given ongoing desaturations only while patient asleep. During her hospitalization, patient was found to have a urinary tract infection and completed a 5 day course of Bactrim (cultures=E. Coli sensitive to Bactrim). Foley and A-line were removed on POD1 and patient had no issues voiding. ___ was consulted on POD2 and recommended discharge home with rolling walker. She was discharged home on ___. At the time of discharge, she was ambulating with rolling walk, tolerating a regular diet, voiding spontaneously, and pain was well controlled with oral medications. She will follow-up in clinic with Dr. ___ in 3 weeks for staple removal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Lisinopril 5 mg PO DAILY 3. TraZODone 25 mg PO QHS:PRN insomnia 4. amLODIPine 2.5 mg PO DAILY 5. Simvastatin 20 mg PO QPM 6. Omeprazole 20 mg PO QAM 7. Furosemide 20 mg PO DAILY 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 10. ipratropium bromide 0.03 % nasal Q8H:PRN 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Ascorbic Acid ___ mg PO DAILY 13. Docusate Sodium 100 mg PO BID 14. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 15. Aspirin 81 mg PO DAILY 16. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Senna 17.2 mg PO HS 3. TraMADol 25 mg PO Q6H:PRN pain Do not drink alcohol or drive while taking this medication. RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 4. Acetaminophen 650 mg PO TID 5. Furosemide 80 mg PO DAILY Duration: 1 Dose RX furosemide 80 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*6 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 7. amLODIPine 2.5 mg PO DAILY 8. Ascorbic Acid ___ mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Gabapentin 300 mg PO TID 12. ipratropium bromide 0.03 % nasal Q8H:PRN 13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB 14. Lisinopril 5 mg PO DAILY 15. Metoprolol Succinate XL 50 mg PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. Omeprazole 20 mg PO QAM 18. Simvastatin 20 mg PO QPM 19. TraZODone 25 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left lower extremity rest pain 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 Ms. ___, You were admitted to ___ with worsening pain in you left leg. Your blood vessel in your leg was found to have a blockage. You were taken to the Operating Room where you underwent a procedure to open the blockage and a stent to keep the vessel open. You have recovered well and are now ready for discharge. Please follow the directions below regarding your care in order to ensure a speedy recovery: MEDICATION: Take Aspirin 81mg once daily Plavix (Clopidogrel) 75mg once daily for 30 days Continue all other medications you were taking before surgery, unless otherwise directed You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: Elevate your leg above the level of your heart with pillows every ___ hours throughout the day and night Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time Drink plenty of fluids and eat small frequent meals It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: When you go home, you may walk and use stairs You may shower (let the soapy water run over groin incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) After 1 week, you may resume sexual activity After 1 week, gradually increase your activities and distance walked as you can tolerate No driving until you are no longer taking pain medications CALL THE OFFICE FOR: ___ Numbness, coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white, yellow or green drainage from incisions Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office ___. If bleeding does not stop, call ___ for transfer to closest Emergency Room. Thank you for allowing us to participate in your care. Sincerely, Your ___ Surgery Team Followup Instructions: ___	[ "I70222", "I5023", "J449", "N390", "I130", "Z6841", "Z006", "N183", "E785", "I2510", "K219", "J45909", "Z87891", "Z96641", "I447", "E6601", "Z7902", "B9620", "G4733", "R197" ]	Allergies: codeine / erythromycin base / cephalasporin / Motrin Chief Complaint: left lower extremity rest pain Major Surgical or Invasive Procedure: [MASKED]: diagnostic angiogram, LLE [MASKED]: Left iliofemoral thromboendarterectomy, external iliac artery stent History of Present Illness: Ms. [MASKED] is an [MASKED] years old woman with history of COPD- not on home O2, CHF (EF 40%), CKDIII, CAD, HTN, HLD who refers having left lower extremity pain since [MASKED] this year. She refers it started as a throbbing pain when walking but has progressed to rest pain for the past two weeks. She denies weakness, nausea, vomit, fever, chills, chest pain or shortness of breath.Vital Signs sheet entries for [MASKED]: Weight: 210.10 (Standing Scale) (Entered in Nursing IPA). Height: 61 (Patient Reported) (Entered in Nursing IPA). BMI: 39.7. The patient refers she did not pursue further workup for her leg pain initially because she was having acute cholecystitis and had been in and out of the hospital for that reason. Her acute cholecystitis finally resolved around [MASKED] (cholecystectomy) and since the leg pain was still there and now was present at rest she consulted Dr. [MASKED] recommended further workup with angiogram and possible angioplasty. Past Medical History: PAST MEDICAL HISTORY COPD- not on home O2 CHF (EF 40%) CKDIII CAD HTN HLD Cognitive dysfunction Obesity GERD Hypercoagulable state-family unsure-no history of clots OA Asthma Gastric polyps Diverticulosis PAST SURGICAL HISTORY Laparoscopic cholecystectomy ([MASKED]) Right shoulder, knee, hip surgery Social History: [MASKED] Family History: Non-contributory Physical Exam: Admission Physical Exam VITAL SIGNS: Temp: 98.0, HR: 66, BP: 130/78, RR: 14, O2Sat:95%RA GENERAL: AAOx3 NAD HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no LAD CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G CAROTIDS: 2+, No bruits or JVD PULSES: Femoral/Popliteal/Dorsalis pedis/Posterior tibial LLE: -/-/-/- RLE: -/-/D/D PULMONARY: CTA [MASKED], No crackles or rhonchi GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or peritoneal signs. +BSx4 EXT/MS/SKIN: Feet warm. NEUROLOGICAL: Reflexes, strength, and sensation grossly intact Discharge Physical Exam Vitals: Tm:98.2 Tc:97.8 HR:91 BP:119/71 RR:18 O2:95% 1L Gen: NAD CV: RRR Pulm: no respiratory distress Abd: soft, NTND Wound: left groin c/d/I Ext: warm bilaterally, + trace edema Pulses: dopplerable DP and [MASKED] pulses bilaterally Brief Hospital Course: Ms. [MASKED] presented to [MASKED] on [MASKED] with worsening pain in her left leg. She was anticoagulated with a heparin drip and taken to the Operating Room on [MASKED] where she underwent diagnostic angiogram which showed occlusion of the left common femoral artery and left posterior tibial artery. She returned to the Operating Room on [MASKED] where she underwent Left iliofemoral thromboendarterectomy with left greater saphenous vein patch angioplasty and Placement of a 7 x 80 mm Complete stent in the left external iliac artery post dilated with a 6 mm balloon. For full details of the procedure, please refer to the separately dictated Operative Report. She was extubated and returned to the PACU in stable condition. After satisfactory recovery from anesthesia, she was transferred to the surgical floor for further monitoring. She was continued on her home Aspirin 81 mg daily and started on Plavix 75 mg daily for 30 days post-operatively. Cardiology was consulted to pre-operative risk stratification and optimization and made recommendations regarding ongoing diuresis. Per their recommendations, her daily maintenance dose of Lasix was increased to 80 mg. They also recommended that patient have outpatient work up of obstructive sleep apnea given ongoing desaturations only while patient asleep. During her hospitalization, patient was found to have a urinary tract infection and completed a 5 day course of Bactrim (cultures=E. Coli sensitive to Bactrim). Foley and A-line were removed on POD1 and patient had no issues voiding. [MASKED] was consulted on POD2 and recommended discharge home with rolling walker. She was discharged home on [MASKED]. At the time of discharge, she was ambulating with rolling walk, tolerating a regular diet, voiding spontaneously, and pain was well controlled with oral medications. She will follow-up in clinic with Dr. [MASKED] in 3 weeks for staple removal. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Lisinopril 5 mg PO DAILY 3. TraZODone 25 mg PO QHS:PRN insomnia 4. amLODIPine 2.5 mg PO DAILY 5. Simvastatin 20 mg PO QPM 6. Omeprazole 20 mg PO QAM 7. Furosemide 20 mg PO DAILY 8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 10. ipratropium bromide 0.03 % nasal Q8H:PRN 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Ascorbic Acid [MASKED] mg PO DAILY 13. Docusate Sodium 100 mg PO BID 14. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 15. Aspirin 81 mg PO DAILY 16. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Senna 17.2 mg PO HS 3. TraMADol 25 mg PO Q6H:PRN pain Do not drink alcohol or drive while taking this medication. RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 4. Acetaminophen 650 mg PO TID 5. Furosemide 80 mg PO DAILY Duration: 1 Dose RX furosemide 80 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*6 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 7. amLODIPine 2.5 mg PO DAILY 8. Ascorbic Acid [MASKED] mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Gabapentin 300 mg PO TID 12. ipratropium bromide 0.03 % nasal Q8H:PRN 13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB 14. Lisinopril 5 mg PO DAILY 15. Metoprolol Succinate XL 50 mg PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. Omeprazole 20 mg PO QAM 18. Simvastatin 20 mg PO QPM 19. TraZODone 25 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Left lower extremity rest pain 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 Ms. [MASKED], You were admitted to [MASKED] with worsening pain in you left leg. Your blood vessel in your leg was found to have a blockage. You were taken to the Operating Room where you underwent a procedure to open the blockage and a stent to keep the vessel open. You have recovered well and are now ready for discharge. Please follow the directions below regarding your care in order to ensure a speedy recovery: MEDICATION: Take Aspirin 81mg once daily Plavix (Clopidogrel) 75mg once daily for 30 days Continue all other medications you were taking before surgery, unless otherwise directed You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: Elevate your leg above the level of your heart with pillows every [MASKED] hours throughout the day and night Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time Drink plenty of fluids and eat small frequent meals It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: When you go home, you may walk and use stairs You may shower (let the soapy water run over groin incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) After 1 week, you may resume sexual activity After 1 week, gradually increase your activities and distance walked as you can tolerate No driving until you are no longer taking pain medications CALL THE OFFICE FOR: [MASKED] Numbness, coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white, yellow or green drainage from incisions Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [MASKED]. If bleeding does not stop, call [MASKED] for transfer to closest Emergency Room. Thank you for allowing us to participate in your care. Sincerely, Your [MASKED] Surgery Team Followup Instructions: [MASKED]	[]	[ "J449", "N390", "I130", "E785", "I2510", "K219", "J45909", "Z87891", "Z7902", "G4733" ]	[ "I70222: Atherosclerosis of native arteries of extremities with rest pain, left leg", "I5023: Acute on chronic systolic (congestive) heart failure", "J449: Chronic obstructive pulmonary disease, unspecified", "N390: Urinary tract infection, site not specified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z6841: Body mass index [BMI]40.0-44.9, adult", "Z006: Encounter for examination for normal comparison and control in clinical research program", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "Z96641: Presence of right artificial hip joint", "I447: Left bundle-branch block, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R197: Diarrhea, unspecified" ]
10,041,312	26,413,298	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: codeine / erythromycin base / cephalasporin / Motrin Attending: ___. Chief Complaint: RUQ abdominal pain Major Surgical or Invasive Procedure: ___: ___ aspiration of perihepatic fluid collection ___: ___ drainage of perihepatic fluid collection, drain placement ___: ___ drainage of perihepatic fluid collection, replacement of drain; percutaneous cholecystostomy tube History of Present Illness: ___ COPD, CHF (EF 40%) was recently treated for acute cholecystitis with a cholecystostomy at beginning of ___ at ___ here with recurrent right upper quadrant pain. She was transferred to ___ from ___ after being found hypotensive and hypoxic at rehab. She responded to 1L of fluid and was started on levaquin and flagyl. She reports having right upper quadrant pain that has been on going but progressive in nature. Her percutaneous cholecystostomy was accidentally removed over the weekend and she saw Dr. ___ in clinic on the ___ who wanted to discuss an interval cholecystectomy with the family. Of note she was discharged from rehab yesterday and last night she felt weak and slid to the floor. She denies any LOC, or head strike. The fire department did come and help her back to bed. The following morning she was taken to the rehab who found her to be hypotensive which prompted the transfer. She reports some nausea and has a decreased appetite. She denies any post prandial pain, diarrhea, vomiting, constipation, back pain, headaches, dysuria, cough, chest pain, shortness of breath, rashes. She is reporting some left foot pain that seems to be chronic and was evaluated by her PCP. Past Medical History: MHx: COPD- not on home O2, CHF/CMO, CKDIII, CAD, HTN, HLD, Cognitive dysfunction, Obesity, GERD Hypercoagulable state-family unsure-no history of clots, OA, asthma, gastric polyps, diverticulosis history of falls, SHx: ___ Family History: Non-contributory Physical Exam: At admission: 97.2 86 105/55 16 96% General: Comfortable, obsese HEENT: anicteric sclera ___: regular rhythm Pulm: clear bilaterally Abdomen: soft, TTP RUQ Ext: WWP, moves all extremities At discharge: 97.9 82 128/81 20 92RA General: NAD HEENT: EOMI, MMM, anicteric sclera Cardiac: RRR Pulm: non-labored breathing, on room air Abdomen: soft, NT, ND, RUQ ___ drains x2 with bilious fluid in bag Ext: no edema Neuro: A&Ox2 Psych: appropriate mood, appropriate affect Pertinent Results: -Ultrasound guided drainage of perihepatic collection (___): IMPRESSION: 1. Technically successful ultrasound guided diagnostic paracentesis. 2. 0.45 L of fluid were removed. -Abdominal Ultrasound (___): IMPRESSION: 1. Reaccumulation of perihepatic ascites appears overall similar to the images obtained prior to ultrasound-guided paracentesis 1 day prior. There is a more loculated portion measuring 5.6 x 2.0 x 5.0 cm in the midline upper abdomen which appears to be connected to the perihepatic ascites 2. Cholelithiasis. -Ultrasound guided drainage of perihepatic collection (___): IMPRESSION: 1. Technically successful US-guided placement of ___ pigtail catheter into the right upper quadrant fluid collection. 2. 160 cc of dark green bilious fluid was removed. -Abdominal Ultrasound (___): IMPRESSION: Perihepatic fluid again identified and a small right pleural effusion is noted. Despite effort the right upper quadrant drain could not be identified with ultrasound. The CT is recommended for further evaluation. CT INTERVENTIONAL PROCEDURE (___): IMPRESSION: 1. Successful CT-guided placement of ___ pigtail catheter into the perihepatic collection. Samples were sent for microbiology evaluation. 2. Successful CT-guided ___ percutaneous cholecystostomy tube placement. ___ Drainage (___): -Tbili 55 -Gram stain: no organisms, no PMNs -Culture: rare GPCs Urine Culture (___): -Preliminary: gram negative rods (>100k CFU), speciation/sensitivity pending Brief Hospital Course: Ms. ___ presented to the ___ ED from ___ on ___ after CT scan showed a perihepatic abscess following accidental removal of her percutaneous cholecystostomy tube 1 week ago. She was admitted and started on IV antibiotics (Cipro/Flagyl). She was kept NPO and ___ was consulted. INR was 1.7 and she was given 1 unit of FFP prior to ___ procedure. She underwent US-guided drainage of a perihepatic fluid collection on ___. Fluid drained was non-purulent and bilious, concerning for a bile leak. She underwent repeat abdominal ultrasound on ___ that showed reaccumulation and she returned to ___ on ___ for placement of an ___ drain. Drain output was initially good, but became minimal on ___. She underwent another ultrasound on ___ which again showed unchanged perihepatic fluid collection with drain unable to be visualized in the collection. She returned to ___ on ___ for replacement of the perihepatic ___ drain and was as placement of percutaneous cholecystostomy tube. Diet was advanced to regular on ___ and she was transitioned to oral antibiotics which she tolerated well. Foley was removed on ___ and patient voided spontaneously without issue. Urine was noted to be concentrated and foul smelling on ___ and a sample was sent for UA and culture. At time of discharge, preliminary culture data showed >100k CFU of gram negative rods. She was already on ciprofloxacin for bile leak and continues on this at the time of discharge for a total 5 day course (stop date ___. Speciation and sensitivity were pending at time of discharge, and the rehab facility will be contacted to make appropriate changes if final culture data shows resistance to ciprofloxacin. She was discharged to rehab on ___. At the time of discharge she ambulating with assistance, voiding spontaneously, tolerating a regular diet, and pain was well controlled with oral medications. She was discharged with instructions to follow up in the ___ with Dr. ___ on ___ at 10:30 am. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. amLODIPine 2.5 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. Simvastatin 20 mg PO QPM 11. TraZODone 50 mg PO QHS 12. Acetaminophen 650 mg PO BID:PRN Pain - Mild Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #5 Tablet Refills:0 2. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #7 Tablet Refills:0 3. Acetaminophen 650 mg PO BID:PRN Pain - Mild 4. amLODIPine 2.5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Gabapentin 300 mg PO TID 8. Lisinopril 20 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Simvastatin 20 mg PO QPM 13. TraZODone 50 mg PO QHS 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: perihepatic fluid collection bile leak s/p cholecystostomy tube Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (___ or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ for drainage of a perihepatic fluid collection that developed after your percutaneous cholecystostomy tube fell out. You were also noted to have a urinary tract infection while you were here, for which you have been prescribed antibiotics. You have recovered well and are now ready for discharge. 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 start some light exercise when you feel comfortable. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. 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. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. 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 folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon. Thank you for allowing us to participate in your medical care. Sincerely, Your ___ Surgery Team Followup Instructions: ___	[ "T85898A", "K750", "I130", "K8010", "I509", "T814XXA", "Z6841", "N390", "J449", "N183", "I2510", "E785", "K219", "E669", "J45909", "Z1621", "Y838", "Y929" ]	Allergies: codeine / erythromycin base / cephalasporin / Motrin Chief Complaint: RUQ abdominal pain Major Surgical or Invasive Procedure: [MASKED]: [MASKED] aspiration of perihepatic fluid collection [MASKED]: [MASKED] drainage of perihepatic fluid collection, drain placement [MASKED]: [MASKED] drainage of perihepatic fluid collection, replacement of drain; percutaneous cholecystostomy tube History of Present Illness: [MASKED] COPD, CHF (EF 40%) was recently treated for acute cholecystitis with a cholecystostomy at beginning of [MASKED] at [MASKED] here with recurrent right upper quadrant pain. She was transferred to [MASKED] from [MASKED] after being found hypotensive and hypoxic at rehab. She responded to 1L of fluid and was started on levaquin and flagyl. She reports having right upper quadrant pain that has been on going but progressive in nature. Her percutaneous cholecystostomy was accidentally removed over the weekend and she saw Dr. [MASKED] in clinic on the [MASKED] who wanted to discuss an interval cholecystectomy with the family. Of note she was discharged from rehab yesterday and last night she felt weak and slid to the floor. She denies any LOC, or head strike. The fire department did come and help her back to bed. The following morning she was taken to the rehab who found her to be hypotensive which prompted the transfer. She reports some nausea and has a decreased appetite. She denies any post prandial pain, diarrhea, vomiting, constipation, back pain, headaches, dysuria, cough, chest pain, shortness of breath, rashes. She is reporting some left foot pain that seems to be chronic and was evaluated by her PCP. Past Medical History: MHx: COPD- not on home O2, CHF/CMO, CKDIII, CAD, HTN, HLD, Cognitive dysfunction, Obesity, GERD Hypercoagulable state-family unsure-no history of clots, OA, asthma, gastric polyps, diverticulosis history of falls, SHx: [MASKED] Family History: Non-contributory Physical Exam: At admission: 97.2 86 105/55 16 96% General: Comfortable, obsese HEENT: anicteric sclera [MASKED]: regular rhythm Pulm: clear bilaterally Abdomen: soft, TTP RUQ Ext: WWP, moves all extremities At discharge: 97.9 82 128/81 20 92RA General: NAD HEENT: EOMI, MMM, anicteric sclera Cardiac: RRR Pulm: non-labored breathing, on room air Abdomen: soft, NT, ND, RUQ [MASKED] drains x2 with bilious fluid in bag Ext: no edema Neuro: A&Ox2 Psych: appropriate mood, appropriate affect Pertinent Results: -Ultrasound guided drainage of perihepatic collection ([MASKED]): IMPRESSION: 1. Technically successful ultrasound guided diagnostic paracentesis. 2. 0.45 L of fluid were removed. -Abdominal Ultrasound ([MASKED]): IMPRESSION: 1. Reaccumulation of perihepatic ascites appears overall similar to the images obtained prior to ultrasound-guided paracentesis 1 day prior. There is a more loculated portion measuring 5.6 x 2.0 x 5.0 cm in the midline upper abdomen which appears to be connected to the perihepatic ascites 2. Cholelithiasis. -Ultrasound guided drainage of perihepatic collection ([MASKED]): IMPRESSION: 1. Technically successful US-guided placement of [MASKED] pigtail catheter into the right upper quadrant fluid collection. 2. 160 cc of dark green bilious fluid was removed. -Abdominal Ultrasound ([MASKED]): IMPRESSION: Perihepatic fluid again identified and a small right pleural effusion is noted. Despite effort the right upper quadrant drain could not be identified with ultrasound. The CT is recommended for further evaluation. CT INTERVENTIONAL PROCEDURE ([MASKED]): IMPRESSION: 1. Successful CT-guided placement of [MASKED] pigtail catheter into the perihepatic collection. Samples were sent for microbiology evaluation. 2. Successful CT-guided [MASKED] percutaneous cholecystostomy tube placement. [MASKED] Drainage ([MASKED]): -Tbili 55 -Gram stain: no organisms, no PMNs -Culture: rare GPCs Urine Culture ([MASKED]): -Preliminary: gram negative rods (>100k CFU), speciation/sensitivity pending Brief Hospital Course: Ms. [MASKED] presented to the [MASKED] ED from [MASKED] on [MASKED] after CT scan showed a perihepatic abscess following accidental removal of her percutaneous cholecystostomy tube 1 week ago. She was admitted and started on IV antibiotics (Cipro/Flagyl). She was kept NPO and [MASKED] was consulted. INR was 1.7 and she was given 1 unit of FFP prior to [MASKED] procedure. She underwent US-guided drainage of a perihepatic fluid collection on [MASKED]. Fluid drained was non-purulent and bilious, concerning for a bile leak. She underwent repeat abdominal ultrasound on [MASKED] that showed reaccumulation and she returned to [MASKED] on [MASKED] for placement of an [MASKED] drain. Drain output was initially good, but became minimal on [MASKED]. She underwent another ultrasound on [MASKED] which again showed unchanged perihepatic fluid collection with drain unable to be visualized in the collection. She returned to [MASKED] on [MASKED] for replacement of the perihepatic [MASKED] drain and was as placement of percutaneous cholecystostomy tube. Diet was advanced to regular on [MASKED] and she was transitioned to oral antibiotics which she tolerated well. Foley was removed on [MASKED] and patient voided spontaneously without issue. Urine was noted to be concentrated and foul smelling on [MASKED] and a sample was sent for UA and culture. At time of discharge, preliminary culture data showed >100k CFU of gram negative rods. She was already on ciprofloxacin for bile leak and continues on this at the time of discharge for a total 5 day course (stop date [MASKED]. Speciation and sensitivity were pending at time of discharge, and the rehab facility will be contacted to make appropriate changes if final culture data shows resistance to ciprofloxacin. She was discharged to rehab on [MASKED]. At the time of discharge she ambulating with assistance, voiding spontaneously, tolerating a regular diet, and pain was well controlled with oral medications. She was discharged with instructions to follow up in the [MASKED] with Dr. [MASKED] on [MASKED] at 10:30 am. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. amLODIPine 2.5 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. Simvastatin 20 mg PO QPM 11. TraZODone 50 mg PO QHS 12. Acetaminophen 650 mg PO BID:PRN Pain - Mild Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #5 Tablet Refills:0 2. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #7 Tablet Refills:0 3. Acetaminophen 650 mg PO BID:PRN Pain - Mild 4. amLODIPine 2.5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Gabapentin 300 mg PO TID 8. Lisinopril 20 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Simvastatin 20 mg PO QPM 13. TraZODone 50 mg PO QHS 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: perihepatic fluid collection bile leak s/p cholecystostomy tube Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid ([MASKED] or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] for drainage of a perihepatic fluid collection that developed after your percutaneous cholecystostomy tube fell out. You were also noted to have a urinary tract infection while you were here, for which you have been prescribed antibiotics. You have recovered well and are now ready for discharge. 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 start some light exercise when you feel comfortable. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. 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. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. 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 folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon. Thank you for allowing us to participate in your medical care. Sincerely, Your [MASKED] Surgery Team Followup Instructions: [MASKED]	[]	[ "I130", "N390", "J449", "I2510", "E785", "K219", "E669", "J45909", "Y929" ]	[ "T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter", "K750: Abscess of liver", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "K8010: Calculus of gallbladder with chronic cholecystitis without obstruction", "I509: Heart failure, unspecified", "T814XXA: Infection following a procedure", "Z6841: Body mass index [BMI]40.0-44.9, adult", "N390: Urinary tract infection, site not specified", "J449: Chronic obstructive pulmonary disease, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified", "J45909: Unspecified asthma, uncomplicated", "Z1621: Resistance to vancomycin", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]
10,041,339	29,569,226	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: pprom Major Surgical or Invasive Procedure: exam under anesthesia s/p vaginal delivery, bakri placed postpartum, removed Physical Exam: On discharge: Vitals: 24 HR Data (last updated ___ @ 018) Temp: 97.5 (Tm 98.1), BP: 101/67 (97-131/61-77), HR: 99 (94-99), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA Fluid Balance (last updated ___ @ 020) Last 8 hours Total cumulative -900ml IN: Total 0ml OUT: Total 900ml, Urine Amt 900ml Last 24 hours Total cumulative -2600ml IN: Total 1000ml, PO Amt 1000ml OUT: Total 3600ml, Urine Amt 3600ml General: NAD, A&Ox3 CV: RRR Lungs: No respiratory distress Abd: soft, overall nontender excepting some mild tenderness over umbilicus, fundus firm below umbilicus Lochia: minimal Extremities: no calf tenderness, no edema Pertinent Results: ___ 03:05AM BLOOD WBC-17.2* RBC-2.59* Hgb-8.6* Hct-25.2* MCV-97 MCH-33.2* MCHC-34.1 RDW-15.1 RDWSD-52.8* Plt Ct-81* ___ 01:18AM BLOOD WBC-16.9* RBC-2.67* Hgb-9.0* Hct-25.3* MCV-95 MCH-33.7* MCHC-35.6 RDW-14.6 RDWSD-50.4* Plt Ct-83* ___ 08:45PM BLOOD WBC-16.2* RBC-2.54* Hgb-8.9* Hct-26.7* MCV-105* MCH-35.0* MCHC-33.3 RDW-14.1 RDWSD-53.8* Plt ___ ___ 03:10PM BLOOD WBC-10.1* RBC-3.07* Hgb-10.7* Hct-31.0* MCV-101* MCH-34.9* MCHC-34.5 RDW-14.2 RDWSD-52.0* Plt ___ ___ 10:40AM BLOOD WBC-8.2 RBC-2.82* Hgb-9.9* Hct-29.3* MCV-104* MCH-35.1* MCHC-33.8 RDW-14.2 RDWSD-53.3* Plt ___ ___ 12:30PM BLOOD WBC-11.2* RBC-2.98* Hgb-10.5* Hct-30.4* MCV-102* MCH-35.2* MCHC-34.5 RDW-13.8 RDWSD-50.6* Plt ___ ___ 01:18AM BLOOD Glucose-92 UreaN-9 Creat-0.4 Na-133* K-3.7 Cl-107 HCO3-17* AnGap-9* Brief Hospital Course: ANTEPARTUM She was admitted to antepartum after it was confirmed that her amniotic membranes ruptured. She was given latency antibiotics, underwent a NICU consult, and received betamethasone. She remained stable until 34 weeks gestational age and underwent induction of labor. POST PARTUM On ___, patient had a spontaneous vaginal delivery. This was complicated by post partum hemorrhage and chorioamnionitis. Regarding her postpartum hemorrhage, her total estimated blood loss was 2400mL due to uterine atony and a posterior cervical laceration. She necessitated an OR takeback for improved visualization and repair of the cervical laceration. She received pitocin, cytotec, methergine, TXA. A Bakri balloon balloon for 240mL was placed as well as vaginal packing. She received 2 units of packed RBCs. Her hematocrit was obtained and noted to be 25.3 (___) with platelets of 83. Her fibrinogen was 180. Her INR was 1.3 over two measurements (___). Her vitals remained stable and her vaginal packing and bakri balloon were removed on ___. Regarding her chorioamnionitis, patient received 2g of ancef in the OR. She had a fever of approximately ___ on ___ at 2145. She received ampicillin and gentamicin for 24 hours first afebrile ___ afebrile 0300 ___. For her GDMA1, patient's fingersticks were not followed. On post partum day 3, ___, patient had stable vitals and accomplished all her post partum milestones. Her bleeding was stable and she was thus discharged to home in stable condition. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #40 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___) 5. Levothyroxine Sodium 25 mcg PO 2X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: s/p vaginal delivery postpartum hemorrhage Discharge Condition: stable Discharge Instructions: pelvic rest for 6 weeks, rest Followup Instructions: ___	[ "O42113", "Z370", "O411230", "O4443", "O4403", "O721", "O713", "O403XX0", "O24420", "O418X30", "O368930", "Z3A32", "O631", "O701", "O99284", "E039", "O9989", "H9041", "O26893", "L298" ]	Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: pprom Major Surgical or Invasive Procedure: exam under anesthesia s/p vaginal delivery, bakri placed postpartum, removed Physical Exam: On discharge: Vitals: 24 HR Data (last updated [MASKED] @ 018) Temp: 97.5 (Tm 98.1), BP: 101/67 (97-131/61-77), HR: 99 (94-99), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA Fluid Balance (last updated [MASKED] @ 020) Last 8 hours Total cumulative -900ml IN: Total 0ml OUT: Total 900ml, Urine Amt 900ml Last 24 hours Total cumulative -2600ml IN: Total 1000ml, PO Amt 1000ml OUT: Total 3600ml, Urine Amt 3600ml General: NAD, A&Ox3 CV: RRR Lungs: No respiratory distress Abd: soft, overall nontender excepting some mild tenderness over umbilicus, fundus firm below umbilicus Lochia: minimal Extremities: no calf tenderness, no edema Pertinent Results: [MASKED] 03:05AM BLOOD WBC-17.2* RBC-2.59* Hgb-8.6* Hct-25.2* MCV-97 MCH-33.2* MCHC-34.1 RDW-15.1 RDWSD-52.8* Plt Ct-81* [MASKED] 01:18AM BLOOD WBC-16.9* RBC-2.67* Hgb-9.0* Hct-25.3* MCV-95 MCH-33.7* MCHC-35.6 RDW-14.6 RDWSD-50.4* Plt Ct-83* [MASKED] 08:45PM BLOOD WBC-16.2* RBC-2.54* Hgb-8.9* Hct-26.7* MCV-105* MCH-35.0* MCHC-33.3 RDW-14.1 RDWSD-53.8* Plt [MASKED] [MASKED] 03:10PM BLOOD WBC-10.1* RBC-3.07* Hgb-10.7* Hct-31.0* MCV-101* MCH-34.9* MCHC-34.5 RDW-14.2 RDWSD-52.0* Plt [MASKED] [MASKED] 10:40AM BLOOD WBC-8.2 RBC-2.82* Hgb-9.9* Hct-29.3* MCV-104* MCH-35.1* MCHC-33.8 RDW-14.2 RDWSD-53.3* Plt [MASKED] [MASKED] 12:30PM BLOOD WBC-11.2* RBC-2.98* Hgb-10.5* Hct-30.4* MCV-102* MCH-35.2* MCHC-34.5 RDW-13.8 RDWSD-50.6* Plt [MASKED] [MASKED] 01:18AM BLOOD Glucose-92 UreaN-9 Creat-0.4 Na-133* K-3.7 Cl-107 HCO3-17* AnGap-9* Brief Hospital Course: ANTEPARTUM She was admitted to antepartum after it was confirmed that her amniotic membranes ruptured. She was given latency antibiotics, underwent a NICU consult, and received betamethasone. She remained stable until 34 weeks gestational age and underwent induction of labor. POST PARTUM On [MASKED], patient had a spontaneous vaginal delivery. This was complicated by post partum hemorrhage and chorioamnionitis. Regarding her postpartum hemorrhage, her total estimated blood loss was 2400mL due to uterine atony and a posterior cervical laceration. She necessitated an OR takeback for improved visualization and repair of the cervical laceration. She received pitocin, cytotec, methergine, TXA. A Bakri balloon balloon for 240mL was placed as well as vaginal packing. She received 2 units of packed RBCs. Her hematocrit was obtained and noted to be 25.3 ([MASKED]) with platelets of 83. Her fibrinogen was 180. Her INR was 1.3 over two measurements ([MASKED]). Her vitals remained stable and her vaginal packing and bakri balloon were removed on [MASKED]. Regarding her chorioamnionitis, patient received 2g of ancef in the OR. She had a fever of approximately [MASKED] on [MASKED] at 2145. She received ampicillin and gentamicin for 24 hours first afebrile [MASKED] afebrile 0300 [MASKED]. For her GDMA1, patient's fingersticks were not followed. On post partum day 3, [MASKED], patient had stable vitals and accomplished all her post partum milestones. Her bleeding was stable and she was thus discharged to home in stable condition. Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild/Fever 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild/Fever NOT relieved by Acetaminophen RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #40 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Levothyroxine Sodium 50 mcg PO 5X/WEEK ([MASKED]) 5. Levothyroxine Sodium 25 mcg PO 2X/WEEK ([MASKED]) Discharge Disposition: Home Discharge Diagnosis: s/p vaginal delivery postpartum hemorrhage Discharge Condition: stable Discharge Instructions: pelvic rest for 6 weeks, rest Followup Instructions: [MASKED]	[]	[ "E039" ]	[ "O42113: Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, third trimester", "Z370: Single live birth", "O411230: Chorioamnionitis, third trimester, not applicable or unspecified", "O4443: Low lying placenta NOS or without hemorrhage, third trimester", "O4403: Complete placenta previa NOS or without hemorrhage, third trimester", "O721: Other immediate postpartum hemorrhage", "O713: Obstetric laceration of cervix", "O403XX0: Polyhydramnios, third trimester, not applicable or unspecified", "O24420: Gestational diabetes mellitus in childbirth, diet controlled", "O418X30: Other specified disorders of amniotic fluid and membranes, third trimester, not applicable or unspecified", "O368930: Maternal care for other specified fetal problems, third trimester, not applicable or unspecified", "Z3A32: 32 weeks gestation of pregnancy", "O631: Prolonged second stage (of labor)", "O701: Second degree perineal laceration during delivery", "O99284: Endocrine, nutritional and metabolic diseases complicating childbirth", "E039: Hypothyroidism, unspecified", "O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium", "H9041: Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side", "O26893: Other specified pregnancy related conditions, third trimester", "L298: Other pruritus" ]
10,041,429	20,403,729	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Vicodin Attending: ___. Chief Complaint: Abdominal pain, fever Major Surgical or Invasive Procedure: Laparoscopic adjustable gastric band and port removal. History of Present Illness: Ms. ___ is a ___ s/p laparoscopic gastric band at ___ in ___ who presented with LLQ abdominal pain. She has a recent history of a motor vehicle accident on ___ with exacerbation in lumbar pain, and underwent L4-S1 3 part laminectomy and instrumented fusion ___ and was discharged from the hospital on ___. She was recovering well after her procedure, but presented to the ED on ___ for fever up to 103 at home. She has been having LLQ pain since her spinal surgery. She reports that she has been having occasional food intolerance and difficult swallowing for the past 5 months, with occasional heartburn but no regurgitation. Her symptoms have gradually worsened during the past 5 months. She reports occasional nausea, no vomiting, no constipation or diarrhea. She has lost 200 pounds after the lap band procedure, her preop weight was 365 and now it is 165lbs. Upon arrival to the ED they performed a CT scan, which demonstrated a large fluid collection in the soft tissues posterior to the lumbar fusion (?seroma/ abscess) and a moderate hiatal hernia and slipped lap band. Past Medical History: PMH/PSH: Multiple lumbar spine surgeries s/p MVC ___ Social History: ___ Family History: Single mother, works but not currently working after ___. Physical Exam: Vitals: T=98.2F; BP=96/60mmHg; HR=76x'; RR=18x'; O2 Sat=98% Ra GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. CARDIAC: Regular rate and rhythm, no murmurs/rubs/gallops. LUNGS: No respiratory distress. Clear to auscultation bilaterally. No wheezes, rhonchi or rales. ABDOMEN: Decreased bowel sounds, non distended, expectedly tender diffusely. No peritoneal signs. Dressings appear clean, dry, and intact EXTREMITIES: No clubbing, cyanosis, or edema. Pertinent Results: ___ 05:08AM BLOOD Hct-30.3* ___ 12:30AM BLOOD WBC-5.1 RBC-3.19* Hgb-8.2* Hct-26.7* MCV-84 MCH-25.7* MCHC-30.7* RDW-15.1 RDWSD-46.1 Plt ___ ___ 12:30AM BLOOD Neuts-71.1* Lymphs-18.9* Monos-8.4 Eos-0.6* Baso-0.8 Im ___ AbsNeut-3.65 AbsLymp-0.97* AbsMono-0.43 AbsEos-0.03* AbsBaso-0.04 ___ 12:30AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-138 K-3.8 Cl-102 HCO3-24 AnGap-16 ___ 12:30AM BLOOD CRP-38.0* CT abdomen/pelvis w/contrast ___ 1. Large fluid collection in the soft tissues posterior to the lumbar fusion surgical bed could represent abscess or post operative seroma. 2. Moderate hiatal hernia and increased stomach above the band consistent with slipped lap band. Brief Hospital Course: Ms. ___ is a ___ who is status post laparoscopic gastric band placed at an outside hospital (___). She presented to the ED on ___ with a history of many months of dysphagia to solids, progressive to liquids over the last day or so. We removed all the fluid from her band with no improvement of symptoms. Her CT scan, demonstrated prolapse. We discussed risks, benefits, alternatives. She understood and consented to have the band removed. She underwent laparoscopic gastric band removal on ___ without complications. Her postoperative hematocrit was stable. Of note, she underwent L4-S1 3 partial laminectomy and instrumented fusion recently and is currently followed by her spine surgeon, who is managing her pain medications. We have given her a prescription for Dilaudid tablets (#10) that should suffice until her next appointment with Dr. ___ spinal surgeon) on ___ at 9:30AM. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ClonazePAM 1 mg PO QID 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 300 mg PO TID 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate 5. Omeprazole 20 mg PO DAILY 6. Sertraline 100 mg PO DAILY 7. Diazepam 5 mg PO Q6H:PRN muscle spasms 8. Mirtazapine 7.5 mg PO QHS 9. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN Discharge Medications: 1. Diazepam 5 mg PO Q6H:PRN muscle spasms 2. Docusate Sodium 100 mg PO BID 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #10 Tablet Refills:*0 4. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN 5. ClonazePAM 1 mg PO QID 6. Gabapentin 300 mg PO TID 7. Mirtazapine 7.5 mg PO QHS 8. Omeprazole 20 mg PO DAILY 9. Sertraline 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Laparoscopic adjustable gastric band prolapse. 2. Dysphagia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You have undergone removal of your adjustable gastric band, recovered in the hospital and are now preparing for discharge to home with the following instructions: Discharge Instructions: Please call your surgeon or return to the Emergency Department if you develop a fever greater than 101 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 IV 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: Pain medication: You will receive a prescription for Dilaudid tablets that should last you until your appointment with Dr. ___. 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. 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. 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: ___	[ "K9509", "R1310", "Y848", "Y929" ]	Allergies: Vicodin Chief Complaint: Abdominal pain, fever Major Surgical or Invasive Procedure: Laparoscopic adjustable gastric band and port removal. History of Present Illness: Ms. [MASKED] is a [MASKED] s/p laparoscopic gastric band at [MASKED] in [MASKED] who presented with LLQ abdominal pain. She has a recent history of a motor vehicle accident on [MASKED] with exacerbation in lumbar pain, and underwent L4-S1 3 part laminectomy and instrumented fusion [MASKED] and was discharged from the hospital on [MASKED]. She was recovering well after her procedure, but presented to the ED on [MASKED] for fever up to 103 at home. She has been having LLQ pain since her spinal surgery. She reports that she has been having occasional food intolerance and difficult swallowing for the past 5 months, with occasional heartburn but no regurgitation. Her symptoms have gradually worsened during the past 5 months. She reports occasional nausea, no vomiting, no constipation or diarrhea. She has lost 200 pounds after the lap band procedure, her preop weight was 365 and now it is 165lbs. Upon arrival to the ED they performed a CT scan, which demonstrated a large fluid collection in the soft tissues posterior to the lumbar fusion (?seroma/ abscess) and a moderate hiatal hernia and slipped lap band. Past Medical History: PMH/PSH: Multiple lumbar spine surgeries s/p MVC [MASKED] Social History: [MASKED] Family History: Single mother, works but not currently working after [MASKED]. Physical Exam: Vitals: T=98.2F; BP=96/60mmHg; HR=76x'; RR=18x'; O2 Sat=98% Ra GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. CARDIAC: Regular rate and rhythm, no murmurs/rubs/gallops. LUNGS: No respiratory distress. Clear to auscultation bilaterally. No wheezes, rhonchi or rales. ABDOMEN: Decreased bowel sounds, non distended, expectedly tender diffusely. No peritoneal signs. Dressings appear clean, dry, and intact EXTREMITIES: No clubbing, cyanosis, or edema. Pertinent Results: [MASKED] 05:08AM BLOOD Hct-30.3* [MASKED] 12:30AM BLOOD WBC-5.1 RBC-3.19* Hgb-8.2* Hct-26.7* MCV-84 MCH-25.7* MCHC-30.7* RDW-15.1 RDWSD-46.1 Plt [MASKED] [MASKED] 12:30AM BLOOD Neuts-71.1* Lymphs-18.9* Monos-8.4 Eos-0.6* Baso-0.8 Im [MASKED] AbsNeut-3.65 AbsLymp-0.97* AbsMono-0.43 AbsEos-0.03* AbsBaso-0.04 [MASKED] 12:30AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-138 K-3.8 Cl-102 HCO3-24 AnGap-16 [MASKED] 12:30AM BLOOD CRP-38.0* CT abdomen/pelvis w/contrast [MASKED] 1. Large fluid collection in the soft tissues posterior to the lumbar fusion surgical bed could represent abscess or post operative seroma. 2. Moderate hiatal hernia and increased stomach above the band consistent with slipped lap band. Brief Hospital Course: Ms. [MASKED] is a [MASKED] who is status post laparoscopic gastric band placed at an outside hospital ([MASKED]). She presented to the ED on [MASKED] with a history of many months of dysphagia to solids, progressive to liquids over the last day or so. We removed all the fluid from her band with no improvement of symptoms. Her CT scan, demonstrated prolapse. We discussed risks, benefits, alternatives. She understood and consented to have the band removed. She underwent laparoscopic gastric band removal on [MASKED] without complications. Her postoperative hematocrit was stable. Of note, she underwent L4-S1 3 partial laminectomy and instrumented fusion recently and is currently followed by her spine surgeon, who is managing her pain medications. We have given her a prescription for Dilaudid tablets (#10) that should suffice until her next appointment with Dr. [MASKED] spinal surgeon) on [MASKED] at 9:30AM. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ClonazePAM 1 mg PO QID 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 300 mg PO TID 4. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate 5. Omeprazole 20 mg PO DAILY 6. Sertraline 100 mg PO DAILY 7. Diazepam 5 mg PO Q6H:PRN muscle spasms 8. Mirtazapine 7.5 mg PO QHS 9. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN Discharge Medications: 1. Diazepam 5 mg PO Q6H:PRN muscle spasms 2. Docusate Sodium 100 mg PO BID 3. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate RX hydromorphone 2 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #10 Tablet Refills:*0 4. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN 5. ClonazePAM 1 mg PO QID 6. Gabapentin 300 mg PO TID 7. Mirtazapine 7.5 mg PO QHS 8. Omeprazole 20 mg PO DAILY 9. Sertraline 100 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: 1. Laparoscopic adjustable gastric band prolapse. 2. Dysphagia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You have undergone removal of your adjustable gastric band, recovered in the hospital and are now preparing for discharge to home with the following instructions: Discharge Instructions: Please call your surgeon or return to the Emergency Department if you develop a fever greater than 101 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 IV 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: Pain medication: You will receive a prescription for Dilaudid tablets that should last you until your appointment with Dr. [MASKED]. 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. 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. 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]	[]	[ "Y929" ]	[ "K9509: Other complications of gastric band procedure", "R1310: Dysphagia, unspecified", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]
10,041,429	28,466,281	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Vicodin Attending: ___. Chief Complaint: recurrent low back pain post mvc and right foot paresthesias and weakness Major Surgical or Invasive Procedure: L4-S1 Decompression/Fusion History of Present Illness: ___ female PMHx lumbar spinal stenosis, chronic low back pain s/p multiple surgeries on her lumbar spine including several microdiscectomies (___ @ ___, ___ @___) s/p L4,L5 laminectomies ___ ___ @ ___ who had been doing relatively well over the past ___ years until she was involved in a high energy MVC ___ following which she had recurrent severe low back pain and also esophageal injury currently being worked up. Since this past ___ she noted that her right foot was unable to dorsiflex and had decreased sensation and paresthesias - this has resulted in several falls over the past week. She had planned follow-up with Dr. ___ ___ this upcoming ___ but became concerned due to these falls and did not feel safe to wait any longer for evaluation. Went to ___, transferred to ___ due to lack of spine consult availability at ___. Denies saddle anesthesia, denies bowel/bladder changes. IMAGING:MRI of the lumbar spine demonstrates diffuse post-surgical changes including superficial seroma. Multiple lumbar disc herniations most prominent at L4/5-right lateral disc. Past Medical History: PMH/PSH: Multiple lumbar spine surgeries s/p MVC ___ Social History: ___ Family History: Single mother, works but not currently working after MVC. Physical Exam: PHYSICAL EXAMINATION: Vitals: AVSS General: Well-appearing female in no acute distress. Spine exam: Surgical wounds well healed over lumbar spine, no erythema. Vascular Radial: L2+, R2+ DPR: L2+, R2+ Motor- Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 2 3 -Sensory: Sensory UE C5 (Ax) R nl, L nl C6 (MC) R nl, L nl C7 (Mid finger) R nl, L nl C8 (MACN) R nl, L nl T1 (MBCN) R nl, L nl T2-L2 Trunk R nl, L nl Sensory ___ L2 (Groin): R nl, L nl L3 (Leg) R nl, L nl L4 (Knee) R decreased sensation, L nl L5 (Grt Toe): R decreased sensation, L nl S1 (Sm toe): R decreased sensation, L nl S2 (Post Thigh): R nl, L nl -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 0 ___: neg Babinski: downgoing Clonus: none Perianal sensation: intact Rectal tone: intact LABS: Pending Pertinent Results: ___ 11:03AM BLOOD WBC-7.3 RBC-3.01* Hgb-8.3* Hct-26.9* MCV-89 MCH-27.6 MCHC-30.9* RDW-15.6* RDWSD-50.6* Plt ___ ___ 10:33AM BLOOD WBC-6.6 RBC-3.09* Hgb-8.7* Hct-27.3* MCV-88 MCH-28.2 MCHC-31.9* RDW-15.0 RDWSD-48.6* Plt ___ ___ 07:30AM BLOOD WBC-7.0# RBC-3.33* Hgb-9.2* Hct-29.4* MCV-88 MCH-27.6 MCHC-31.3* RDW-15.2 RDWSD-48.9* Plt ___ ___ 01:35PM BLOOD Neuts-81.9* Lymphs-13.5* Monos-3.6* Eos-0.2* Baso-0.6 Im ___ AbsNeut-3.82# AbsLymp-0.63* AbsMono-0.17* AbsEos-0.01* AbsBaso-0.03 ___ 08:00AM BLOOD Neuts-54.5 ___ Monos-6.5 Eos-3.5 Baso-0.8 Im ___ AbsNeut-2.17 AbsLymp-1.37 AbsMono-0.26 AbsEos-0.14 AbsBaso-0.03 ___ 11:03AM BLOOD Plt ___ ___ 10:33AM BLOOD Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 01:35PM BLOOD ___ PTT-27.5 ___ ___ 08:00AM BLOOD Plt ___ ___ 08:00AM BLOOD ___ PTT-27.8 ___ ___ 11:03AM BLOOD Glucose-122* UreaN-7 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-22 AnGap-15 ___ 10:33AM BLOOD Glucose-153* UreaN-7 Creat-0.4 Na-137 K-4.3 Cl-104 HCO3-22 AnGap-15 ___ 07:30AM BLOOD Glucose-99 UreaN-12 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-25 AnGap-12 ___ 10:33AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8 ___ 07:30AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9 ___ 03:01PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8 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: Clonazepam Gabapentin Mirtazapine Omeprazole Sertraline Discharge Medications: 1. Diazepam 5 mg PO Q6H:PRN muscle spasms may cause drowsiness RX diazepam 5 mg 1 tab by mouth every eight (8) hours Disp #60 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID please take with narcotic pain medications RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate please do not operate heavy machinery, drink alcohol or drive RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #90 Tablet Refills:0 4. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #90 Tablet Refills:0 5. ClonazePAM 1 mg PO QID 6. Gabapentin 300 mg PO TID 7. Mirtazapine 7.5 mg PO QHS 8. Omeprazole 20 mg PO DAILY 9. Sertraline 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Lumbar spondylosis and stenosis and scoliosis. 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: Lumbar Decompression With Fusion: You have undergone the following operation: Lumbar Decompression With Fusion Immediately after the operation: Activity:You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit or stand more than~45 minutes without getting up and walking around. Rehabilitation/ Physical ___ times a day you should go for a walk for ___ minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. Diet: Eat a normal healthy diet.You may have some constipation after surgery.You have been given medication to help with this issue. Brace:You may have been given a brace.If you have been given a brace,this brace is to be worn when you are walking.You may take it off when sitting in a chair or while lying in bed. Wound Care:Remove the dressing in 2 days.If the incision is draining cover it with a new sterile dressing.If it is dry then you can leave the incision open to the air.Once the incision is completely dry (usually ___ days after the operation) you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery, do not get the incision wet.Cover it with a sterile dressing.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 ___ 2.We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision,take baseline X-rays and answer any questions.We may at that time start physical therapy We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: 1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. Treatments Frequency: Remove the dressing in 2 days.If the incision is draining cover it with a new sterile dressing.If it is dry then you can leave the incision open to the air.Once the incision is completely dry (usually ___ days after the operation) you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery,do not get the incision wet.Cover it with a sterile dressing.Call the office. Followup Instructions: ___	[ "M47896", "M419", "M4806", "M5136", "M21371", "R21" ]	Allergies: Vicodin Chief Complaint: recurrent low back pain post mvc and right foot paresthesias and weakness Major Surgical or Invasive Procedure: L4-S1 Decompression/Fusion History of Present Illness: [MASKED] female PMHx lumbar spinal stenosis, chronic low back pain s/p multiple surgeries on her lumbar spine including several microdiscectomies ([MASKED] @ [MASKED], [MASKED] @[MASKED]) s/p L4,L5 laminectomies [MASKED] [MASKED] @ [MASKED] who had been doing relatively well over the past [MASKED] years until she was involved in a high energy MVC [MASKED] following which she had recurrent severe low back pain and also esophageal injury currently being worked up. Since this past [MASKED] she noted that her right foot was unable to dorsiflex and had decreased sensation and paresthesias - this has resulted in several falls over the past week. She had planned follow-up with Dr. [MASKED] [MASKED] this upcoming [MASKED] but became concerned due to these falls and did not feel safe to wait any longer for evaluation. Went to [MASKED], transferred to [MASKED] due to lack of spine consult availability at [MASKED]. Denies saddle anesthesia, denies bowel/bladder changes. IMAGING:MRI of the lumbar spine demonstrates diffuse post-surgical changes including superficial seroma. Multiple lumbar disc herniations most prominent at L4/5-right lateral disc. Past Medical History: PMH/PSH: Multiple lumbar spine surgeries s/p MVC [MASKED] Social History: [MASKED] Family History: Single mother, works but not currently working after MVC. Physical Exam: PHYSICAL EXAMINATION: Vitals: AVSS General: Well-appearing female in no acute distress. Spine exam: Surgical wounds well healed over lumbar spine, no erythema. Vascular Radial: L2+, R2+ DPR: L2+, R2+ Motor- Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc L 5 [MASKED] [MASKED] 5 5 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 2 3 -Sensory: Sensory UE C5 (Ax) R nl, L nl C6 (MC) R nl, L nl C7 (Mid finger) R nl, L nl C8 (MACN) R nl, L nl T1 (MBCN) R nl, L nl T2-L2 Trunk R nl, L nl Sensory [MASKED] L2 (Groin): R nl, L nl L3 (Leg) R nl, L nl L4 (Knee) R decreased sensation, L nl L5 (Grt Toe): R decreased sensation, L nl S1 (Sm toe): R decreased sensation, L nl S2 (Post Thigh): R nl, L nl -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 2 2 R 2 2 2 2 0 [MASKED]: neg Babinski: downgoing Clonus: none Perianal sensation: intact Rectal tone: intact LABS: Pending Pertinent Results: [MASKED] 11:03AM BLOOD WBC-7.3 RBC-3.01* Hgb-8.3* Hct-26.9* MCV-89 MCH-27.6 MCHC-30.9* RDW-15.6* RDWSD-50.6* Plt [MASKED] [MASKED] 10:33AM BLOOD WBC-6.6 RBC-3.09* Hgb-8.7* Hct-27.3* MCV-88 MCH-28.2 MCHC-31.9* RDW-15.0 RDWSD-48.6* Plt [MASKED] [MASKED] 07:30AM BLOOD WBC-7.0# RBC-3.33* Hgb-9.2* Hct-29.4* MCV-88 MCH-27.6 MCHC-31.3* RDW-15.2 RDWSD-48.9* Plt [MASKED] [MASKED] 01:35PM BLOOD Neuts-81.9* Lymphs-13.5* Monos-3.6* Eos-0.2* Baso-0.6 Im [MASKED] AbsNeut-3.82# AbsLymp-0.63* AbsMono-0.17* AbsEos-0.01* AbsBaso-0.03 [MASKED] 08:00AM BLOOD Neuts-54.5 [MASKED] Monos-6.5 Eos-3.5 Baso-0.8 Im [MASKED] AbsNeut-2.17 AbsLymp-1.37 AbsMono-0.26 AbsEos-0.14 AbsBaso-0.03 [MASKED] 11:03AM BLOOD Plt [MASKED] [MASKED] 10:33AM BLOOD Plt [MASKED] [MASKED] 07:30AM BLOOD Plt [MASKED] [MASKED] 01:35PM BLOOD [MASKED] PTT-27.5 [MASKED] [MASKED] 08:00AM BLOOD Plt [MASKED] [MASKED] 08:00AM BLOOD [MASKED] PTT-27.8 [MASKED] [MASKED] 11:03AM BLOOD Glucose-122* UreaN-7 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-22 AnGap-15 [MASKED] 10:33AM BLOOD Glucose-153* UreaN-7 Creat-0.4 Na-137 K-4.3 Cl-104 HCO3-22 AnGap-15 [MASKED] 07:30AM BLOOD Glucose-99 UreaN-12 Creat-0.6 Na-136 K-3.9 Cl-103 HCO3-25 AnGap-12 [MASKED] 10:33AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8 [MASKED] 07:30AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9 [MASKED] 03:01PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8 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: Clonazepam Gabapentin Mirtazapine Omeprazole Sertraline Discharge Medications: 1. Diazepam 5 mg PO Q6H:PRN muscle spasms may cause drowsiness RX diazepam 5 mg 1 tab by mouth every eight (8) hours Disp #60 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID please take with narcotic pain medications RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 3. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate please do not operate heavy machinery, drink alcohol or drive RX hydromorphone [Dilaudid] 2 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #90 Tablet Refills:0 4. TraMADol 50 mg PO BID:PRN BREAKTHROUGH PAIN RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #90 Tablet Refills:0 5. ClonazePAM 1 mg PO QID 6. Gabapentin 300 mg PO TID 7. Mirtazapine 7.5 mg PO QHS 8. Omeprazole 20 mg PO DAILY 9. Sertraline 100 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Lumbar spondylosis and stenosis and scoliosis. 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: Lumbar Decompression With Fusion: You have undergone the following operation: Lumbar Decompression With Fusion Immediately after the operation: Activity:You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit or stand more than~45 minutes without getting up and walking around. Rehabilitation/ Physical [MASKED] times a day you should go for a walk for [MASKED] minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. Diet: Eat a normal healthy diet.You may have some constipation after surgery.You have been given medication to help with this issue. Brace:You may have been given a brace.If you have been given a brace,this brace is to be worn when you are walking.You may take it off when sitting in a chair or while lying in bed. Wound Care:Remove the dressing in 2 days.If the incision is draining cover it with a new sterile dressing.If it is dry then you can leave the incision open to the air.Once the incision is completely dry (usually [MASKED] days after the operation) you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery, do not get the incision wet.Cover it with a sterile dressing.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] 2.We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision,take baseline X-rays and answer any questions.We may at that time start physical therapy We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: 1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. Treatments Frequency: Remove the dressing in 2 days.If the incision is draining cover it with a new sterile dressing.If it is dry then you can leave the incision open to the air.Once the incision is completely dry (usually [MASKED] days after the operation) you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery,do not get the incision wet.Cover it with a sterile dressing.Call the office. Followup Instructions: [MASKED]	[]	[]	[ "M47896: Other spondylosis, lumbar region", "M419: Scoliosis, unspecified", "M4806: Spinal stenosis, lumbar region", "M5136: Other intervertebral disc degeneration, lumbar region", "M21371: Foot drop, right foot", "R21: Rash and other nonspecific skin eruption" ]
10,041,690	23,389,330	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / escitalopram / lisinopril / aspirin / latex / hydrochlorothiazide Attending: ___. Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with hypertension, hypothyroidism and anxiety presenting with hyponatremia found on outside labs. For approximately the past 10 days she has not been feeling herself. Over this time frame she has had a headache, dizziness, general weakness and bilateral tinnitus. Notably in the end of ___ she has a diarrheal illness, which her son had at the same time. She recovered from this spontaneously. She went to an urgent care on ___ and was given HCTZ 25mg BID for hypertension. She took a single dose of this medication on ___ in the evening. She then presented to her primary care physician ___ ___ for hypertension and had a chem panel drawn in this setting. Her sodium resulted as 118 and she was called to come to the ED. Her last sodium check prior to this was about 3 months prior and was normal at 135. Of note, she describes an incident about ___ years ago when she was very weak after a diarrheal illness and collapsed. She was admitted to the hospital at that time reportedly because of severe hyponatremia. Ms. ___ reports she typically has about 4 cups of tea every morning and then ___ bottles of water later in the day. Overall she eats a fairly mixed diet. She has not had chest pain, vomiting, diarrhea, fevers, chills. She endorses some anorexia. In the ED, - Initial Vitals: T97.8, HR 75, BP 178/89, RR 16, O2 100% RA - Exam: Physical General: well-appearing HEENT: MMM, neck supple Lungs: CTAB, normal work of breathing Heart: RRR, normal S1/S2, no murmurs Abd: soft, nontener, nondistended Skin: WWP, cap refill <2 sec Ext: no edema, ecchymosis Neuro: CN II-XII grossly intact, ___ strength and sensation to light touch throughout Her initial sodium was 121 on presentation. She received 1L NS for this and overcorrected to 130. She then received DDAVP 2mcg and her sodium dropped to 126 before coming to the floor. ROS: Positives as per HPI; otherwise negative. Past Medical History: - Osteoporosis - Anxiety - HTN - Hypothyroidism - Sciatica Social History: ___ Family History: No known family history of electrolyte derangement Physical Exam: ============================ ADMISSION PHYSICAL EXAMINATION ============================ VS: T98.7, HR 81, BP 142/87, RR 16, ___ 98% RA GEN: Sitting up in bed and speaking with me. Somewhat anxious. EYES: Pupils equal and reactive. No icterus or injection HENNT: Moist mucous membranes. CV: S1/S2 regular with no murmurs, rubs or S3/S4. RESP: Clear bilaterally, no respiratory distress. GI: Soft, non-tender, non-distended. EXT: Warm extremities, no lower extremity edema. SKIN: Warm, dry. Bruising on L dorsum of hand. NEURO: CN II-XII normal, ___ strength in upper and lower extremities. PSYCH: Anxious appearing. ============================ DISCHARGE PHYSICAL EXAMINATION VS: 24 HR Data (last updated ___ @ 749) Temp: 98.1 (Tm 98.3), BP: 155/87 (132-155/83-87), HR: 70 (67-70), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: Ra\ GEN: Ambulating around room/hall, NAD EYES: Pupils equal and reactive. No icterus or injection HENNT: Moist mucous membranes. No CLAD CV: S1/S2 regular with no murmurs, rubs or S3/S4. RESP: Clear bilaterally, no respiratory distress. GI: Soft, non-tender, non-distended. EXT: Warm extremities, no lower extremity edema. SKIN: Warm, dry. NEURO: CN II-XII normal, ___ strength in upper and lower extremities. PSYCH: Mildly anxious appearing. Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ ___ 04:30PM BLOOD WBC-6.7 RBC-4.31 Hgb-13.6 Hct-37.8 MCV-88 MCH-31.6 MCHC-36.0 RDW-11.1 RDWSD-35.6 Plt ___ ___ 04:30PM BLOOD UreaN-8 Creat-0.4 Na-118* K-3.6 Cl-81* HCO3-24 AnGap-13 ___ 12:59AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2 ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== ___ 10:26AM BLOOD Na-122* K-3.2* ___ 02:12PM BLOOD Na-127* ___ 04:22PM BLOOD Na-130* ___ 04:48PM BLOOD Na-126* ___ 06:28PM BLOOD Na-125* K-3.8 ___ 09:27PM BLOOD Na-127* ___ 01:12AM BLOOD Na-126* ___ 04:36AM BLOOD Na-126* ___ 08:29AM BLOOD Na-124* ___ 01:08PM BLOOD Na-125* ___ 04:35PM BLOOD Na-130* ___ 11:52PM BLOOD Na-126* ___ 07:07AM BLOOD Na-127* =========================== REPORTS AND IMAGING STUDIES =========================== ___ CXR FINDINGS: The lungs are hyperexpanded. There is no focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiomediastinal silhouette is within normal limits. The bony thorax is grossly intact. IMPRESSION: No acute cardiopulmonary abnormality. ============ MICROBIOLOGY ============ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: ASSESSMENT/PLAN: ___ w/ HTN, hypothyroidism, and anxiety p/w hyponatremia that is likely multifactorial iso recent HCTZ use and excessive water intake in relation to solute intake. #Hyponatremia: 10 days of constitutional symptoms prompting PCP visit and lab testing revealing hyponatremia to 118. Likely multifactorial in the setting of poor solute intake, high water intake, recent HCTZ use. ___ have been precipitated by diarrheal illness 3 weeks ago. She seems prone to this with a similar episode about ___ years ago. Received a total of 2 doses of DDAVP while in the ICU. Sodium improved with 1L/day fluid restriction; however, by day of discharge it had not fully normalized and urine osms had increased to 458 from 121, raising the possibility of an additional underlying process such as SIADH. Discharged home on fluid restriction per renal recommendation with PCP ___ in two days for sodium check. HCTZ added to allergy list. Discharge Na 131 by serum, 129 by whole blood. Plan for repeat labs on ___ with results faxed to PCP and nephrology. PCP received ___ warm hand off on patient. #HTN: On metop XL 25 TID at home, which is an unusual regimen. Appears that patient feels some sense of reassurance by taking this medication more frequently. We therefore changed her metoprolol succ to metop tartrate 25 tid. Added amlodipine 5mg daily for blood pressure control. Chronic Issues #Anxiety: Continued home alprazolam #GERD: Continued Maalox, ranitidine Transitional Issues: [] ___ blood sodium, consider SIADH if not normalized [] Patient was taking metoprolol XL 25 TID at home. We changed this to metop tartrate 25 tid. [] HCTZ added to allergy list, would use caution with diuretics in this patient given 2x episodes of hyponatremia [] ___ blood pressures on amlodipine 5mg initiated on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Metoprolol Succinate XL 25 mg PO TID 3. ALPRAZolam 0.25 mg PO TID:PRN anxiety 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 5. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Metoprolol Tartrate 25 mg PO TID RX metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 4. ALPRAZolam 0.25 mg PO TID:PRN anxiety 5. Levothyroxine Sodium 50 mcg PO DAILY 6.Outpatient Lab Work E87.1 Please obtain chem 7, fax results to ___ attention ___ ___ MD Discharge Disposition: Home Discharge Diagnosis: hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted because you had a low sodium level in your blood. The medical term for this condition is 'hyponatremia'. What was done for me while I was in the hospital? Your blood's sodium level was increased to a near-normal level by managing your body's fluid level. Your blood sodium level did not completely normalize, and we made an appointment for you with your PCP to follow up on this issue as an outpatient in the next ___ days. What should I do when I leave the hospital? Limit your fluid intake to no more than 1 liter per day, until you see your PCP. Make sure to attend your scheduled PCP appointment, which should be scheduled for ___ days from your discharge from the hospital. Please make sure to get labs drawn on ___. The results will be faxed to your doctors. We started you on amlodipine which is blood pressure medication in place of HCTZ. Please take all of your medications as prescribed. Sincerely, Your ___ Care Team Followup Instructions: ___	[ "E871", "F419", "I10", "E039", "M810", "M5430", "T502X5A", "Y92009" ]	Allergies: Codeine / escitalopram / lisinopril / aspirin / latex / hydrochlorothiazide Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with hypertension, hypothyroidism and anxiety presenting with hyponatremia found on outside labs. For approximately the past 10 days she has not been feeling herself. Over this time frame she has had a headache, dizziness, general weakness and bilateral tinnitus. Notably in the end of [MASKED] she has a diarrheal illness, which her son had at the same time. She recovered from this spontaneously. She went to an urgent care on [MASKED] and was given HCTZ 25mg BID for hypertension. She took a single dose of this medication on [MASKED] in the evening. She then presented to her primary care physician [MASKED] [MASKED] for hypertension and had a chem panel drawn in this setting. Her sodium resulted as 118 and she was called to come to the ED. Her last sodium check prior to this was about 3 months prior and was normal at 135. Of note, she describes an incident about [MASKED] years ago when she was very weak after a diarrheal illness and collapsed. She was admitted to the hospital at that time reportedly because of severe hyponatremia. Ms. [MASKED] reports she typically has about 4 cups of tea every morning and then [MASKED] bottles of water later in the day. Overall she eats a fairly mixed diet. She has not had chest pain, vomiting, diarrhea, fevers, chills. She endorses some anorexia. In the ED, - Initial Vitals: T97.8, HR 75, BP 178/89, RR 16, O2 100% RA - Exam: Physical General: well-appearing HEENT: MMM, neck supple Lungs: CTAB, normal work of breathing Heart: RRR, normal S1/S2, no murmurs Abd: soft, nontener, nondistended Skin: WWP, cap refill <2 sec Ext: no edema, ecchymosis Neuro: CN II-XII grossly intact, [MASKED] strength and sensation to light touch throughout Her initial sodium was 121 on presentation. She received 1L NS for this and overcorrected to 130. She then received DDAVP 2mcg and her sodium dropped to 126 before coming to the floor. ROS: Positives as per HPI; otherwise negative. Past Medical History: - Osteoporosis - Anxiety - HTN - Hypothyroidism - Sciatica Social History: [MASKED] Family History: No known family history of electrolyte derangement Physical Exam: ============================ ADMISSION PHYSICAL EXAMINATION ============================ VS: T98.7, HR 81, BP 142/87, RR 16, [MASKED] 98% RA GEN: Sitting up in bed and speaking with me. Somewhat anxious. EYES: Pupils equal and reactive. No icterus or injection HENNT: Moist mucous membranes. CV: S1/S2 regular with no murmurs, rubs or S3/S4. RESP: Clear bilaterally, no respiratory distress. GI: Soft, non-tender, non-distended. EXT: Warm extremities, no lower extremity edema. SKIN: Warm, dry. Bruising on L dorsum of hand. NEURO: CN II-XII normal, [MASKED] strength in upper and lower extremities. PSYCH: Anxious appearing. ============================ DISCHARGE PHYSICAL EXAMINATION VS: 24 HR Data (last updated [MASKED] @ 749) Temp: 98.1 (Tm 98.3), BP: 155/87 (132-155/83-87), HR: 70 (67-70), RR: 18 ([MASKED]), O2 sat: 99% (97-99), O2 delivery: Ra\ GEN: Ambulating around room/hall, NAD EYES: Pupils equal and reactive. No icterus or injection HENNT: Moist mucous membranes. No CLAD CV: S1/S2 regular with no murmurs, rubs or S3/S4. RESP: Clear bilaterally, no respiratory distress. GI: Soft, non-tender, non-distended. EXT: Warm extremities, no lower extremity edema. SKIN: Warm, dry. NEURO: CN II-XII normal, [MASKED] strength in upper and lower extremities. PSYCH: Mildly anxious appearing. Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ [MASKED] 04:30PM BLOOD WBC-6.7 RBC-4.31 Hgb-13.6 Hct-37.8 MCV-88 MCH-31.6 MCHC-36.0 RDW-11.1 RDWSD-35.6 Plt [MASKED] [MASKED] 04:30PM BLOOD UreaN-8 Creat-0.4 Na-118* K-3.6 Cl-81* HCO3-24 AnGap-13 [MASKED] 12:59AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2 ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== [MASKED] 10:26AM BLOOD Na-122* K-3.2* [MASKED] 02:12PM BLOOD Na-127* [MASKED] 04:22PM BLOOD Na-130* [MASKED] 04:48PM BLOOD Na-126* [MASKED] 06:28PM BLOOD Na-125* K-3.8 [MASKED] 09:27PM BLOOD Na-127* [MASKED] 01:12AM BLOOD Na-126* [MASKED] 04:36AM BLOOD Na-126* [MASKED] 08:29AM BLOOD Na-124* [MASKED] 01:08PM BLOOD Na-125* [MASKED] 04:35PM BLOOD Na-130* [MASKED] 11:52PM BLOOD Na-126* [MASKED] 07:07AM BLOOD Na-127* =========================== REPORTS AND IMAGING STUDIES =========================== [MASKED] CXR FINDINGS: The lungs are hyperexpanded. There is no focal consolidation, pleural effusion or pneumothorax identified. The size of the cardiomediastinal silhouette is within normal limits. The bony thorax is grossly intact. IMPRESSION: No acute cardiopulmonary abnormality. ============ MICROBIOLOGY ============ URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: ASSESSMENT/PLAN: [MASKED] w/ HTN, hypothyroidism, and anxiety p/w hyponatremia that is likely multifactorial iso recent HCTZ use and excessive water intake in relation to solute intake. #Hyponatremia: 10 days of constitutional symptoms prompting PCP visit and lab testing revealing hyponatremia to 118. Likely multifactorial in the setting of poor solute intake, high water intake, recent HCTZ use. [MASKED] have been precipitated by diarrheal illness 3 weeks ago. She seems prone to this with a similar episode about [MASKED] years ago. Received a total of 2 doses of DDAVP while in the ICU. Sodium improved with 1L/day fluid restriction; however, by day of discharge it had not fully normalized and urine osms had increased to 458 from 121, raising the possibility of an additional underlying process such as SIADH. Discharged home on fluid restriction per renal recommendation with PCP [MASKED] in two days for sodium check. HCTZ added to allergy list. Discharge Na 131 by serum, 129 by whole blood. Plan for repeat labs on [MASKED] with results faxed to PCP and nephrology. PCP received [MASKED] warm hand off on patient. #HTN: On metop XL 25 TID at home, which is an unusual regimen. Appears that patient feels some sense of reassurance by taking this medication more frequently. We therefore changed her metoprolol succ to metop tartrate 25 tid. Added amlodipine 5mg daily for blood pressure control. Chronic Issues #Anxiety: Continued home alprazolam #GERD: Continued Maalox, ranitidine Transitional Issues: [] [MASKED] blood sodium, consider SIADH if not normalized [] Patient was taking metoprolol XL 25 TID at home. We changed this to metop tartrate 25 tid. [] HCTZ added to allergy list, would use caution with diuretics in this patient given 2x episodes of hyponatremia [] [MASKED] blood pressures on amlodipine 5mg initiated on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Metoprolol Succinate XL 25 mg PO TID 3. ALPRAZolam 0.25 mg PO TID:PRN anxiety 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 5. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Metoprolol Tartrate 25 mg PO TID RX metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 4. ALPRAZolam 0.25 mg PO TID:PRN anxiety 5. Levothyroxine Sodium 50 mcg PO DAILY 6.Outpatient Lab Work E87.1 Please obtain chem 7, fax results to [MASKED] attention [MASKED] [MASKED] MD Discharge Disposition: Home Discharge Diagnosis: hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking part in your care here at [MASKED]! Why was I admitted to the hospital? - You were admitted because you had a low sodium level in your blood. The medical term for this condition is 'hyponatremia'. What was done for me while I was in the hospital? Your blood's sodium level was increased to a near-normal level by managing your body's fluid level. Your blood sodium level did not completely normalize, and we made an appointment for you with your PCP to follow up on this issue as an outpatient in the next [MASKED] days. What should I do when I leave the hospital? Limit your fluid intake to no more than 1 liter per day, until you see your PCP. Make sure to attend your scheduled PCP appointment, which should be scheduled for [MASKED] days from your discharge from the hospital. Please make sure to get labs drawn on [MASKED]. The results will be faxed to your doctors. We started you on amlodipine which is blood pressure medication in place of HCTZ. Please take all of your medications as prescribed. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "E871", "F419", "I10", "E039" ]	[ "E871: Hypo-osmolality and hyponatremia", "F419: Anxiety disorder, unspecified", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "M5430: Sciatica, unspecified side", "T502X5A: Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,041,894	27,875,571	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Aortic Insufficiency Major Surgical or Invasive Procedure: Cardiac Catheterization ___ Transesophageal Echocardiogram ___ Transcatheter Aortic Valve Replacement (TAVR) ___ History of Present Illness: ___ year old man with HTN, HLD, s/p bioprosthetic AVR/MVR in ___ at ___, AF on Coumadin, severe MR due to flail leaflet due to mitral prosthetic valve endocarditis in ___ s/p percutaneous mitral valve replacement at ___ in ___, aortic insufficiency, tricuspid regurgitation, renal failure who presents for a planned pre-operative evaluation for TAVR. Per his outpatient cardiologist, his endocarditis involved not only the mitral valve but the aortic prosthetic valve. Therefore, his aortic insufficiency has worsened leading to severe TR, right sided heart failure, and worsening renal failure. His symptoms had thus worsened over the past few years. The patient had a recent admission to ___ in ___ with acute diastolic HF. He has dyspnea on exertion. He has no CP, orthopnea, PND or leg edema. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - HFpEF - History of severe aortic stenosis, status ___ aortic valve ___ ___ - Severe mitral regurgitation status ___ aortic mitral valve ___ ___ - severe TR - Atrial fibrillation on Coumadin - History of strep pneumo bacteremia and prosthetic valve endocarditis in ___ 3. OTHER PAST MEDICAL HISTORY - gout - CKD - BPH - DJD - hernia repair x3 Social History: ___ Family History: FAMILY HISTORY: Notable for father with lung cancer, deceased. Mother with congestive heart failure, deceased. Physical Exam: On Admission: VS: BP 122/49 HR 66 RR 19 SpO2 96% RA Weight: 74.8 kg / 164.6 lbs 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. no JVD but has elevated v wave CARDIAC: PMI located in ___ intercostal space, midclavicular line. irregularly irregular rhythm, holosystolic murmur best appreciated at right lower sternal border 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. Pulsatile liver. 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. At Discharge: VS: T 97.9 BP 133/63 HR 73 RR 18 SpO2 98% RA Weight: 72.4 kg / 159.3 lbs Gen: Patient is in no acute distress. HEENT: Face symmetrical, trachea midline. Neuro: A/Ox3. Speaking in complete, coherent sentences. No face, arm, or leg weakness. Pulm: Breathing unlabored. Breath sounds clear bilaterally. Cardiac: JVD at collar bone while sitting up. No thrills or bruits heard on carotids bilaterally. Heart rhythm irregular. II/VI systolic murmur. Vasc: 2+ edema noted in bilateral lower extremities. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, ___ pulses palpable 1+. Access: Bilateral femoral access site soft, non-tender. No drainage, swelling or hematoma noted. No bruits auscultated. Gauze dressings removed and left open to air. No sutures in place. Abd: Rounded, soft, non-tender. Pertinent Results: Admission Labs: ___ 07:10AM BLOOD WBC-9.6 RBC-2.49* Hgb-8.3* Hct-25.5* MCV-102* MCH-33.3* MCHC-32.5 RDW-16.4* RDWSD-60.8* Plt Ct-72* ___ 07:30AM BLOOD ___ ___ 07:10AM BLOOD Glucose-98 UreaN-59* Creat-1.9* Na-146 K-4.0 Cl-108 HCO3-22 AnGap-16 ___ 07:10AM BLOOD ALT-21 AST-45* AlkPhos-135* TotBili-0.8 ___ 07:10AM BLOOD Calcium-8.5 Phos-2.2* Mg-2.4 Discharge Labs: ___ 07:20AM BLOOD WBC-10.6* RBC-2.37* Hgb-8.1* Hct-24.4* MCV-103* MCH-34.2* MCHC-33.2 RDW-17.6* RDWSD-65.4* Plt ___ ___ 07:20AM BLOOD ___ ___ 07:20AM BLOOD Glucose-89 UreaN-67* Creat-2.3* Na-142 K-4.1 Cl-106 HCO3-24 AnGap-12 ___ 07:20AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.7* ___ Cardiovascular Cardiac Cath Coronary Description The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 50% stenosis in the proximal and mid segments. 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. There is a 60% stenosis in the mid segment. The Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The Atrioventricular Circumflex, arising from the distal segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a 40% stenosis in the ostium. The Acute Marginal, arising from the proximal segment, is a small caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. Interventional Details Complications: There were no clinically significant complications. Findings Elevated left and right heart filling pressures. Moderate coronary coronary artery disease. Failed surgical aortic valve with severe aortic regurgitation Possible mitral valve regurgitation through TMVR Severe triscuspid regrugitation Recommendations Maximize medical therapy CSURG consult TEE (Is AI valvular or paravalvular) CTA (sizing of valve and position of the coronaries TEE ___: CONCLUSION: There is no spontaneous echo contrast in the body of the left atrium. There is mild spontaneous echo contrast in the left atrial appendage. No thrombus/mass is seen in the body of the left atrium/left atrial appendage. The left atial appendage ejection velocity is very depressed. No spontaneous echo contrast or thrombus is seen in the body of the right atrium/right atrial appendage. The right atrial appendage ejection velocity is depressed. There is no evidence for an atrial septal defect by 2D/color Doppler. Overall left ventricular systolic function is mildly depressed. Mildly dilated right ventricular cavity with mild global free wall hypokinesis. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. There are no aortic arch atheroma with simple atheroma in the descending aorta to 40cm from the incisors. An aortic valve bioprosthesis is present. The prosthesis is well seated with thickened leaflets but normal gradient. No masses or vegetations are seen on the aortic valve. No abscess is seen. There is a valvular jet of moderate to severe [3+] aortic regurgitation. There is ___ 3 TMVR prosthesis. The prosthesis is well-seated, with thin/mobile leaflets and high normal mean gradient. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is a valvular and paravalvular jet of trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is moderate [2+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Well seated bioprosthetic aortic valve prosthesis with thickened leaflets and moderate to severe valvular regurgitation. Well seated bioprosthetic mitral valve prosthesis (TMVR) with thin/mobile leaflets and very mild valvular and paravalvular regurgitation. Right ventricular cavity dilation with free wall hypokinesis. Moderate pulmonary artery systolic hypertension. Moderate tricuspid regurgitation. Cardiac Structure/Morph ___: IMPRESSION: Status post aortic and mitral valve replacements, now here for possible TAVR procedure. Dilated right and left atrium and right ventricle. Severe coronary atherosclerotic disease. The left appendage is not filled with contrast on the current study which could be related either to a thrombus or slowed filling. If clinical concern exists, an echocardiogram can better assess this finding. Patent femoral and subclavian arteries bilaterally with largest lumen diameter in the left femoral and left subclavian arteries. Scaterred pulmonary nodules surrounded by ground glass opacities and mild interlobular septal thickening. These are attributable to pulmonary edema with possible superimposed infection. TAVR Report ___: Interventional Details Complications: There were no clinically significant complications. Successful TAVR: A 26 mm Evolut with proper fluoroscopic loading was then advanced to the aortic valve. The valve was deployed under TEE and fluoro guidance and using and placement of a Pigtail catheter was usedto demonstrate the position of the Evolut 2 mm below the prosthetic frame. After final deployment, there was none-trace aortic regurgitation by TEE. The gradient was <5 mmHg across the valve with some LVOT gradient The right groin was closed with a two Proglide in a Pre-Close fashion and an angioseal. The left femoral artery was closed with a ___ Fr Angioseal. IMPRESSION: Well-seated, normally functioning ___ 3 aortic bioprosthesis within a ___ bioprosthetic aortic valve. Mild resting LVOT obstruction without inducible gradient increase. Bioprosthetic mitral valve with elevated transmitral pressure gradient. Severe biatrial enlargement. Preserved left ventricular systolic function. Dilated, mildly hypokinetic right ventricle. Severe tricuspid regurgitation. Severe pulmonary hypertension. Compared with the prior TTE (images reviewed) of ___, the ___ 3 aortic bioprosthesis is new. The tranmitral pressure gradient has increased (previously 10 mmHg). The severity of tricuspid regurgitation is higher. The pulmonary pressure has increased. LVEF 65%. AV Peak/Mean 29 mmHg/15 mmHg. ___ 1.8 cm2. Brief Hospital Course: Assessment/Plan: Mr. ___ is a ___ year old man with HTN, HLD, s/p bioprosthetic AVR/MVR in ___, AF on Coumadin, severe MR due to flail leaflet due to mitral prosthetic valve endocarditis in ___, percutaneous mitral valve replacement at ___ in ___, aortic insufficiency, tricuspid regurgitation, renal failure who is now s/p TAVR. ============== ACTIVE ISSUES: ============== # Aortic Insufficiency s/p successful TAVR ___. Pre-op work up included Cardiac cath, TEE, and CTA Cardiac. Post- op echocardiogram findings showed AV gradients improved peak/mean: ___ mmHg compared to ___ mmHg on TEE ___. He has been diuresing since TAVR. Down cumulatively over -8L, including down -1.5L on PO Torsemide 40mg prior to discharge. He is down from admission weight (74.8 kg) to 72.4 kg. On exam he denied SOB, his lung sounds were CTA, JVD was at collarbone while sitting, he still had 2+ BLE edema. He still has severe TR, which may be contributing to JVD and edema. Cr peak was up to 3.3 and downtrending to 2.3 today. -Diuresis: He received IV Lasix 80mg daily post TAVR, and responded well. He is converted and discharged on Torsemide 40mg PO. We have instructed him to monitor his weight and call if he gains over 3 lbs in one day. He will have his Kidney Function checked on ___. He will follow up with his PCP, ___. ___ on ___ and his cardiologist, Dr. ___ on ___. If he continues to downtrend on his weight, and BUN/Cr increase again, consider decreasing torsemide dose. -Anticoagulation plan includes Plavix and Warfarin per Dr. ___. -Hold home BB as he has been rate controlled off of metoprolol. ___ be restarted as outpatient if HR or BP up. -Continue Amlodipine. # Atrial fibrillation/flutter: Rate controlled. Was bridged on heparin gtt pre-TAVR, now dc'd and warfarin restarted. -Continue Warfarin, INR goal ___. No need for bridge per Dr. ___. INR was 1.5 on discharge. He was discharged on Warfarin 4mg ___, 30. He is scheduled to follow up at ___ ___ on ___. Anticoagulation managed by PCP ___. -Hold metoprolol as he has been rate controlled. Consider resuming as outpatient if HR/BP. # ___ on CKD: Cr down to 2.3 on discharge. Cr was as high as 3.3 ___. Likely due to worsening heart failure, and contrast-induced after pre-TAVR cardiac cath and cardiac CT. He received no contrast for TAVR. -He will have his kidney function checked again on ___, ___. -He is discharged on Torsemide PO 40mg daily. Consider decreasing dose if Cr trends back up. =============== CHRONIC ISSUES: =============== # Coronary artery disease: Moderate CAD Per cardiac catheterization report ___ -Continue Simvastatin 40 mg tablet -Metoprolol on hold since pre-TAVR as he has been rate controlled; consider resuming as outpatient. # Iron deficiency anemia: Required 1 unit PRBCs the day before TAVR for Hgb 6.9. Since his TAVR, his H/H has been stable: 8.1/24.4 today. - Continue FeroSul 325 mg (65 mg iron) tablet BID # BPH: Stable -Continue tamsulosin 0.4mg PO daily # Insomnia: Stable -Continue trazodone 50 mg tablet PO qhs # Gout: No signs of acute illness -Continue allopurinol ___ mg PO daily # Vitamin D deficiency: -Cholecalciferol (vitamin D3) 5,000 unit tablet PO daily # DISPO: Anticipate: [X] d/c home [] d/c home with services [] d/c to rehab/LTC # Transitional issues: 1. Structural to follow outpatient as he may need clip for wide open TR per Dr. ___ would be scheduled at a later time. Dr. ___ will schedule TAVR follow up and concurrent TTE in ___ weeks. 2. Anticoagulation Plan: Coumadin and Plavix - will be checked at ___ on ___. 3. Follow up with PCP, ___, ___. 4. Follow up with cardiologist, Dr. ___, ___. [x] Plan discussed and reviewed with Dr. ___. [x] Plan discussed Mr. ___, who appears to understand and agree to proceed with the outlined treatment plan. All questions answered to apparent satisfaction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Metoprolol Succinate XL 12.5 mg PO DAILY 3. Warfarin 2 mg PO 3X/WEEK (___) 4. Warfarin 4 mg PO 4X/WEEK (___) 5. amLODIPine 5 mg PO DAILY 6. Ferrous Sulfate 325 mg PO BID 7. Torsemide 40 mg PO 3X/WEEK (___) 8. Multivitamins 1 TAB PO DAILY 9. Torsemide 20 mg PO 4X/WEEK (___) 10. Tamsulosin 0.4 mg PO QHS 11. TraZODone 50 mg PO QHS 12. Metolazone 2.5 mg PO DAILY:PRN if weight up by ___ pounds. 13. FoLIC Acid 1 mg PO DAILY 14. Vitamin D ___ UNIT PO DAILY 15. Simvastatin 40 mg PO QPM Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Torsemide 40 mg PO DAILY 3. Warfarin 4 mg PO DAILY16 Take tonight and tomorrow night. Then as directed by ___. 4. Allopurinol ___ mg PO DAILY 5. amLODIPine 5 mg PO DAILY 6. Ferrous Sulfate 325 mg PO BID 7. FoLIC Acid 1 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Simvastatin 40 mg PO QPM 10. Tamsulosin 0.4 mg PO QHS 11. TraZODone 50 mg PO QHS 12. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Aortic Insufficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. See discharge summary Discharge Instructions: You were admitted prior to your TAVR (trans catheter aortic valve repair) procedure to treat your aortic valve stenosis. As a part of work up, you had heart catheterization, Echo, and CT scan done this admission. You underwent a successful TAVR on ___ with no complications. By repairing the valve your heart can pump blood more easily. You will likely need your other valve (Tricuspid Valve) fixed in the near future as well. Dr. ___ (Valve team) will be calling you at home to see how you are doing. It is very important to take all of your heart healthy medications. Resume your home medications with the following changes: - Take Torsemide 40mg daily - this is to help get any extra fluid off of you. Your PCP and cardiologist may adjust the dose when you follow up with them. We want to ensure you do not gain weight once you get home. - Take Clopidogrel 75mg daily - this is a blood thinner to prevent clots from forming around the valve. - Take Warfarin 4mg tonight and tomorrow night. Have your INR checked at the ___. They will be in contact with you to schedule an INR check on ___, ___. Call ___ tomorrow if you do not receive a call to schedule this appointment. - Stop Metoprolol. This was held during your hospitalization and your heart rate and blood pressure were under control. Your blood pressure was on the low side. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 159 lbs. We are sending you home with lab slip to check your kidney function and INR by ___. Have you labs drawn and results will be faxed to your PCP. If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the ___ HeartLine at ___ to speak to a cardiologist or cardiac nurse practitioner. It has been a pleasure to have participated in your care and we wish you the best with your health! Followup Instructions: ___	[ "T82897A", "I130", "I5032", "N179", "Z006", "D509", "N183", "D631", "D696", "I482", "I082", "N189", "N400", "G4700", "M109", "E559", "Z8619", "Z953", "Z7901", "Y712" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Aortic Insufficiency Major Surgical or Invasive Procedure: Cardiac Catheterization [MASKED] Transesophageal Echocardiogram [MASKED] Transcatheter Aortic Valve Replacement (TAVR) [MASKED] History of Present Illness: [MASKED] year old man with HTN, HLD, s/p bioprosthetic AVR/MVR in [MASKED] at [MASKED], AF on Coumadin, severe MR due to flail leaflet due to mitral prosthetic valve endocarditis in [MASKED] s/p percutaneous mitral valve replacement at [MASKED] in [MASKED], aortic insufficiency, tricuspid regurgitation, renal failure who presents for a planned pre-operative evaluation for TAVR. Per his outpatient cardiologist, his endocarditis involved not only the mitral valve but the aortic prosthetic valve. Therefore, his aortic insufficiency has worsened leading to severe TR, right sided heart failure, and worsening renal failure. His symptoms had thus worsened over the past few years. The patient had a recent admission to [MASKED] in [MASKED] with acute diastolic HF. He has dyspnea on exertion. He has no CP, orthopnea, PND or leg edema. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - HFpEF - History of severe aortic stenosis, status [MASKED] aortic valve [MASKED] [MASKED] - Severe mitral regurgitation status [MASKED] aortic mitral valve [MASKED] [MASKED] - severe TR - Atrial fibrillation on Coumadin - History of strep pneumo bacteremia and prosthetic valve endocarditis in [MASKED] 3. OTHER PAST MEDICAL HISTORY - gout - CKD - BPH - DJD - hernia repair x3 Social History: [MASKED] Family History: FAMILY HISTORY: Notable for father with lung cancer, deceased. Mother with congestive heart failure, deceased. Physical Exam: On Admission: VS: BP 122/49 HR 66 RR 19 SpO2 96% RA Weight: 74.8 kg / 164.6 lbs 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. no JVD but has elevated v wave CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. irregularly irregular rhythm, holosystolic murmur best appreciated at right lower sternal border 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. Pulsatile liver. 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. At Discharge: VS: T 97.9 BP 133/63 HR 73 RR 18 SpO2 98% RA Weight: 72.4 kg / 159.3 lbs Gen: Patient is in no acute distress. HEENT: Face symmetrical, trachea midline. Neuro: A/Ox3. Speaking in complete, coherent sentences. No face, arm, or leg weakness. Pulm: Breathing unlabored. Breath sounds clear bilaterally. Cardiac: JVD at collar bone while sitting up. No thrills or bruits heard on carotids bilaterally. Heart rhythm irregular. II/VI systolic murmur. Vasc: 2+ edema noted in bilateral lower extremities. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, [MASKED] pulses palpable 1+. Access: Bilateral femoral access site soft, non-tender. No drainage, swelling or hematoma noted. No bruits auscultated. Gauze dressings removed and left open to air. No sutures in place. Abd: Rounded, soft, non-tender. Pertinent Results: Admission Labs: [MASKED] 07:10AM BLOOD WBC-9.6 RBC-2.49* Hgb-8.3* Hct-25.5* MCV-102* MCH-33.3* MCHC-32.5 RDW-16.4* RDWSD-60.8* Plt Ct-72* [MASKED] 07:30AM BLOOD [MASKED] [MASKED] 07:10AM BLOOD Glucose-98 UreaN-59* Creat-1.9* Na-146 K-4.0 Cl-108 HCO3-22 AnGap-16 [MASKED] 07:10AM BLOOD ALT-21 AST-45* AlkPhos-135* TotBili-0.8 [MASKED] 07:10AM BLOOD Calcium-8.5 Phos-2.2* Mg-2.4 Discharge Labs: [MASKED] 07:20AM BLOOD WBC-10.6* RBC-2.37* Hgb-8.1* Hct-24.4* MCV-103* MCH-34.2* MCHC-33.2 RDW-17.6* RDWSD-65.4* Plt [MASKED] [MASKED] 07:20AM BLOOD [MASKED] [MASKED] 07:20AM BLOOD Glucose-89 UreaN-67* Creat-2.3* Na-142 K-4.1 Cl-106 HCO3-24 AnGap-12 [MASKED] 07:20AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.7* [MASKED] Cardiovascular Cardiac Cath Coronary Description The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 50% stenosis in the proximal and mid segments. 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. There is a 60% stenosis in the mid segment. The Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The Atrioventricular Circumflex, arising from the distal segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a 40% stenosis in the ostium. The Acute Marginal, arising from the proximal segment, is a small caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. Interventional Details Complications: There were no clinically significant complications. Findings Elevated left and right heart filling pressures. Moderate coronary coronary artery disease. Failed surgical aortic valve with severe aortic regurgitation Possible mitral valve regurgitation through TMVR Severe triscuspid regrugitation Recommendations Maximize medical therapy CSURG consult TEE (Is AI valvular or paravalvular) CTA (sizing of valve and position of the coronaries TEE [MASKED]: CONCLUSION: There is no spontaneous echo contrast in the body of the left atrium. There is mild spontaneous echo contrast in the left atrial appendage. No thrombus/mass is seen in the body of the left atrium/left atrial appendage. The left atial appendage ejection velocity is very depressed. No spontaneous echo contrast or thrombus is seen in the body of the right atrium/right atrial appendage. The right atrial appendage ejection velocity is depressed. There is no evidence for an atrial septal defect by 2D/color Doppler. Overall left ventricular systolic function is mildly depressed. Mildly dilated right ventricular cavity with mild global free wall hypokinesis. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. There are no aortic arch atheroma with simple atheroma in the descending aorta to 40cm from the incisors. An aortic valve bioprosthesis is present. The prosthesis is well seated with thickened leaflets but normal gradient. No masses or vegetations are seen on the aortic valve. No abscess is seen. There is a valvular jet of moderate to severe [3+] aortic regurgitation. There is [MASKED] 3 TMVR prosthesis. The prosthesis is well-seated, with thin/mobile leaflets and high normal mean gradient. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is a valvular and paravalvular jet of trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is moderate [2+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Well seated bioprosthetic aortic valve prosthesis with thickened leaflets and moderate to severe valvular regurgitation. Well seated bioprosthetic mitral valve prosthesis (TMVR) with thin/mobile leaflets and very mild valvular and paravalvular regurgitation. Right ventricular cavity dilation with free wall hypokinesis. Moderate pulmonary artery systolic hypertension. Moderate tricuspid regurgitation. Cardiac Structure/Morph [MASKED]: IMPRESSION: Status post aortic and mitral valve replacements, now here for possible TAVR procedure. Dilated right and left atrium and right ventricle. Severe coronary atherosclerotic disease. The left appendage is not filled with contrast on the current study which could be related either to a thrombus or slowed filling. If clinical concern exists, an echocardiogram can better assess this finding. Patent femoral and subclavian arteries bilaterally with largest lumen diameter in the left femoral and left subclavian arteries. Scaterred pulmonary nodules surrounded by ground glass opacities and mild interlobular septal thickening. These are attributable to pulmonary edema with possible superimposed infection. TAVR Report [MASKED]: Interventional Details Complications: There were no clinically significant complications. Successful TAVR: A 26 mm Evolut with proper fluoroscopic loading was then advanced to the aortic valve. The valve was deployed under TEE and fluoro guidance and using and placement of a Pigtail catheter was usedto demonstrate the position of the Evolut 2 mm below the prosthetic frame. After final deployment, there was none-trace aortic regurgitation by TEE. The gradient was <5 mmHg across the valve with some LVOT gradient The right groin was closed with a two Proglide in a Pre-Close fashion and an angioseal. The left femoral artery was closed with a [MASKED] Fr Angioseal. IMPRESSION: Well-seated, normally functioning [MASKED] 3 aortic bioprosthesis within a [MASKED] bioprosthetic aortic valve. Mild resting LVOT obstruction without inducible gradient increase. Bioprosthetic mitral valve with elevated transmitral pressure gradient. Severe biatrial enlargement. Preserved left ventricular systolic function. Dilated, mildly hypokinetic right ventricle. Severe tricuspid regurgitation. Severe pulmonary hypertension. Compared with the prior TTE (images reviewed) of [MASKED], the [MASKED] 3 aortic bioprosthesis is new. The tranmitral pressure gradient has increased (previously 10 mmHg). The severity of tricuspid regurgitation is higher. The pulmonary pressure has increased. LVEF 65%. AV Peak/Mean 29 mmHg/15 mmHg. [MASKED] 1.8 cm2. Brief Hospital Course: Assessment/Plan: Mr. [MASKED] is a [MASKED] year old man with HTN, HLD, s/p bioprosthetic AVR/MVR in [MASKED], AF on Coumadin, severe MR due to flail leaflet due to mitral prosthetic valve endocarditis in [MASKED], percutaneous mitral valve replacement at [MASKED] in [MASKED], aortic insufficiency, tricuspid regurgitation, renal failure who is now s/p TAVR. ============== ACTIVE ISSUES: ============== # Aortic Insufficiency s/p successful TAVR [MASKED]. Pre-op work up included Cardiac cath, TEE, and CTA Cardiac. Post- op echocardiogram findings showed AV gradients improved peak/mean: [MASKED] mmHg compared to [MASKED] mmHg on TEE [MASKED]. He has been diuresing since TAVR. Down cumulatively over -8L, including down -1.5L on PO Torsemide 40mg prior to discharge. He is down from admission weight (74.8 kg) to 72.4 kg. On exam he denied SOB, his lung sounds were CTA, JVD was at collarbone while sitting, he still had 2+ BLE edema. He still has severe TR, which may be contributing to JVD and edema. Cr peak was up to 3.3 and downtrending to 2.3 today. -Diuresis: He received IV Lasix 80mg daily post TAVR, and responded well. He is converted and discharged on Torsemide 40mg PO. We have instructed him to monitor his weight and call if he gains over 3 lbs in one day. He will have his Kidney Function checked on [MASKED]. He will follow up with his PCP, [MASKED]. [MASKED] on [MASKED] and his cardiologist, Dr. [MASKED] on [MASKED]. If he continues to downtrend on his weight, and BUN/Cr increase again, consider decreasing torsemide dose. -Anticoagulation plan includes Plavix and Warfarin per Dr. [MASKED]. -Hold home BB as he has been rate controlled off of metoprolol. [MASKED] be restarted as outpatient if HR or BP up. -Continue Amlodipine. # Atrial fibrillation/flutter: Rate controlled. Was bridged on heparin gtt pre-TAVR, now dc'd and warfarin restarted. -Continue Warfarin, INR goal [MASKED]. No need for bridge per Dr. [MASKED]. INR was 1.5 on discharge. He was discharged on Warfarin 4mg [MASKED], 30. He is scheduled to follow up at [MASKED] [MASKED] on [MASKED]. Anticoagulation managed by PCP [MASKED]. -Hold metoprolol as he has been rate controlled. Consider resuming as outpatient if HR/BP. # [MASKED] on CKD: Cr down to 2.3 on discharge. Cr was as high as 3.3 [MASKED]. Likely due to worsening heart failure, and contrast-induced after pre-TAVR cardiac cath and cardiac CT. He received no contrast for TAVR. -He will have his kidney function checked again on [MASKED], [MASKED]. -He is discharged on Torsemide PO 40mg daily. Consider decreasing dose if Cr trends back up. =============== CHRONIC ISSUES: =============== # Coronary artery disease: Moderate CAD Per cardiac catheterization report [MASKED] -Continue Simvastatin 40 mg tablet -Metoprolol on hold since pre-TAVR as he has been rate controlled; consider resuming as outpatient. # Iron deficiency anemia: Required 1 unit PRBCs the day before TAVR for Hgb 6.9. Since his TAVR, his H/H has been stable: 8.1/24.4 today. - Continue FeroSul 325 mg (65 mg iron) tablet BID # BPH: Stable -Continue tamsulosin 0.4mg PO daily # Insomnia: Stable -Continue trazodone 50 mg tablet PO qhs # Gout: No signs of acute illness -Continue allopurinol [MASKED] mg PO daily # Vitamin D deficiency: -Cholecalciferol (vitamin D3) 5,000 unit tablet PO daily # DISPO: Anticipate: [X] d/c home [] d/c home with services [] d/c to rehab/LTC # Transitional issues: 1. Structural to follow outpatient as he may need clip for wide open TR per Dr. [MASKED] would be scheduled at a later time. Dr. [MASKED] will schedule TAVR follow up and concurrent TTE in [MASKED] weeks. 2. Anticoagulation Plan: Coumadin and Plavix - will be checked at [MASKED] on [MASKED]. 3. Follow up with PCP, [MASKED], [MASKED]. 4. Follow up with cardiologist, Dr. [MASKED], [MASKED]. [x] Plan discussed and reviewed with Dr. [MASKED]. [x] Plan discussed Mr. [MASKED], who appears to understand and agree to proceed with the outlined treatment plan. All questions answered to apparent satisfaction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Metoprolol Succinate XL 12.5 mg PO DAILY 3. Warfarin 2 mg PO 3X/WEEK ([MASKED]) 4. Warfarin 4 mg PO 4X/WEEK ([MASKED]) 5. amLODIPine 5 mg PO DAILY 6. Ferrous Sulfate 325 mg PO BID 7. Torsemide 40 mg PO 3X/WEEK ([MASKED]) 8. Multivitamins 1 TAB PO DAILY 9. Torsemide 20 mg PO 4X/WEEK ([MASKED]) 10. Tamsulosin 0.4 mg PO QHS 11. TraZODone 50 mg PO QHS 12. Metolazone 2.5 mg PO DAILY:PRN if weight up by [MASKED] pounds. 13. FoLIC Acid 1 mg PO DAILY 14. Vitamin D [MASKED] UNIT PO DAILY 15. Simvastatin 40 mg PO QPM Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Torsemide 40 mg PO DAILY 3. Warfarin 4 mg PO DAILY16 Take tonight and tomorrow night. Then as directed by [MASKED]. 4. Allopurinol [MASKED] mg PO DAILY 5. amLODIPine 5 mg PO DAILY 6. Ferrous Sulfate 325 mg PO BID 7. FoLIC Acid 1 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Simvastatin 40 mg PO QPM 10. Tamsulosin 0.4 mg PO QHS 11. TraZODone 50 mg PO QHS 12. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Aortic Insufficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. See discharge summary Discharge Instructions: You were admitted prior to your TAVR (trans catheter aortic valve repair) procedure to treat your aortic valve stenosis. As a part of work up, you had heart catheterization, Echo, and CT scan done this admission. You underwent a successful TAVR on [MASKED] with no complications. By repairing the valve your heart can pump blood more easily. You will likely need your other valve (Tricuspid Valve) fixed in the near future as well. Dr. [MASKED] (Valve team) will be calling you at home to see how you are doing. It is very important to take all of your heart healthy medications. Resume your home medications with the following changes: - Take Torsemide 40mg daily - this is to help get any extra fluid off of you. Your PCP and cardiologist may adjust the dose when you follow up with them. We want to ensure you do not gain weight once you get home. - Take Clopidogrel 75mg daily - this is a blood thinner to prevent clots from forming around the valve. - Take Warfarin 4mg tonight and tomorrow night. Have your INR checked at the [MASKED]. They will be in contact with you to schedule an INR check on [MASKED], [MASKED]. Call [MASKED] tomorrow if you do not receive a call to schedule this appointment. - Stop Metoprolol. This was held during your hospitalization and your heart rate and blood pressure were under control. Your blood pressure was on the low side. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 159 lbs. We are sending you home with lab slip to check your kidney function and INR by [MASKED]. Have you labs drawn and results will be faxed to your PCP. If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the [MASKED] HeartLine at [MASKED] to speak to a cardiologist or cardiac nurse practitioner. It has been a pleasure to have participated in your care and we wish you the best with your health! Followup Instructions: [MASKED]	[]	[ "I130", "I5032", "N179", "D509", "D696", "N189", "N400", "G4700", "M109", "Z7901" ]	[ "T82897A: Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program", "D509: Iron deficiency anemia, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "D631: Anemia in chronic kidney disease", "D696: Thrombocytopenia, unspecified", "I482: Chronic atrial fibrillation", "I082: Rheumatic disorders of both aortic and tricuspid valves", "N189: Chronic kidney disease, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "G4700: Insomnia, unspecified", "M109: Gout, unspecified", "E559: Vitamin D deficiency, unspecified", "Z8619: Personal history of other infectious and parasitic diseases", "Z953: Presence of xenogenic heart valve", "Z7901: Long term (current) use of anticoagulants", "Y712: Prosthetic and other implants, materials and accessory cardiovascular devices associated with adverse incidents" ]
10,041,894	29,235,759	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: TEE History of Present Illness: Mr. ___ is a ___ y/o man with a PMH of AFib on warfarin, bioprosthetic AVR/MVR, gout, HTN, and HLD, who was transferred from ___ for ___ and anemia. He has been having fatigue, back pain and intermittent fevers for the past five weeks up to ___ (most recently AM of ___. Notes a 10 lb weight loss over this time. 2 weeks ago he saw his PCP for these fevers as well as cough, who felt that his presentation was consistent with community-acquired pneumonia, for which he received a five-day course of azithromycin with some relief. He subsequently received a one week course of levofloxacin. Yesterday, he returned to his PCP because he was having sacral pain for the past three weeks. This sacral pain was previously treated with cyclobenzaprine and orphenadrine. Denied any trauma. In conjunction with these fevers, his PCP was concerned for pyelonephritis, and he was sent to the ED at ___. There, a CT chest/abd/pelvis was performed. CT chest had no acute abnormality. The abdomen and pelvis scan showed cardiomegaly, mild splenomegaly, degenerative spine changes, and severe prostate enlargement. Labs at ___ were notable for: WBC 22, H/H 10.1/29, plt 116, bands 4, Na 128, K 4.5, BUN 41, Cr 2.08, trop .08, lactate 1.1, CRP 21, INR 4.35. EKG: AFib 91, LAD, QTc 471, TWI III Blood cultures grew GPC in pairs and chains. He received IV fluids, vancomycin, and Zosyn, and he was transferred to ___. In the ___ ED, initial vitals: T 99.6 P 80 BP 116/74 RR 16 O2 96% RA - Exam notable for PE: dry mucous membranes, CTAB, ___, abdomen soft, NT, ND, no CVAT, no midline spine tenderness. Brown, weakly positive guaiac stool. - Labs were notable for: Chemistries: 132 100 44 -------------< 115 4.7 20 1.8 CBC: 8.5 16.0 >---< 96 25.1 DIFF: N:84 Band:7 ___ M:7 E:0 Bas:0 Nrbc: 1 Absneut: 14.56 Abslymp: 0.32 Absmono: 1.12 Abseos: 0.00 Absbaso: 0.00 Coags: ___: 78.3 PTT: 46.1 INR: 6.9 Trop-T: <0.01 Lactate:1.2 UA: WBC 68, many bacteria, large leuks, negative nitrites, large blood, trace ketones - Patient was given: ___ 00:56 IVF 1000 mL NS 500 mL ___ 02:19 IV Pantoprazole Started 8 mg/hr ___ 02:19 IV Phytonadione 2.5 mg ___ 02:39 IV Gentamicin 350 mg ___ 02:39 IVF 1000 mL NS 1000 mL - Consults: none On arrival to the MICU, he reported L flank pain and sacral pain. He denied chest pain, shortness of breath. He has previously had fevers and chills, which had subsequently resolved. Denied nausea, vomiting, lightheadedness, dizziness, dysuria, hematuria, melena, or hematochezia. Denied sick contacts. Review of systems: - as above, otherwise a 10 point review of systems was negative Past Medical History: atrial fibrillation on warfarin - severe aortic stenosis s/p #23 ___ pericardial valve (___) - severe mitral regurgitation s/p #33 ___ porcine valve (___) - gout - hypertension - hyperlipidemia Social History: ___ Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 97.6F BP 106/51 mmHg P 70 RR 22 O2 97% 2L O2 General: Pleasant, elderly man appearing his stated age in NAD. HEENT: PERRL; EOMs intact. Dry mucous membranes. OP clear. Neck: Supple, neck veins flat. No JVD. CV: Irregularly irregular. III/VI systolic murmur; no rubs or gallops. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended. NABS. Back: Point tenderness to palpation over sacrum. Ext: Warm and well-perfused. Lone splinter hemorrhage on L thumb. No ___ nodes. 2+ DP pulses. No edema. Neuro: A&Ox3; CNs II-XII grossly intact. Distal sensation intact to light touch. DISCHARGE PHYSICAL EXAM: ========================= Vital Signs: 99.0 121/64 74 18 94%RA GEN: Alert, NAD HEENT: NC/AT CV: irreg, ___ systolic murmur PULM: CTA B, bilateral rales in the lower lung fields GI: S/NT/ND, BS present EXT: no calf tenderness ___ edema NEURO: A&Ox3 Pertinent Results: Admission Labs: ___ 12:15AM BLOOD WBC-16.0* RBC-2.73* Hgb-8.5* Hct-25.1* MCV-92 MCH-31.1 MCHC-33.9 RDW-14.2 RDWSD-47.6* Plt Ct-96* ___ 12:15AM BLOOD Neuts-84* Bands-7* Lymphs-2* Monos-7 Eos-0 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-14.56* AbsLymp-0.32* AbsMono-1.12* AbsEos-0.00* AbsBaso-0.00* ___ 12:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL ___ 12:15AM BLOOD ___ PTT-46.1* ___ ___ 06:12AM BLOOD ___ ___ 06:12AM BLOOD Ret Aut-1.1 Abs Ret-0.03 ___ 12:15AM BLOOD Glucose-115* UreaN-44* Creat-1.8* Na-132* K-4.7 Cl-100 HCO3-20* AnGap-17 ___ 06:12AM BLOOD ALT-31 AST-40 LD(LDH)-356* AlkPhos-135* TotBili-0.6 ___ 12:15AM BLOOD cTropnT-<0.01 ___ 06:12AM BLOOD Albumin-2.5* Calcium-7.6* Phos-4.4 Mg-2.0 Iron-14* ___ 06:12AM BLOOD calTIBC-146* Hapto-278* Ferritn-1144* TRF-112* ___ 12:18AM BLOOD Lactate-1.2 Discharge Labs: ___ 05:42AM BLOOD WBC-14.1* RBC-2.79* Hgb-8.7* Hct-26.0* MCV-93 MCH-31.2 MCHC-33.5 RDW-14.3 RDWSD-48.4* Plt ___ ___ 05:42AM BLOOD ___ PTT-40.6* ___ ___ 05:42AM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-133 K-3.9 Cl-100 HCO3-23 AnGap-14 ___ 05:42AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8 ___ 01:00AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 01:00AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 01:00AM URINE RBC-131* WBC-68* Bacteri-MANY Yeast-NONE Epi-<1 TransE-<1 Blood Cx x 4 negative, OSH blood cx growing strep pneuma URINE CULTURE (Final ___: NO GROWTH. IMAGING: ========== ___ EKG: Probable atrial fibrillation. Compared to the previous tracing no change. ___ TTE: The left atrium is markedly dilated. The right atrium is markedly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral valve leaflets appear thickened in some views. The gradients across the prosthesis are likley mildly elevated (not knowing what type of prosthesis this is). No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Marked biatrial enlargement. Normal left ventricular systolic function. Moderately dilated right ventricle with borderline normal free wall motion (intrinsically depressed due to volume of tricuspid regurgitation). Well seated aortic valve bioprosthesis with normal gradients and no evidence of endocarditis. Mildly increased gradients across the mitral valve bioprosthesis without definitive vegetation. Moderate to severe tricuspid regurgitation with at least mild pulmonary hypertension (likely higher given increased RA pressures). No mobile masses on the tricuspid valve. No prior echos for comparison. If there is a high clinical suspicion for endocarditis, TTE cannot exclude with two bioprosthetic valves. ___ TEE: No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and the descending thoracic aorta to 38 cm from the incisors. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. There is a highly mobile echodensity on the anterior leaflet of the bioprosthetic mitral valve, measuring 0.5 cm x 0.4 cm, most consistent with a small vegetation. No mitral valve abscess is seen. Trivial mitral regurgitation is seen. There is no abscess of the tricuspid valve. The tricuspid regurgitation jet is eccentric and may be underestimated. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Well-seated mitral valve bioprosthesis with small vegetation on the anterior leaflet and trivial mitral regurgitation. Well-seated aortic valve bioprosthesis with no vegetation and no aortic regurgitation. Normal global biventricular systolic function. CXR - IMPRESSION: No previous images. There is been placement of a left subclavian PICC line that extends to the lower portion of the SVC. There is substantial enlargement of the cardiac silhouette in a patient with intact midline sternal wires. No definite vascular congestion. Mild blunting of the left costophrenic angle with opacification at the left base suggests small pleural effusion and atelectatic changes. MRI L Spine (___) - IMPRESSION: 1. Due to patient discomfort postcontrast imaging and multiplanar, multisequence imaging of the sacrum were not performed. 2. L2-L3 and L3-L4 severe spinal canal stenosis which crowds the central nerve roots and compresses the traversing L3 and L4 nerve roots in the subarticular zones. 3. L5-S1 subarticular zone stenosis which contacts the traversing S1 nerve roots. 4. Edema at L3-L4 articulating endplates with fluid signal within the intervertebral disc space, likely representing degenerative type ___ ___ change. No specific findings for infection, without cortical dehiscence, epidural fluid, or paraspinal soft tissue edema. Recommend clinical correlation. If there is high suspicion for infection, consider follow-up postcontrast imaging to assess for interval change. MRI Pelvis (___) - IMPRESSION: 1. Punctate foci of high T2 signal are seen along the inferior edge of both SI joints. The appearance is not typical for infectious or inflammatory sacroiliitis. Otherwise, the sacroiliac joints are within normal limits. 2. No evidence of osteomyelitis or abscess formation. 3. Diffuse soft tissue edema including small amount of pelvic free fluid, an atypical finding in a male. 4. Focal edema and enhancement in the left gluteus muscle near the coccyx could represent a focal area of phlegmon. The differential diagnosis could include an site of prior intramuscular injection. 5. Please see separate report of L-spine MRI performed on ___. MRI L Spine (___) - IMPRESSION: No enhancement to support discitis, osteomyelitis. No epidural or prevertebral fluid collection. Brief Hospital Course: Mr. ___ is a ___ y/o man with a PMH of AFib on warfarin, AVR/MVR, gout, HTN, and HLD, who was transferred from ___ for ___ and anemia, found to have strep pneumo bacteremia / endocarditis. #Strep pneumococcus bacteremia / endocarditis: Strep pneumo in ___ bottles from ___. TEE showed small mitral valve veg. Now narrowed to CTX with ID input. No further positive blood cultures on labs here. Will continue CTX for total of 6-week course. Discharged home with services for home infusion via ___. # Lower back pain: Initial concern for epidural abscess v. osteomyelitis in light of bacteremia. CT torso at ___ negative for fluid collection. MRI performed here without evidence of infection. #Coagulopathy. INR of 6.9 on admission; most likely appears to have been ___ concomitant usage of azithromycin, levofloxacin, and warfarin. He received 2.5 mg Vitamin Kx1 in ED, with INR downtrended to 2 and warfarin was resumed. However, INR trended back up, once again likely ___ abx. Coumadin was held at discharged with plans for INR recheck on Modnay ___. This was communicated with pt's PCP's office. #Thrombocytopenia: His platelets were at nadir of 77-97, and may have been acute response to infection vs. medication side-effect. There were no signs of bleeding. Plts were trending back up at discharge. #Acute Kidney Injury: Patient's creatinine initially was 2.1, likely pre-renal injury improved with fluid resuscitation. #Atrial Fibrillation: Goal INR 2.0-3.0, warfarin held on discharge as above. #Concern for GI bleeding: Patient's hemoglobin was 8.5 on admission from 10.2 at OSH. His serial H/H remained stable since his transfer to ___. He had a weakly guaiac positive, stool but was at high risk of bleeding given coagulopathy with elevated INR. Patient's initial hypotension appeared to be likely hypovolemic and vasodilatory from infection, with no evidence of an active bleed. He was initially on an IV proton pump inhibitor transitioned to oral form. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Warfarin 4 mg PO DAILY16 5. Aspirin 81 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Simvastatin 40 mg PO QPM 5. Allopurinol ___ mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. CefTRIAXone 2 gm IV Q 24H RX ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV q 24 hours Disp #38 Intravenous Bag Refills:*0 8. Outpatient Lab Work Weekly labs: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, ESR/CRP. RESULTS SHOULD BE SENT TO ___ CLINIC - FAX: ___ 9. Outpatient Lab Work Please check INR on ___. Results should be faxed to Dr. ___ (Fax: ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Endocarditis Bacteremia Acute Kidney Injury Coagulopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred here with an fevers, an infection in your heart valve, as well as a blood stream infection. You were seen by our infectious diseases team, and you were started on antibiotics. You will continue the IV antibiotics for 6 weeks total. Of note, you also underwent an MRI of your lower back given your back pain. This did not show any evidence of infection. As we discussed on ___, your INR (Coumadin level) is very high. Please hold your Coumadin on ___ and ___. Please call your PCP's office on ___ morning to have your INR checked and Coumadin dose adjusted accordingly. Followup Instructions: ___	[ "N179", "D62", "D6832", "E872", "D696", "I959", "K921", "I4891", "E871", "B953", "I059", "M4806", "Z7901", "M109", "I10", "E785", "N400", "T45515A", "Y92239", "R339", "Z952", "T363X5A", "T368X5A" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Back Pain Major Surgical or Invasive Procedure: TEE History of Present Illness: Mr. [MASKED] is a [MASKED] y/o man with a PMH of AFib on warfarin, bioprosthetic AVR/MVR, gout, HTN, and HLD, who was transferred from [MASKED] for [MASKED] and anemia. He has been having fatigue, back pain and intermittent fevers for the past five weeks up to [MASKED] (most recently AM of [MASKED]. Notes a 10 lb weight loss over this time. 2 weeks ago he saw his PCP for these fevers as well as cough, who felt that his presentation was consistent with community-acquired pneumonia, for which he received a five-day course of azithromycin with some relief. He subsequently received a one week course of levofloxacin. Yesterday, he returned to his PCP because he was having sacral pain for the past three weeks. This sacral pain was previously treated with cyclobenzaprine and orphenadrine. Denied any trauma. In conjunction with these fevers, his PCP was concerned for pyelonephritis, and he was sent to the ED at [MASKED]. There, a CT chest/abd/pelvis was performed. CT chest had no acute abnormality. The abdomen and pelvis scan showed cardiomegaly, mild splenomegaly, degenerative spine changes, and severe prostate enlargement. Labs at [MASKED] were notable for: WBC 22, H/H 10.1/29, plt 116, bands 4, Na 128, K 4.5, BUN 41, Cr 2.08, trop .08, lactate 1.1, CRP 21, INR 4.35. EKG: AFib 91, LAD, QTc 471, TWI III Blood cultures grew GPC in pairs and chains. He received IV fluids, vancomycin, and Zosyn, and he was transferred to [MASKED]. In the [MASKED] ED, initial vitals: T 99.6 P 80 BP 116/74 RR 16 O2 96% RA - Exam notable for PE: dry mucous membranes, CTAB, [MASKED], abdomen soft, NT, ND, no CVAT, no midline spine tenderness. Brown, weakly positive guaiac stool. - Labs were notable for: Chemistries: 132 100 44 -------------< 115 4.7 20 1.8 CBC: 8.5 16.0 >---< 96 25.1 DIFF: N:84 Band:7 [MASKED] M:7 E:0 Bas:0 Nrbc: 1 Absneut: 14.56 Abslymp: 0.32 Absmono: 1.12 Abseos: 0.00 Absbaso: 0.00 Coags: [MASKED]: 78.3 PTT: 46.1 INR: 6.9 Trop-T: <0.01 Lactate:1.2 UA: WBC 68, many bacteria, large leuks, negative nitrites, large blood, trace ketones - Patient was given: [MASKED] 00:56 IVF 1000 mL NS 500 mL [MASKED] 02:19 IV Pantoprazole Started 8 mg/hr [MASKED] 02:19 IV Phytonadione 2.5 mg [MASKED] 02:39 IV Gentamicin 350 mg [MASKED] 02:39 IVF 1000 mL NS 1000 mL - Consults: none On arrival to the MICU, he reported L flank pain and sacral pain. He denied chest pain, shortness of breath. He has previously had fevers and chills, which had subsequently resolved. Denied nausea, vomiting, lightheadedness, dizziness, dysuria, hematuria, melena, or hematochezia. Denied sick contacts. Review of systems: - as above, otherwise a 10 point review of systems was negative Past Medical History: atrial fibrillation on warfarin - severe aortic stenosis s/p #23 [MASKED] pericardial valve ([MASKED]) - severe mitral regurgitation s/p #33 [MASKED] porcine valve ([MASKED]) - gout - hypertension - hyperlipidemia Social History: [MASKED] Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 97.6F BP 106/51 mmHg P 70 RR 22 O2 97% 2L O2 General: Pleasant, elderly man appearing his stated age in NAD. HEENT: PERRL; EOMs intact. Dry mucous membranes. OP clear. Neck: Supple, neck veins flat. No JVD. CV: Irregularly irregular. III/VI systolic murmur; no rubs or gallops. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended. NABS. Back: Point tenderness to palpation over sacrum. Ext: Warm and well-perfused. Lone splinter hemorrhage on L thumb. No [MASKED] nodes. 2+ DP pulses. No edema. Neuro: A&Ox3; CNs II-XII grossly intact. Distal sensation intact to light touch. DISCHARGE PHYSICAL EXAM: ========================= Vital Signs: 99.0 121/64 74 18 94%RA GEN: Alert, NAD HEENT: NC/AT CV: irreg, [MASKED] systolic murmur PULM: CTA B, bilateral rales in the lower lung fields GI: S/NT/ND, BS present EXT: no calf tenderness [MASKED] edema NEURO: A&Ox3 Pertinent Results: Admission Labs: [MASKED] 12:15AM BLOOD WBC-16.0* RBC-2.73* Hgb-8.5* Hct-25.1* MCV-92 MCH-31.1 MCHC-33.9 RDW-14.2 RDWSD-47.6* Plt Ct-96* [MASKED] 12:15AM BLOOD Neuts-84* Bands-7* Lymphs-2* Monos-7 Eos-0 Baso-0 [MASKED] Myelos-0 NRBC-1* AbsNeut-14.56* AbsLymp-0.32* AbsMono-1.12* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [MASKED] 12:15AM BLOOD [MASKED] PTT-46.1* [MASKED] [MASKED] 06:12AM BLOOD [MASKED] [MASKED] 06:12AM BLOOD Ret Aut-1.1 Abs Ret-0.03 [MASKED] 12:15AM BLOOD Glucose-115* UreaN-44* Creat-1.8* Na-132* K-4.7 Cl-100 HCO3-20* AnGap-17 [MASKED] 06:12AM BLOOD ALT-31 AST-40 LD(LDH)-356* AlkPhos-135* TotBili-0.6 [MASKED] 12:15AM BLOOD cTropnT-<0.01 [MASKED] 06:12AM BLOOD Albumin-2.5* Calcium-7.6* Phos-4.4 Mg-2.0 Iron-14* [MASKED] 06:12AM BLOOD calTIBC-146* Hapto-278* Ferritn-1144* TRF-112* [MASKED] 12:18AM BLOOD Lactate-1.2 Discharge Labs: [MASKED] 05:42AM BLOOD WBC-14.1* RBC-2.79* Hgb-8.7* Hct-26.0* MCV-93 MCH-31.2 MCHC-33.5 RDW-14.3 RDWSD-48.4* Plt [MASKED] [MASKED] 05:42AM BLOOD [MASKED] PTT-40.6* [MASKED] [MASKED] 05:42AM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-133 K-3.9 Cl-100 HCO3-23 AnGap-14 [MASKED] 05:42AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8 [MASKED] 01:00AM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 01:00AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [MASKED] 01:00AM URINE RBC-131* WBC-68* Bacteri-MANY Yeast-NONE Epi-<1 TransE-<1 Blood Cx x 4 negative, OSH blood cx growing strep pneuma URINE CULTURE (Final [MASKED]: NO GROWTH. IMAGING: ========== [MASKED] EKG: Probable atrial fibrillation. Compared to the previous tracing no change. [MASKED] TTE: The left atrium is markedly dilated. The right atrium is markedly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral valve leaflets appear thickened in some views. The gradients across the prosthesis are likley mildly elevated (not knowing what type of prosthesis this is). No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Marked biatrial enlargement. Normal left ventricular systolic function. Moderately dilated right ventricle with borderline normal free wall motion (intrinsically depressed due to volume of tricuspid regurgitation). Well seated aortic valve bioprosthesis with normal gradients and no evidence of endocarditis. Mildly increased gradients across the mitral valve bioprosthesis without definitive vegetation. Moderate to severe tricuspid regurgitation with at least mild pulmonary hypertension (likely higher given increased RA pressures). No mobile masses on the tricuspid valve. No prior echos for comparison. If there is a high clinical suspicion for endocarditis, TTE cannot exclude with two bioprosthetic valves. [MASKED] TEE: No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and the descending thoracic aorta to 38 cm from the incisors. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. There is a highly mobile echodensity on the anterior leaflet of the bioprosthetic mitral valve, measuring 0.5 cm x 0.4 cm, most consistent with a small vegetation. No mitral valve abscess is seen. Trivial mitral regurgitation is seen. There is no abscess of the tricuspid valve. The tricuspid regurgitation jet is eccentric and may be underestimated. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Well-seated mitral valve bioprosthesis with small vegetation on the anterior leaflet and trivial mitral regurgitation. Well-seated aortic valve bioprosthesis with no vegetation and no aortic regurgitation. Normal global biventricular systolic function. CXR - IMPRESSION: No previous images. There is been placement of a left subclavian PICC line that extends to the lower portion of the SVC. There is substantial enlargement of the cardiac silhouette in a patient with intact midline sternal wires. No definite vascular congestion. Mild blunting of the left costophrenic angle with opacification at the left base suggests small pleural effusion and atelectatic changes. MRI L Spine ([MASKED]) - IMPRESSION: 1. Due to patient discomfort postcontrast imaging and multiplanar, multisequence imaging of the sacrum were not performed. 2. L2-L3 and L3-L4 severe spinal canal stenosis which crowds the central nerve roots and compresses the traversing L3 and L4 nerve roots in the subarticular zones. 3. L5-S1 subarticular zone stenosis which contacts the traversing S1 nerve roots. 4. Edema at L3-L4 articulating endplates with fluid signal within the intervertebral disc space, likely representing degenerative type [MASKED] [MASKED] change. No specific findings for infection, without cortical dehiscence, epidural fluid, or paraspinal soft tissue edema. Recommend clinical correlation. If there is high suspicion for infection, consider follow-up postcontrast imaging to assess for interval change. MRI Pelvis ([MASKED]) - IMPRESSION: 1. Punctate foci of high T2 signal are seen along the inferior edge of both SI joints. The appearance is not typical for infectious or inflammatory sacroiliitis. Otherwise, the sacroiliac joints are within normal limits. 2. No evidence of osteomyelitis or abscess formation. 3. Diffuse soft tissue edema including small amount of pelvic free fluid, an atypical finding in a male. 4. Focal edema and enhancement in the left gluteus muscle near the coccyx could represent a focal area of phlegmon. The differential diagnosis could include an site of prior intramuscular injection. 5. Please see separate report of L-spine MRI performed on [MASKED]. MRI L Spine ([MASKED]) - IMPRESSION: No enhancement to support discitis, osteomyelitis. No epidural or prevertebral fluid collection. Brief Hospital Course: Mr. [MASKED] is a [MASKED] y/o man with a PMH of AFib on warfarin, AVR/MVR, gout, HTN, and HLD, who was transferred from [MASKED] for [MASKED] and anemia, found to have strep pneumo bacteremia / endocarditis. #Strep pneumococcus bacteremia / endocarditis: Strep pneumo in [MASKED] bottles from [MASKED]. TEE showed small mitral valve veg. Now narrowed to CTX with ID input. No further positive blood cultures on labs here. Will continue CTX for total of 6-week course. Discharged home with services for home infusion via [MASKED]. # Lower back pain: Initial concern for epidural abscess v. osteomyelitis in light of bacteremia. CT torso at [MASKED] negative for fluid collection. MRI performed here without evidence of infection. #Coagulopathy. INR of 6.9 on admission; most likely appears to have been [MASKED] concomitant usage of azithromycin, levofloxacin, and warfarin. He received 2.5 mg Vitamin Kx1 in ED, with INR downtrended to 2 and warfarin was resumed. However, INR trended back up, once again likely [MASKED] abx. Coumadin was held at discharged with plans for INR recheck on Modnay [MASKED]. This was communicated with pt's PCP's office. #Thrombocytopenia: His platelets were at nadir of 77-97, and may have been acute response to infection vs. medication side-effect. There were no signs of bleeding. Plts were trending back up at discharge. #Acute Kidney Injury: Patient's creatinine initially was 2.1, likely pre-renal injury improved with fluid resuscitation. #Atrial Fibrillation: Goal INR 2.0-3.0, warfarin held on discharge as above. #Concern for GI bleeding: Patient's hemoglobin was 8.5 on admission from 10.2 at OSH. His serial H/H remained stable since his transfer to [MASKED]. He had a weakly guaiac positive, stool but was at high risk of bleeding given coagulopathy with elevated INR. Patient's initial hypotension appeared to be likely hypovolemic and vasodilatory from infection, with no evidence of an active bleed. He was initially on an IV proton pump inhibitor transitioned to oral form. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Simvastatin 40 mg PO QPM 4. Warfarin 4 mg PO DAILY16 5. Aspirin 81 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Simvastatin 40 mg PO QPM 5. Allopurinol [MASKED] mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. CefTRIAXone 2 gm IV Q 24H RX ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV q 24 hours Disp #38 Intravenous Bag Refills:*0 8. Outpatient Lab Work Weekly labs: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, ESR/CRP. RESULTS SHOULD BE SENT TO [MASKED] CLINIC - FAX: [MASKED] 9. Outpatient Lab Work Please check INR on [MASKED]. Results should be faxed to Dr. [MASKED] (Fax: [MASKED]. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Endocarditis Bacteremia Acute Kidney Injury Coagulopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred here with an fevers, an infection in your heart valve, as well as a blood stream infection. You were seen by our infectious diseases team, and you were started on antibiotics. You will continue the IV antibiotics for 6 weeks total. Of note, you also underwent an MRI of your lower back given your back pain. This did not show any evidence of infection. As we discussed on [MASKED], your INR (Coumadin level) is very high. Please hold your Coumadin on [MASKED] and [MASKED]. Please call your PCP's office on [MASKED] morning to have your INR checked and Coumadin dose adjusted accordingly. Followup Instructions: [MASKED]	[]	[ "N179", "D62", "E872", "D696", "I4891", "E871", "Z7901", "M109", "I10", "E785", "N400" ]	[ "N179: Acute kidney failure, unspecified", "D62: Acute posthemorrhagic anemia", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "E872: Acidosis", "D696: Thrombocytopenia, unspecified", "I959: Hypotension, unspecified", "K921: Melena", "I4891: Unspecified atrial fibrillation", "E871: Hypo-osmolality and hyponatremia", "B953: Streptococcus pneumoniae as the cause of diseases classified elsewhere", "I059: Rheumatic mitral valve disease, unspecified", "M4806: Spinal stenosis, lumbar region", "Z7901: Long term (current) use of anticoagulants", "M109: Gout, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "T45515A: Adverse effect of anticoagulants, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R339: Retention of urine, unspecified", "Z952: Presence of prosthetic heart valve", "T363X5A: Adverse effect of macrolides, initial encounter", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter" ]
10,042,315	23,955,319	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: Large symptomatic fibroid uterus. Major Surgical or Invasive Procedure: abdominal myomectomy, lysis of adhesions, partial omentectomy, and drainage of a left ovarian cyst History of Present Illness: ___ ___ who on ___, underwent a bilateral uterine fibroid embolization. Again, she presents to discuss further the requested operative management. She continues to have pelvic pain, fullness, constipation, increased urinary frequency. On ___, she had an MR of her pelvis, which showed large fibroid uterus extending to the upper abdomen. The uterus including fibroids measured 30 x 18 x 24 cm, minimally decreased in size prior to examination on ___, when it measured 30 x 18 x 26 cm. The endometrium was somewhat distorted by the fibroids. The largest intramural fibroid was at the uterine fundus, minimally decreased in size and measured 17.6 x 15.6 x 16.2 cm, previously measured 18.3 x 17.9 x 18 0.6 cm. This fibroid subserosal less than 50% intramural and did not abut the endometrium. An additional large fibroid was subserosal pedunculated fibroid on the right which measured 11.2 x 11.3 x 8.6 cm, previously measured 9.1 x 12.7 x 13.2 cm, minimally decreased in size. Two additional large subserosal pedunculated fibroids arise from the anterior lower uterus measuring 6.5 x 3.9 x 5.1 cm, previously measured 5.8 x 8.4 x 5.6 cm and last 7.6 x 6.7 x 8.5 cm, previously 10.7 x 7.9 x 8.9 cm. Both of these fibroids were minimally decreased in size from prior examination. The ovaries were normal in appearance, trace pelvic free fluid was in physiologic limits. These findings were discussed with the patient and her questions were answered. Her ___ Pap was negative for intraepithelial lesion or malignancy and she tested negative for the high-risk HPV. She also had a negative endometrial biopsy. ___ her Hct was 36.3%. She continues to eat Iron rich food and supplement with daily po Iron. Of note, she continues to have decreased platelets and is being seen by her hematologist. I am waiting for intraoperative and post-operative recommendations. Past Medical History: Ob/Gyn hx: G0, would like to keep future childbearing options open, if possible. Menarche 10 x 28 x 5, hx of heavy menses with no clots, no metrorraghia, no post coital bleeding, absent dyspareunia, no dysmenorrhea. Problems: FIBROIDS, UTERUS KERATITIS OVERWEIGHT PHARYNGITIS Surgical History: none Social History: Social History: ___ Family History: Family History: MGM HYPERTENSION denies family hx of GYN malignancies, DM, CAD Physical Exam: Pre-Admission Physical Exam WDWN obese woman in NAD BP: 138/98. Weight: 287 (With Clothes; With Shoes). Height: 67. BMI: 44.9. LMP: ___. ABDOMEN: Soft, obese, nondistended, nontender. There was a large palpable mass 5 fingerbreadths above the umbilicus, from the pubic symphysis to the top of the uterine fundus is 34 cm. There was no inguinal lymphadenopathy and again no tenderness on palpation of this mass which was c/w a large uterus. PELVIC: Deferred secondary to the patient having no complaints. Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP Pertinent Results: ___ 12:19PM WBC-12.2* RBC-4.51 HGB-13.8 HCT-38.2 MCV-85 MCH-30.6 MCHC-36.1 RDW-13.7 RDWSD-42.5 ___ 12:19PM PLT COUNT-117* Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after undergoing abdominal myomectomy, lysis of adhesions, partial omentectomy, and drainage of a left ovarian cyst. During her procedure 11 fibroids were removed, the largest being 20cm. Notably there were multiple adhesions concerning for previous PID. Immediately post-op, her pain was controlled with IV Dilaudid/Toradol. Please see the operative report for full details. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her post-operative course was complicated by persistant tachycardia and development of a post-operative ileus. She had symptomatic tachycardia to the 110-120s. EKG showed sinus tachycardia. Her hematocrit was trended. Her pre-op HCT (___) of 38.2 and remained stable at an appropriate decrease to 33, after an intraoperative EBL 500cc. Her urine output remained adequate. Tachycardia was not responsive to a fluid bolus. A CTA was ordered to rule out a thromboembolic event which was significant for no segmental PE and showed only bilateral atelectasis, and a fluid filled gastric lumen consistent with an ileus. She was started on subcutaneous heparin prophylactically. She had a leukocytosis with a max of 30.3 with no other accompanying symptoms such as fever or chill or other localizing symptoms such as severe abdominal pain, dysuria, cough/sputum production. Of note, the patient has had an elevated heart rates since her uterine artery embolization ___ during which time she was extensively worked up and thought to be secondary to post-embolization syndrome. On POD 2, she had an episode of 600cc of emesis. She was made NPO overnight. The following day her diet was advanced without incident with no additional episodes of emesis. She was transitioned to PO oxycodone/ibuprofen/acetaminophen for pain control. By post-operative day 4, 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 cardiology and gynecology follow-up scheduled. Medications on Admission: Medications - Prescription IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth Q6 hours as needed for pain/cramping - (Not Taking as Prescribed) Medications - OTC MULTIVITAMIN [DAILY MULTI-VITAMIN] - Daily Multi-Vitamin tablet. 1 (One) tablet(s) by mouth once daily - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild no more than 4g in 24hrs RX acetaminophen 500 mg ___ tablet(s) by mouth every 6 hrs Disp #40 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild take with food, no more than 2400mg in 24hrs RX ibuprofen 600 mg 1 tablet(s) by mouth every 6 hrs Disp #40 Tablet Refills:0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate don't drink alcohol and don't drive on this medication RX oxycodone 5 mg ___ tablet(s) by mouth every 4 hrs Disp #40 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 staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___	[ "D252", "K913", "D282", "N8320", "K660", "R000", "Y838", "Y92239" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Large symptomatic fibroid uterus. Major Surgical or Invasive Procedure: abdominal myomectomy, lysis of adhesions, partial omentectomy, and drainage of a left ovarian cyst History of Present Illness: [MASKED] [MASKED] who on [MASKED], underwent a bilateral uterine fibroid embolization. Again, she presents to discuss further the requested operative management. She continues to have pelvic pain, fullness, constipation, increased urinary frequency. On [MASKED], she had an MR of her pelvis, which showed large fibroid uterus extending to the upper abdomen. The uterus including fibroids measured 30 x 18 x 24 cm, minimally decreased in size prior to examination on [MASKED], when it measured 30 x 18 x 26 cm. The endometrium was somewhat distorted by the fibroids. The largest intramural fibroid was at the uterine fundus, minimally decreased in size and measured 17.6 x 15.6 x 16.2 cm, previously measured 18.3 x 17.9 x 18 0.6 cm. This fibroid subserosal less than 50% intramural and did not abut the endometrium. An additional large fibroid was subserosal pedunculated fibroid on the right which measured 11.2 x 11.3 x 8.6 cm, previously measured 9.1 x 12.7 x 13.2 cm, minimally decreased in size. Two additional large subserosal pedunculated fibroids arise from the anterior lower uterus measuring 6.5 x 3.9 x 5.1 cm, previously measured 5.8 x 8.4 x 5.6 cm and last 7.6 x 6.7 x 8.5 cm, previously 10.7 x 7.9 x 8.9 cm. Both of these fibroids were minimally decreased in size from prior examination. The ovaries were normal in appearance, trace pelvic free fluid was in physiologic limits. These findings were discussed with the patient and her questions were answered. Her [MASKED] Pap was negative for intraepithelial lesion or malignancy and she tested negative for the high-risk HPV. She also had a negative endometrial biopsy. [MASKED] her Hct was 36.3%. She continues to eat Iron rich food and supplement with daily po Iron. Of note, she continues to have decreased platelets and is being seen by her hematologist. I am waiting for intraoperative and post-operative recommendations. Past Medical History: Ob/Gyn hx: G0, would like to keep future childbearing options open, if possible. Menarche 10 x 28 x 5, hx of heavy menses with no clots, no metrorraghia, no post coital bleeding, absent dyspareunia, no dysmenorrhea. Problems: FIBROIDS, UTERUS KERATITIS OVERWEIGHT PHARYNGITIS Surgical History: none Social History: Social History: [MASKED] Family History: Family History: MGM HYPERTENSION denies family hx of GYN malignancies, DM, CAD Physical Exam: Pre-Admission Physical Exam WDWN obese woman in NAD BP: 138/98. Weight: 287 (With Clothes; With Shoes). Height: 67. BMI: 44.9. LMP: [MASKED]. ABDOMEN: Soft, obese, nondistended, nontender. There was a large palpable mass 5 fingerbreadths above the umbilicus, from the pubic symphysis to the top of the uterine fundus is 34 cm. There was no inguinal lymphadenopathy and again no tenderness on palpation of this mass which was c/w a large uterus. PELVIC: Deferred secondary to the patient having no complaints. Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP Pertinent Results: [MASKED] 12:19PM WBC-12.2* RBC-4.51 HGB-13.8 HCT-38.2 MCV-85 MCH-30.6 MCHC-36.1 RDW-13.7 RDWSD-42.5 [MASKED] 12:19PM PLT COUNT-117* Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after undergoing abdominal myomectomy, lysis of adhesions, partial omentectomy, and drainage of a left ovarian cyst. During her procedure 11 fibroids were removed, the largest being 20cm. Notably there were multiple adhesions concerning for previous PID. Immediately post-op, her pain was controlled with IV Dilaudid/Toradol. Please see the operative report for full details. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her post-operative course was complicated by persistant tachycardia and development of a post-operative ileus. She had symptomatic tachycardia to the 110-120s. EKG showed sinus tachycardia. Her hematocrit was trended. Her pre-op HCT ([MASKED]) of 38.2 and remained stable at an appropriate decrease to 33, after an intraoperative EBL 500cc. Her urine output remained adequate. Tachycardia was not responsive to a fluid bolus. A CTA was ordered to rule out a thromboembolic event which was significant for no segmental PE and showed only bilateral atelectasis, and a fluid filled gastric lumen consistent with an ileus. She was started on subcutaneous heparin prophylactically. She had a leukocytosis with a max of 30.3 with no other accompanying symptoms such as fever or chill or other localizing symptoms such as severe abdominal pain, dysuria, cough/sputum production. Of note, the patient has had an elevated heart rates since her uterine artery embolization [MASKED] during which time she was extensively worked up and thought to be secondary to post-embolization syndrome. On POD 2, she had an episode of 600cc of emesis. She was made NPO overnight. The following day her diet was advanced without incident with no additional episodes of emesis. She was transitioned to PO oxycodone/ibuprofen/acetaminophen for pain control. By post-operative day 4, 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 cardiology and gynecology follow-up scheduled. Medications on Admission: Medications - Prescription IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth Q6 hours as needed for pain/cramping - (Not Taking as Prescribed) Medications - OTC MULTIVITAMIN [DAILY MULTI-VITAMIN] - Daily Multi-Vitamin tablet. 1 (One) tablet(s) by mouth once daily - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild no more than 4g in 24hrs RX acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hrs Disp #40 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild take with food, no more than 2400mg in 24hrs RX ibuprofen 600 mg 1 tablet(s) by mouth every 6 hrs Disp #40 Tablet Refills:0 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate don't drink alcohol and don't drive on this medication RX oxycodone 5 mg [MASKED] tablet(s) by mouth every 4 hrs Disp #40 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 staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]	[]	[]	[ "D252: Subserosal leiomyoma of uterus", "K913: Postprocedural intestinal obstruction", "D282: Benign neoplasm of uterine tubes and ligaments", "N8320: Unspecified ovarian cysts", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "R000: Tachycardia, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]
10,042,793	20,808,241	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with the past medical history noted below who was recently admitted at ___ on trauma service from ___ and discharged to a facility. Her brief hospital summary from Dr. ___ paperwork, is copied below for reference. On the day of admission, which was the same day as discharge from prior hospitalization, pt was found to be altered in her room at the facility, and had removed her splint from her arm. Her daughter (HCP) was called, who felt that she was "significantly off her baseline and very agitated, seemingly delirious", and she was sent back to ___ for further evaluation. Upon arrival to ___ ER, she was seen by trauma surgery, and her arm was casted. Her labs and NCHCT were normal. Given her lack of surgical or trauma indication, but her persistent AMS, she was admitted to Internal Medicine for further workup and evaluation of her AMS. She was admitted to 11R at approximately 0615am on ___, at which time she was minimally responsive and sleeping. All VS were normal. No immediate medical interventions were made at the time of admission. I called her daughter, following my initial examination of the patient, and corroborated the history. Further discussion of plan below. Brief Hospital Course ___: Ms. ___ was transferred to ___ from ___ after a witnessed fall at her facility with a right radius fracture, supraorbital laceration and subarachnoid hemorrhage. At the outside hospital she received K Centra, splint was applied to right wrist, and dermabond over her right eye laceration prior to transfer. When she presented to ___ ___ she was febrile with urine sample consistent with a urinary tract infection and was treated with ceftriaxone. Her coumadin was held while in the hospital. On HD2 she was noted to have evolution of the subarachnoid hemorrhage per neurosurgery this is the expected sequelae. On HD2 she was monitored for cardiac ectopy to further work up her fall, none was reported by nursing as visualized by the monitor. She was on telemetry and will discharge you with a holter monitor for further cardiac workup. She was seen by orthopedics who placed a brace on her right wrist. She was seen by neurosurgery who determined no surgery was necessary. Tertiary trauma survey was complete without new findings. She was discharged on HD3 to a rehabilitation facility to continue physical therapy. Past Medical History: PMH: -DVT/PE -Alzheimers Dementia -Volvulus Social History: ___ Family History: FH: non-contributory Physical Exam: DISCHARGE EXAM: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Minimally verbal, but engaged and making eye-contact. EYES: Anicteric, pupils equally round. Periorbital echhymoses. ENT: Ears and nose without visible erythema, masses. R eyebrow laceration/abrasion, healing, 2-3cm. R facial echhymosis. 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. Patient wearing diaper. No rash appreciated. MSK: Neck supple, moves all extremities. Did not test strength / sensation due to patient's ability to participate. RUE casted from fingers to elbow, in sling. SKIN: No rashes or ulcerations noted. Multiple echhymoses on LUE and RUE. NEURO: Unable to complete neurological exam due to patient's ability to cooperate w/ exam. PSYCH: Quiet, tracking with her eyes, minimally responsive. Pertinent Results: ___ 10:15AM BLOOD TSH-0.06* BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___ ___ 06:45 251 ___ 06:45 11.1 28.4 1.0 Brief Hospital Course: HOSPITAL COURSE and TRANSITIONAL ISSUES: #AMS: Pt was found to be at baseline w/in 12hrs after arrival. This was likely Subsequently, pt had no further e/o AMS. She was agitated but not obtunded; there was no suspicion that she had a seizure. All labs normal, except TSH (as below), non-con head CT normal. #Hypothyroid: Pt's TSH was checked and found to be 0.06. Dose was down-titrated from 150mcg to 125mcg. Daughter aware of this change. Outpatient provider should check TSH in ___ to titrate dose accordingly. #Dispo: Pt discharged to a long-term care facility w/ follow-up appt's scheduled. Anticipated length of stay of less than 30 days. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Senna 17.2 mg PO HS 4. Levothyroxine Sodium 150 mcg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Donepezil 10 mg PO QHS 7. Furosemide 20 mg PO DAILY 8. Warfarin 1 mg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Acetaminophen 650 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Donepezil 10 mg PO QHS 5. Furosemide 20 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Senna 17.2 mg PO HS 8. Warfarin 1 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Altered mental status Discharge Condition: Minimally verbal, but engages with eye contact and occasional verbal replies. Discharge Instructions: You were hospitalized for confusion. You improved during the course of your hospitalization, and now are stable to go to a long-term care facility. Followup Instructions: ___	[ "G92", "G309", "F0280", "Z86718", "Z7901", "Z86711", "E039", "W19XXXD", "Z9181", "Z66", "S52571D" ]	Allergies: shellfish derived Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female with the past medical history noted below who was recently admitted at [MASKED] on trauma service from [MASKED] and discharged to a facility. Her brief hospital summary from Dr. [MASKED] paperwork, is copied below for reference. On the day of admission, which was the same day as discharge from prior hospitalization, pt was found to be altered in her room at the facility, and had removed her splint from her arm. Her daughter (HCP) was called, who felt that she was "significantly off her baseline and very agitated, seemingly delirious", and she was sent back to [MASKED] for further evaluation. Upon arrival to [MASKED] ER, she was seen by trauma surgery, and her arm was casted. Her labs and NCHCT were normal. Given her lack of surgical or trauma indication, but her persistent AMS, she was admitted to Internal Medicine for further workup and evaluation of her AMS. She was admitted to 11R at approximately 0615am on [MASKED], at which time she was minimally responsive and sleeping. All VS were normal. No immediate medical interventions were made at the time of admission. I called her daughter, following my initial examination of the patient, and corroborated the history. Further discussion of plan below. Brief Hospital Course [MASKED]: Ms. [MASKED] was transferred to [MASKED] from [MASKED] after a witnessed fall at her facility with a right radius fracture, supraorbital laceration and subarachnoid hemorrhage. At the outside hospital she received K Centra, splint was applied to right wrist, and dermabond over her right eye laceration prior to transfer. When she presented to [MASKED] [MASKED] she was febrile with urine sample consistent with a urinary tract infection and was treated with ceftriaxone. Her coumadin was held while in the hospital. On HD2 she was noted to have evolution of the subarachnoid hemorrhage per neurosurgery this is the expected sequelae. On HD2 she was monitored for cardiac ectopy to further work up her fall, none was reported by nursing as visualized by the monitor. She was on telemetry and will discharge you with a holter monitor for further cardiac workup. She was seen by orthopedics who placed a brace on her right wrist. She was seen by neurosurgery who determined no surgery was necessary. Tertiary trauma survey was complete without new findings. She was discharged on HD3 to a rehabilitation facility to continue physical therapy. Past Medical History: PMH: -DVT/PE -Alzheimers Dementia -Volvulus Social History: [MASKED] Family History: FH: non-contributory Physical Exam: DISCHARGE EXAM: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Minimally verbal, but engaged and making eye-contact. EYES: Anicteric, pupils equally round. Periorbital echhymoses. ENT: Ears and nose without visible erythema, masses. R eyebrow laceration/abrasion, healing, 2-3cm. R facial echhymosis. 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. Patient wearing diaper. No rash appreciated. MSK: Neck supple, moves all extremities. Did not test strength / sensation due to patient's ability to participate. RUE casted from fingers to elbow, in sling. SKIN: No rashes or ulcerations noted. Multiple echhymoses on LUE and RUE. NEURO: Unable to complete neurological exam due to patient's ability to cooperate w/ exam. PSYCH: Quiet, tracking with her eyes, minimally responsive. Pertinent Results: [MASKED] 10:15AM BLOOD TSH-0.06* BASIC COAGULATION [MASKED], PTT, PLT, INR) [MASKED] PTT Plt Ct [MASKED] [MASKED] 06:45 251 [MASKED] 06:45 11.1 28.4 1.0 Brief Hospital Course: HOSPITAL COURSE and TRANSITIONAL ISSUES: #AMS: Pt was found to be at baseline w/in 12hrs after arrival. This was likely Subsequently, pt had no further e/o AMS. She was agitated but not obtunded; there was no suspicion that she had a seizure. All labs normal, except TSH (as below), non-con head CT normal. #Hypothyroid: Pt's TSH was checked and found to be 0.06. Dose was down-titrated from 150mcg to 125mcg. Daughter aware of this change. Outpatient provider should check TSH in [MASKED] to titrate dose accordingly. #Dispo: Pt discharged to a long-term care facility w/ follow-up appt's scheduled. Anticipated length of stay of less than 30 days. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Senna 17.2 mg PO HS 4. Levothyroxine Sodium 150 mcg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Donepezil 10 mg PO QHS 7. Furosemide 20 mg PO DAILY 8. Warfarin 1 mg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Acetaminophen 650 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Donepezil 10 mg PO QHS 5. Furosemide 20 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Senna 17.2 mg PO HS 8. Warfarin 1 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Altered mental status Discharge Condition: Minimally verbal, but engages with eye contact and occasional verbal replies. Discharge Instructions: You were hospitalized for confusion. You improved during the course of your hospitalization, and now are stable to go to a long-term care facility. Followup Instructions: [MASKED]	[]	[ "Z86718", "Z7901", "E039", "Z66" ]	[ "G92: Toxic encephalopathy", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "Z86711: Personal history of pulmonary embolism", "E039: Hypothyroidism, unspecified", "W19XXXD: Unspecified fall, subsequent encounter", "Z9181: History of falling", "Z66: Do not resuscitate", "S52571D: Other intraarticular fracture of lower end of right radius, subsequent encounter for closed fracture with routine healing" ]
10,042,793	24,693,778	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: shellfish derived Attending: ___ Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: Patient is ___ with PMH of PE/DVT on warfarin, Alzheimer's (nonverbal at baseline) who presents as a transfer from ___ ___ after evaluation of witnessed fall from her nursing home today. History and exam limited as patient has dementia and is nonverbal at baseline. Per ___ notes: ___ year old female with Alzheimer's, nonverbal, presenting after a witnessed fall at her facility. She struck her head and was transferred here. She is not endorsing any pain or changes from her baseline. She has a 2cm laceration on her right forehead and significant swelling and bruising around her right eye. She takes warfarin." At ___, Vitals: T100.6R 63 20 96% RA 133/60. Patient's PE was significant for "tenderness to palpation and pain with movement of the right wrist. Remainder of the exam was unremarkable." Labs were notable for INR of 2.1. CT head wo contrast showed acute SAH along the frontal and temporal lobes bilaterally with no midline shift. CT cervical spine wo contrast showed no fracture or traumatic malalignment. She received K Centra, splint was applied to right wrist, and her laceration over her right eye was treated with dermabond prior to transfer. At ___, vitals were 98.8 64 143/60 19 98%RA At the bedside, patient endorses pain in right wrist. Denies HA, chest pain, or abdominal pain. Past Medical History: PMH: -DVT/PE -Alzheimers Dementia -Volvulus Social History: ___ Family History: ___: non-contributory Physical Exam: Physical: General: NAD Vitals: 101.0 70 139/69 16 96%RA HEENT: PERRLA, 2cm laceration to right forehead with swelling and ecchymosis around right eye Cardio: RRR, II/VI systolic murmur Pulm: breathing comfortably on RA Abdomen: soft, NT, ND, no rebound or guarding Neuro: AOx1 to self, believes she is at home; Responds to name; intermittently follows commands; moving extremities spontaneously; denies sensory deficits Extremities: warm, well-perfused, trace peripheral edema; ace wrap over right wrist Skin: Grade 1 pressure ulcer to left of coccyx Physical Exam At Discharge: VS: 98.4, 132/68, 56, 18 95%Ra HEENT: PERRLA, 2cm laceration R supraorbital healing, R infraobrital hematoma healing Cardio: RRR, soft II systolic murmur Pulm: clear to auscultation bl Abdomen: soft, NT, ND, no rebound or guarding Neuro: AOx1 to self, not place or time, moving extremities spontaneously with slow to respond on right lower extrem Extremities: warm, well-perfused, trace peripheral edema; R arm in cast Pertinent Results: Wrist XRay ___: IMPRESSION: Overlying cast material obscures fine bony detail. Similar appearance of slightly impacted, dorsally angulated distal intra-articular fracture of the radius. CT Head wo Con ___: IMPRESSION: Slight increase in the volume of subarachnoid hemorrhage, particularly in the right sylvian fissure, since the prior study. Otherwise unchanged examination. CXR ___: IMPRESSION: No focal consolidation. Stable small hiatal hernia and mild cardiomegaly. Pelvis ___: IMPRESSION: No evidence of acute fracture or dislocation with limited evaluation of the sacrum due to overlying bowel gas. LABS: ___ 04:10AM cTropnT-0.01 ___ 11:40PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11:40PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD* ___ 11:40PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 ___ 11:40PM URINE HYALINE-7* ___ 11:40PM URINE MUCOUS-RARE* ___ 11:07PM LACTATE-1.8 K+-4.0 ___ 11:00PM GLUCOSE-132* UREA N-24* CREAT-1.0 SODIUM-137 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-27 ANION GAP-13 ___ 11:00PM cTropnT-0.03* ___ 11:00PM WBC-12.4* RBC-4.00 HGB-11.8 HCT-36.6 MCV-92 MCH-29.5 MCHC-32.2 RDW-13.6 RDWSD-45.7 ___ 11:00PM NEUTS-83.7* LYMPHS-7.9* MONOS-7.3 EOS-0.4* BASOS-0.2 IM ___ AbsNeut-10.33* AbsLymp-0.98* AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03 ___ 11:00PM PLT COUNT-228 ___ 11:00PM ___ PTT-29.5 ___ Brief Hospital Course: Ms. ___ was transferred to ___ from ___ after a witnessed fall at her facility with a right radius fracture, supraorbital laceration and subarachnoid hemorrhage. At the outside hospital she received K Centra, splint was applied to right wrist, and dermabond over her right eye laceration prior to transfer. When she presented to ___ ___ she was febrile with urine sample consistent with a urinary tract infection and was treated with ceftriaxone. Her coumadin was held while in the hospital. On HD2 she was noted to have evolution of the subarachnoid hemorrhage per neurosurgery this is the expected sequelae. On HD2 she was monitored for cardiac ectopy to further work up her fall, none was reported by nursing as visualized by the monitor. She was on telemetry and will discharge you with a holter monitor for further cardiac workup. She was seen by orthopedics who placed a brace on her right wrist. She was seen by neurosurgery who determined no surgery was necessary. Tertiary trauma survey was complete without new findings. She was discharged on HD3 to a rehabilitation facility to continue physical therapy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 1 mg PO DAILY 2. Levothyroxine Sodium 150 mcg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Donepezil 10 mg PO QHS 5. Multivitamins 1 TAB PO DAILY 6. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID Please do not exceed 4000mg in 24 hours 2. Docusate Sodium 100 mg PO BID 3. Senna 17.2 mg PO HS 4. Vitamin D unknown PO DAILY 5. Donepezil 10 mg PO QHS 6. Furosemide 20 mg PO DAILY 7. Levothyroxine Sodium 150 mcg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. HELD- Warfarin 1 mg PO DAILY This medication was held. Do not restart Warfarin until ___ and after you talk to your PCP about the risks and benefits of this drug. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: mechanical fall subarachnoid hemorrhage radius fracture R 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. ___, You were transferred to ___ from ___ after a witnessed fall at her facility with a radius fracture on the r, supraorbital laceration and subarachnoid hemorrhage. At the outside hospital you received K Centra, splint was applied to right wrist, and dermabond over your right eye laceration prior to transfer. When you got to ___ you were noted to have a urinary tract infection which we treated with antibiotics. We placed you on telemetry and will discharge you with a holter monitor for further cardiac workup. You were seen by orthopedics who placed a brace on your right wrist. You were seen by neurosurgery who determined no surgery was necessary. You are doing well and are ready for discharge. General Surgery: 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 new onset 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. Holter: There was concern that your heart may be the case for your falls. You were placed on a holter monitor at the time of discharge. Your cardiac monitor will be evaluated after 30 days. If you have any questions please call the office ___. Medications: Please resume all regular home medications. Please hold Coumadin for total of 7days until at least ___ and you talk to your PCP about the risks and benefits with restarting this medication. Also, please take any new medications as prescribed. General Care: Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting with your right arm until you are cleared by physical therapy or your orthopedic surgeon as an outpatient. Avoid driving or operating heavy machinery while taking pain medications. Thank you for letting us participate in your care! Followup Instructions: ___	[ "S066X0A", "G92", "N390", "S52531A", "L89151", "G309", "F0280", "Z86711", "Z7901", "Z86718", "Z66", "E039", "W19XXXA", "Z9181", "Y92129" ]	Allergies: shellfish derived Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: Patient is [MASKED] with PMH of PE/DVT on warfarin, Alzheimer's (nonverbal at baseline) who presents as a transfer from [MASKED] [MASKED] after evaluation of witnessed fall from her nursing home today. History and exam limited as patient has dementia and is nonverbal at baseline. Per [MASKED] notes: [MASKED] year old female with Alzheimer's, nonverbal, presenting after a witnessed fall at her facility. She struck her head and was transferred here. She is not endorsing any pain or changes from her baseline. She has a 2cm laceration on her right forehead and significant swelling and bruising around her right eye. She takes warfarin." At [MASKED], Vitals: T100.6R 63 20 96% RA 133/60. Patient's PE was significant for "tenderness to palpation and pain with movement of the right wrist. Remainder of the exam was unremarkable." Labs were notable for INR of 2.1. CT head wo contrast showed acute SAH along the frontal and temporal lobes bilaterally with no midline shift. CT cervical spine wo contrast showed no fracture or traumatic malalignment. She received K Centra, splint was applied to right wrist, and her laceration over her right eye was treated with dermabond prior to transfer. At [MASKED], vitals were 98.8 64 143/60 19 98%RA At the bedside, patient endorses pain in right wrist. Denies HA, chest pain, or abdominal pain. Past Medical History: PMH: -DVT/PE -Alzheimers Dementia -Volvulus Social History: [MASKED] Family History: [MASKED]: non-contributory Physical Exam: Physical: General: NAD Vitals: 101.0 70 139/69 16 96%RA HEENT: PERRLA, 2cm laceration to right forehead with swelling and ecchymosis around right eye Cardio: RRR, II/VI systolic murmur Pulm: breathing comfortably on RA Abdomen: soft, NT, ND, no rebound or guarding Neuro: AOx1 to self, believes she is at home; Responds to name; intermittently follows commands; moving extremities spontaneously; denies sensory deficits Extremities: warm, well-perfused, trace peripheral edema; ace wrap over right wrist Skin: Grade 1 pressure ulcer to left of coccyx Physical Exam At Discharge: VS: 98.4, 132/68, 56, 18 95%Ra HEENT: PERRLA, 2cm laceration R supraorbital healing, R infraobrital hematoma healing Cardio: RRR, soft II systolic murmur Pulm: clear to auscultation bl Abdomen: soft, NT, ND, no rebound or guarding Neuro: AOx1 to self, not place or time, moving extremities spontaneously with slow to respond on right lower extrem Extremities: warm, well-perfused, trace peripheral edema; R arm in cast Pertinent Results: Wrist XRay [MASKED]: IMPRESSION: Overlying cast material obscures fine bony detail. Similar appearance of slightly impacted, dorsally angulated distal intra-articular fracture of the radius. CT Head wo Con [MASKED]: IMPRESSION: Slight increase in the volume of subarachnoid hemorrhage, particularly in the right sylvian fissure, since the prior study. Otherwise unchanged examination. CXR [MASKED]: IMPRESSION: No focal consolidation. Stable small hiatal hernia and mild cardiomegaly. Pelvis [MASKED]: IMPRESSION: No evidence of acute fracture or dislocation with limited evaluation of the sacrum due to overlying bowel gas. LABS: [MASKED] 04:10AM cTropnT-0.01 [MASKED] 11:40PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 11:40PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD* [MASKED] 11:40PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 [MASKED] 11:40PM URINE HYALINE-7* [MASKED] 11:40PM URINE MUCOUS-RARE* [MASKED] 11:07PM LACTATE-1.8 K+-4.0 [MASKED] 11:00PM GLUCOSE-132* UREA N-24* CREAT-1.0 SODIUM-137 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-27 ANION GAP-13 [MASKED] 11:00PM cTropnT-0.03* [MASKED] 11:00PM WBC-12.4* RBC-4.00 HGB-11.8 HCT-36.6 MCV-92 MCH-29.5 MCHC-32.2 RDW-13.6 RDWSD-45.7 [MASKED] 11:00PM NEUTS-83.7* LYMPHS-7.9* MONOS-7.3 EOS-0.4* BASOS-0.2 IM [MASKED] AbsNeut-10.33* AbsLymp-0.98* AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03 [MASKED] 11:00PM PLT COUNT-228 [MASKED] 11:00PM [MASKED] PTT-29.5 [MASKED] Brief Hospital Course: Ms. [MASKED] was transferred to [MASKED] from [MASKED] after a witnessed fall at her facility with a right radius fracture, supraorbital laceration and subarachnoid hemorrhage. At the outside hospital she received K Centra, splint was applied to right wrist, and dermabond over her right eye laceration prior to transfer. When she presented to [MASKED] [MASKED] she was febrile with urine sample consistent with a urinary tract infection and was treated with ceftriaxone. Her coumadin was held while in the hospital. On HD2 she was noted to have evolution of the subarachnoid hemorrhage per neurosurgery this is the expected sequelae. On HD2 she was monitored for cardiac ectopy to further work up her fall, none was reported by nursing as visualized by the monitor. She was on telemetry and will discharge you with a holter monitor for further cardiac workup. She was seen by orthopedics who placed a brace on her right wrist. She was seen by neurosurgery who determined no surgery was necessary. Tertiary trauma survey was complete without new findings. She was discharged on HD3 to a rehabilitation facility to continue physical therapy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 1 mg PO DAILY 2. Levothyroxine Sodium 150 mcg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Donepezil 10 mg PO QHS 5. Multivitamins 1 TAB PO DAILY 6. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID Please do not exceed 4000mg in 24 hours 2. Docusate Sodium 100 mg PO BID 3. Senna 17.2 mg PO HS 4. Vitamin D unknown PO DAILY 5. Donepezil 10 mg PO QHS 6. Furosemide 20 mg PO DAILY 7. Levothyroxine Sodium 150 mcg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. HELD- Warfarin 1 mg PO DAILY This medication was held. Do not restart Warfarin until [MASKED] and after you talk to your PCP about the risks and benefits of this drug. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: mechanical fall subarachnoid hemorrhage radius fracture R 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], You were transferred to [MASKED] from [MASKED] after a witnessed fall at her facility with a radius fracture on the r, supraorbital laceration and subarachnoid hemorrhage. At the outside hospital you received K Centra, splint was applied to right wrist, and dermabond over your right eye laceration prior to transfer. When you got to [MASKED] you were noted to have a urinary tract infection which we treated with antibiotics. We placed you on telemetry and will discharge you with a holter monitor for further cardiac workup. You were seen by orthopedics who placed a brace on your right wrist. You were seen by neurosurgery who determined no surgery was necessary. You are doing well and are ready for discharge. General Surgery: 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 new onset 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. Holter: There was concern that your heart may be the case for your falls. You were placed on a holter monitor at the time of discharge. Your cardiac monitor will be evaluated after 30 days. If you have any questions please call the office [MASKED]. Medications: Please resume all regular home medications. Please hold Coumadin for total of 7days until at least [MASKED] and you talk to your PCP about the risks and benefits with restarting this medication. Also, please take any new medications as prescribed. General Care: Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting with your right arm until you are cleared by physical therapy or your orthopedic surgeon as an outpatient. Avoid driving or operating heavy machinery while taking pain medications. Thank you for letting us participate in your care! Followup Instructions: [MASKED]	[]	[ "N390", "Z7901", "Z86718", "Z66", "E039" ]	[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "G92: Toxic encephalopathy", "N390: Urinary tract infection, site not specified", "S52531A: Colles' fracture of right radius, initial encounter for closed fracture", "L89151: Pressure ulcer of sacral region, stage 1", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "Z86718: Personal history of other venous thrombosis and embolism", "Z66: Do not resuscitate", "E039: Hypothyroidism, unspecified", "W19XXXA: Unspecified fall, initial encounter", "Z9181: History of falling", "Y92129: Unspecified place in nursing home as the place of occurrence of the external cause" ]
10,042,810	29,537,203	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keflex / Penicillins / latex Attending: ___ Chief Complaint: dyspnea, hypoxemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ hx of COPD Gold IV, POD1 from ablation to left lung nodule presenting with hypoxia w/ SpO2 60% upon arrival. Baseline O2 use is 1L at night, home O2 w/ sats 93 @ baseline. Had recent cold and increased o/n needs to 2L for past few days. Presented for ablation yesterday. Returned home and took 1 oxycodone for pain around midnight, went to bed. Awoke in morning w/ HA, walked downstairs, sitting at table to have coffee and felt worsening SOB. Checked finger O2 and was dipping into ___. Increased to 3L on home cannister, took hydrocodone and came to ER. By the time of arrival the battery on her home O2 canister had died. Her O2 sats dropped to ___ on ambulating from car to ER. Placed on 6L upon arrival w/ good response, sats returned to ___ ___. Successfully weaned down to 2L in ED. Patient also w/ complaints of epigastric discomfort, one episode of hemoptysis, and headache. Says epigastric pain triggered by albuterol. Headache preceded procedure w/ URI sx. In the ED, patient 60% RA, after 6L of NC, vitals were: 98.4 76 143/96 30 97% Nasal Cannula In the ER, patient seen by ___ who confirmed no pneumothorax on imaging and thought symptoms likely ___ post-procedural inflammation and COPD exacerbation. Patient admitted once she had recurrent desats to mid ___ when ambulating to the urinal. Labs notable for negative UA, normal chem 7, CBC, INR Imaging notable for CXR w/ no pneumothorax, faint opacity in the left apex correlating to recently ablated lesion with post treatment changes, mild pulmonary vascular congestion and bibasilar atelectasis, and known severe emphysema. Patient was given albuterol and ipratropium nebs, azithromycin 500mg, and IV methylpred 125mg. On the floor, the patient feels improved, though still some shortness of breath. Her pain level is ___. She also reports elevated mood bordering on agitation, energy and feeling hot which are her typical side effects of prednisone. Otherwise, no complaints. Review of systems: as per HPI, also notes fragile skin w/ multiple UE bruises; b/l ___ skin chronic skin changes, one RLE skin nodule. Denies diarrhea, constipation, neurologic, GU symptoms. Past Medical History: PAST MEDICAL HISTORY: # GERD # HTN # obesity # HLD # OSA # COPD PAST SURGICAL HISTORY: open appendectomy as a child Social History: ___ Family History: unknown Physical Exam: ADMISSION: ========== VS: 98.6 PO 144 / 83 99 18 95 3.5L Gen: Older appearing woman, lying in bed, speaking in short sentences, no acute distress HEENT: NCAT, EOMI, PERRL, OP clear CV: Heart sounds distant, S1 and S2, ___ systolic murmur best over LLSB Pulm: Pursed lip breathing, intermittently using accessory muscles. Decreased breath sounds bilaterally with dry atelectasis at bilateral bases Abd: NTND, scar in RLQ Ext: WWP, b/l ___ edema Skin: b/l UE with multiple bruises. b/l ___ with chronic venous stasis changes, R knee with large macule that has irregular borders, and hyperkeratotic, hyperpigmented o.5cm nodule with surrounding dry skin Neuro: CN II=XII intact, intentionally moving all four extremities, sensation to light touch intact throughout Psych: Mood and affect appropriate DISCHARGE: ========== VS: 98.3 PO 131 / 91 83 20 97 2l Gen: Standing playing electronic card games, NC in place, speaking in full sentences, no acute distress HEENT: NCAT, EOMI, PERRL, OP clear CV: Heart sounds distant, S1 and S2, ___ systolic murmur best over LLSB Pulm: Breathing comfortably, speaking in full sentences Abd: NTND, scar in RLQ Ext: WWP, b/l ___ edema Skin: UE bruising and ___ venous stasis changes stable from day prior Neuro: CN II-XII groslly intact, intentionally moving all four extremities, sensation to light touch intact throughout Psych: Mood and affect appropriate Pertinent Results: ADMISSION: ========== ___ 01:30PM BLOOD WBC-6.3 RBC-3.76* Hgb-12.6 Hct-39.7 MCV-106* MCH-33.5* MCHC-31.7* RDW-14.6 RDWSD-56.4* Plt ___ ___ 01:30PM BLOOD Neuts-72.0* Lymphs-14.0* Monos-11.8 Eos-1.4 Baso-0.3 Im ___ AbsNeut-4.52 AbsLymp-0.88* AbsMono-0.74 AbsEos-0.09 AbsBaso-0.02 ___ 01:30PM BLOOD ___ PTT-29.1 ___ ___ 01:30PM BLOOD Glucose-110* UreaN-12 Creat-0.7 Na-138 K-4.1 Cl-99 HCO3-27 AnGap-16 ___ 06:11AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.9 MICRO: ====== ___ 2:20 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======== ___ 1:11 ___ CHEST (PORTABLE AP) IMPRESSION: 1. No pneumothorax identified. Faint opacity in the left apex correlating to recently ablated lesion with post treatment changes. 2. Mild pulmonary vascular congestion and bibasilar atelectasis. 3. Severe emphysema and chronic dilatation of the pulmonary arteries compatible with pulmonary arterial hypertension. DISCHARGE: ========== ___ 06:11AM BLOOD WBC-4.1 RBC-3.60 Hgb-12.4 Hct-36.7 MCV-102* MCH-34.4* MCHC-33.8 RDW-13.8 RDWSD-51.8* Plt ___ ___ 06:05AM BLOOD Glucose-86 UreaN-21* Creat-0.5 Na-142 K-3.7 Cl-102 HCO3-28 AnGap-___ y/o F w/ COPD (Gold Stage IV), lung nodules c/f malignancy, s/p ___ RFA of lung nodule x2, most recently 1d PTA, p/w new hypoxia (60s on RA). ACUTE ISSUES: ============= # Lung nodule s/p RFA ablation # COPD exacerbation: Patient presented with hypoxemia s/p RFA ablation. Symptoms attributed to COPD exacerbation. She was treated for COPD exacerbation with gradual clinical improvement. At baseline she only requires 1.5-2L 02 at night. On the day of discharge she continued to require 2L 02 during the day, and 3L with ambulation. As she clinically felt well at rest and with ambulation after initiation of COPD treatment, she was discharged home with instructions to use 2L while at rest and 3L with ambulation. She will likely require a few more days to return to her baseline pulmonary function. She is instructed to schedule a follow up with her PCP or covering physician this upcoming week to assess her ambulatory sats at that time. She will be scheduled for follow up with ___. CHRONIC ISSUES: =============== # GERD: Continued omeprazole # HTN: Continued valsartan/HCTZ TRANSITIONAL ISSUES: ==================== [] Finish pred pulse - last dose ___ [] please check ambulatory saturation at next follow-up visit, patient told to use 2L O2 at rest and 3L O2 with ambulation [] EKG Changes - FYI - EKG in-house w/ ST-depressions in V4, V5. Has had lateral lead depressions and TWI in past. [] Cardiac Eval - No stress test or Echo in our records, but patient reports failing one ___ poor exercise tolerance in ___ a few years ago. Please consider need for re-evaluation # CODE: Full (confirmed) # CONTACT: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Metoprolol Tartrate 50 mg PO BID 5. Montelukast 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. roflumilast 500 mcg oral DAILY 8. Tiotropium Bromide 1 CAP IH DAILY 9. valsartan-hydrochlorothiazide 160-12.5 mg oral DAILY 10. Fexofenadine 180 mg PO DAILY 11. Magnesium Oxide 400 mg PO DAILY 12. LORazepam 0.5 mg PO TID:PRN anxiety Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 4 Doses RX azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth once a day Disp #2 Tablet Refills:0 2. PredniSONE 40 mg PO DAILY Duration: 4 Doses RX prednisone 20 mg 2 tablet(s) by mouth once a day Disp #4 Tablet Refills:0 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 4. Fexofenadine 180 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. LORazepam 0.5 mg PO TID:PRN anxiety 7. Magnesium Oxide 400 mg PO DAILY 8. Metoprolol Tartrate 50 mg PO BID 9. Montelukast 10 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. roflumilast 500 mcg oral DAILY 12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 13. Tiotropium Bromide 1 CAP IH DAILY 14. valsartan-hydrochlorothiazide 160-12.5 mg oral DAILY 15.Home Oxygen Please use two liters oxygen at rest and three liters with activity until follow-up with your primary care provider ___: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================ Chronic Obstructive Pulmonary Disease (COPD) Exacerbation SECONDARY DIAGNOSES: ==================== Hypertension Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came to ___ because you were short of breath and needed more oxygen at home. What was done during this hospitalization? - You received medications to treat a COPD exacerbation - We did tests and took x-rays to look for a trigger for the exacerbation, like infection - You most likely had some inflammation caused by a recent cold and the lung nodule ablation - Your breathing status and oxygen needs were monitored What should you do now that you are leaving the hospital? - Take all your medications as prescribed - Make follow-up appointments with your primary care doctor or nurse practitioner for this week (ambulatory saturation should be checked at that visit) - Make follow-up appointments with your pulmonologist - You should use 2L of O2 at rest and 3L with activity - Call your doctor or return to the Emergency Department if you have any concerning symptoms including fever > 100.5 F, oxygen saturations with activity that drop below 80% and do not recover quickly, oxygen saturations below 88% when you are sitting or resting It was a pleasure taking care of you! -Your ___ TEAM Followup Instructions: ___	[ "J439", "J90", "C3412", "Z9981", "R0902", "K219", "J45909", "I10", "G4733", "E669", "Z6826", "I878", "R9431", "Z87891" ]	Allergies: Keflex / Penicillins / latex Chief Complaint: dyspnea, hypoxemia Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/ hx of COPD Gold IV, POD1 from ablation to left lung nodule presenting with hypoxia w/ SpO2 60% upon arrival. Baseline O2 use is 1L at night, home O2 w/ sats 93 @ baseline. Had recent cold and increased o/n needs to 2L for past few days. Presented for ablation yesterday. Returned home and took 1 oxycodone for pain around midnight, went to bed. Awoke in morning w/ HA, walked downstairs, sitting at table to have coffee and felt worsening SOB. Checked finger O2 and was dipping into [MASKED]. Increased to 3L on home cannister, took hydrocodone and came to ER. By the time of arrival the battery on her home O2 canister had died. Her O2 sats dropped to [MASKED] on ambulating from car to ER. Placed on 6L upon arrival w/ good response, sats returned to [MASKED] [MASKED]. Successfully weaned down to 2L in ED. Patient also w/ complaints of epigastric discomfort, one episode of hemoptysis, and headache. Says epigastric pain triggered by albuterol. Headache preceded procedure w/ URI sx. In the ED, patient 60% RA, after 6L of NC, vitals were: 98.4 76 143/96 30 97% Nasal Cannula In the ER, patient seen by [MASKED] who confirmed no pneumothorax on imaging and thought symptoms likely [MASKED] post-procedural inflammation and COPD exacerbation. Patient admitted once she had recurrent desats to mid [MASKED] when ambulating to the urinal. Labs notable for negative UA, normal chem 7, CBC, INR Imaging notable for CXR w/ no pneumothorax, faint opacity in the left apex correlating to recently ablated lesion with post treatment changes, mild pulmonary vascular congestion and bibasilar atelectasis, and known severe emphysema. Patient was given albuterol and ipratropium nebs, azithromycin 500mg, and IV methylpred 125mg. On the floor, the patient feels improved, though still some shortness of breath. Her pain level is [MASKED]. She also reports elevated mood bordering on agitation, energy and feeling hot which are her typical side effects of prednisone. Otherwise, no complaints. Review of systems: as per HPI, also notes fragile skin w/ multiple UE bruises; b/l [MASKED] skin chronic skin changes, one RLE skin nodule. Denies diarrhea, constipation, neurologic, GU symptoms. Past Medical History: PAST MEDICAL HISTORY: # GERD # HTN # obesity # HLD # OSA # COPD PAST SURGICAL HISTORY: open appendectomy as a child Social History: [MASKED] Family History: unknown Physical Exam: ADMISSION: ========== VS: 98.6 PO 144 / 83 99 18 95 3.5L Gen: Older appearing woman, lying in bed, speaking in short sentences, no acute distress HEENT: NCAT, EOMI, PERRL, OP clear CV: Heart sounds distant, S1 and S2, [MASKED] systolic murmur best over LLSB Pulm: Pursed lip breathing, intermittently using accessory muscles. Decreased breath sounds bilaterally with dry atelectasis at bilateral bases Abd: NTND, scar in RLQ Ext: WWP, b/l [MASKED] edema Skin: b/l UE with multiple bruises. b/l [MASKED] with chronic venous stasis changes, R knee with large macule that has irregular borders, and hyperkeratotic, hyperpigmented o.5cm nodule with surrounding dry skin Neuro: CN II=XII intact, intentionally moving all four extremities, sensation to light touch intact throughout Psych: Mood and affect appropriate DISCHARGE: ========== VS: 98.3 PO 131 / 91 83 20 97 2l Gen: Standing playing electronic card games, NC in place, speaking in full sentences, no acute distress HEENT: NCAT, EOMI, PERRL, OP clear CV: Heart sounds distant, S1 and S2, [MASKED] systolic murmur best over LLSB Pulm: Breathing comfortably, speaking in full sentences Abd: NTND, scar in RLQ Ext: WWP, b/l [MASKED] edema Skin: UE bruising and [MASKED] venous stasis changes stable from day prior Neuro: CN II-XII groslly intact, intentionally moving all four extremities, sensation to light touch intact throughout Psych: Mood and affect appropriate Pertinent Results: ADMISSION: ========== [MASKED] 01:30PM BLOOD WBC-6.3 RBC-3.76* Hgb-12.6 Hct-39.7 MCV-106* MCH-33.5* MCHC-31.7* RDW-14.6 RDWSD-56.4* Plt [MASKED] [MASKED] 01:30PM BLOOD Neuts-72.0* Lymphs-14.0* Monos-11.8 Eos-1.4 Baso-0.3 Im [MASKED] AbsNeut-4.52 AbsLymp-0.88* AbsMono-0.74 AbsEos-0.09 AbsBaso-0.02 [MASKED] 01:30PM BLOOD [MASKED] PTT-29.1 [MASKED] [MASKED] 01:30PM BLOOD Glucose-110* UreaN-12 Creat-0.7 Na-138 K-4.1 Cl-99 HCO3-27 AnGap-16 [MASKED] 06:11AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.9 MICRO: ====== [MASKED] 2:20 pm URINE *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======== [MASKED] 1:11 [MASKED] CHEST (PORTABLE AP) IMPRESSION: 1. No pneumothorax identified. Faint opacity in the left apex correlating to recently ablated lesion with post treatment changes. 2. Mild pulmonary vascular congestion and bibasilar atelectasis. 3. Severe emphysema and chronic dilatation of the pulmonary arteries compatible with pulmonary arterial hypertension. DISCHARGE: ========== [MASKED] 06:11AM BLOOD WBC-4.1 RBC-3.60 Hgb-12.4 Hct-36.7 MCV-102* MCH-34.4* MCHC-33.8 RDW-13.8 RDWSD-51.8* Plt [MASKED] [MASKED] 06:05AM BLOOD Glucose-86 UreaN-21* Creat-0.5 Na-142 K-3.7 Cl-102 HCO3-28 AnGap-[MASKED] y/o F w/ COPD (Gold Stage IV), lung nodules c/f malignancy, s/p [MASKED] RFA of lung nodule x2, most recently 1d PTA, p/w new hypoxia (60s on RA). ACUTE ISSUES: ============= # Lung nodule s/p RFA ablation # COPD exacerbation: Patient presented with hypoxemia s/p RFA ablation. Symptoms attributed to COPD exacerbation. She was treated for COPD exacerbation with gradual clinical improvement. At baseline she only requires 1.5-2L 02 at night. On the day of discharge she continued to require 2L 02 during the day, and 3L with ambulation. As she clinically felt well at rest and with ambulation after initiation of COPD treatment, she was discharged home with instructions to use 2L while at rest and 3L with ambulation. She will likely require a few more days to return to her baseline pulmonary function. She is instructed to schedule a follow up with her PCP or covering physician this upcoming week to assess her ambulatory sats at that time. She will be scheduled for follow up with [MASKED]. CHRONIC ISSUES: =============== # GERD: Continued omeprazole # HTN: Continued valsartan/HCTZ TRANSITIONAL ISSUES: ==================== [] Finish pred pulse - last dose [MASKED] [] please check ambulatory saturation at next follow-up visit, patient told to use 2L O2 at rest and 3L O2 with ambulation [] EKG Changes - FYI - EKG in-house w/ ST-depressions in V4, V5. Has had lateral lead depressions and TWI in past. [] Cardiac Eval - No stress test or Echo in our records, but patient reports failing one [MASKED] poor exercise tolerance in [MASKED] a few years ago. Please consider need for re-evaluation # CODE: Full (confirmed) # CONTACT: [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Metoprolol Tartrate 50 mg PO BID 5. Montelukast 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. roflumilast 500 mcg oral DAILY 8. Tiotropium Bromide 1 CAP IH DAILY 9. valsartan-hydrochlorothiazide 160-12.5 mg oral DAILY 10. Fexofenadine 180 mg PO DAILY 11. Magnesium Oxide 400 mg PO DAILY 12. LORazepam 0.5 mg PO TID:PRN anxiety Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 4 Doses RX azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth once a day Disp #2 Tablet Refills:0 2. PredniSONE 40 mg PO DAILY Duration: 4 Doses RX prednisone 20 mg 2 tablet(s) by mouth once a day Disp #4 Tablet Refills:0 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 4. Fexofenadine 180 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. LORazepam 0.5 mg PO TID:PRN anxiety 7. Magnesium Oxide 400 mg PO DAILY 8. Metoprolol Tartrate 50 mg PO BID 9. Montelukast 10 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. roflumilast 500 mcg oral DAILY 12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 13. Tiotropium Bromide 1 CAP IH DAILY 14. valsartan-hydrochlorothiazide 160-12.5 mg oral DAILY 15.Home Oxygen Please use two liters oxygen at rest and three liters with activity until follow-up with your primary care provider [MASKED]: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================ Chronic Obstructive Pulmonary Disease (COPD) Exacerbation SECONDARY DIAGNOSES: ==================== Hypertension Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You came to [MASKED] because you were short of breath and needed more oxygen at home. What was done during this hospitalization? - You received medications to treat a COPD exacerbation - We did tests and took x-rays to look for a trigger for the exacerbation, like infection - You most likely had some inflammation caused by a recent cold and the lung nodule ablation - Your breathing status and oxygen needs were monitored What should you do now that you are leaving the hospital? - Take all your medications as prescribed - Make follow-up appointments with your primary care doctor or nurse practitioner for this week (ambulatory saturation should be checked at that visit) - Make follow-up appointments with your pulmonologist - You should use 2L of O2 at rest and 3L with activity - Call your doctor or return to the Emergency Department if you have any concerning symptoms including fever > 100.5 F, oxygen saturations with activity that drop below 80% and do not recover quickly, oxygen saturations below 88% when you are sitting or resting It was a pleasure taking care of you! -Your [MASKED] TEAM Followup Instructions: [MASKED]	[]	[ "K219", "J45909", "I10", "G4733", "E669", "Z87891" ]	[ "J439: Emphysema, unspecified", "J90: Pleural effusion, not elsewhere classified", "C3412: Malignant neoplasm of upper lobe, left bronchus or lung", "Z9981: Dependence on supplemental oxygen", "R0902: Hypoxemia", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E669: Obesity, unspecified", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "I878: Other specified disorders of veins", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "Z87891: Personal history of nicotine dependence" ]
10,042,896	27,960,228	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: RUQ abdominal/flank pain, R pleuritic chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with GERD, hiatal hernia, h/o thyroid Ca s/p thyroidectomy ___ years ago who presents with RUQ/lower R chest pain since ___. Patient reports pain started suddenly and was initially concerned that it was muscle pull or reflux. She took pepcid without benefit. Unable to sleep given pain. Took 6 tabs ibuprofen without relief. Pain was worse with inspiration, worse when lying on affected side. Denies chest pain, denies SOB, denies lightheadedness, denies ___ edema. Not affected by eating (pt does have a h/o gallstones). No f/c, N/V/D. In the ED, initial vitals were: 97.9 111 139/60 8 97% RA - Exam notable for: Tachy to 111, otherwise VSS Gen: well-appearing CV: RRR, no M/R/G Resp: unable to take deep breath, CTAB Chest wall: no TTP Abd: non-distended, soft, non-tender. Neg ___ sign Ext: no swelling, no calf tenderness - Labs notable for: DDimer 770 - Imaging was notable for: CTA chest: 1. Segmental and subsegmental pulmonary emboli within the right lower lobe associated with pulmonary infarction in the peripheral anterior aspect of the right lower lobe. No CT evidence for right heart strain. 2. Small right pleural effusion. CXR: Wedge-shaped opacity within the periphery of the right lower lobe concerning for pulmonary infarction and further assessment with chest CTA is recommended to evaluate for pulmonary embolism. No pneumothorax. - Patient was given: lovenox 70 mg SQ - Vitals prior to transfer: 98.1 97 116/67 14 98% RA Upon arrival to the floor, patient reports pain is persistent, worse with inspiration, worse when lying on affected side. Denies palpitations, lightheadedness, chest tightness, chest pain. Notably, denies long plane ___ car rides, recent surgery or immobility. Last ___ within the year, had breast bx that was negative for malignancy per pt report. Last pap smear ___ years ago, wnl per pt. No prior cervical bx. No weight loss, fevers, chills, night sweats. Follows with endocrinologist at ___ for her hypothyroidism (s/p thyroidectomy), had bone scan notable for osteoporosis. Does not have routine imaging for thyroid malignancy follow up. No hormonal use. Never smoker REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: - GERD, hiatal hernia -macular degeneration -papillary thyroid Ca s/p partial thyroidectomy ___ -Hypothyroidism -high cholesterol Social History: ___ Family History: father had ___ disease. Mother had breast cancer (___) and dementia. One daughter has primary biliary cholangitis. No ___ blood clots, PE, DVT. Father was on ___ for unknown indication Physical Exam: ADMISSION EXAM: Vital Signs: 99.8 103/59 109 20 94 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: tachycardic, regular. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. No chest wall tenderness Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE EXAM: Vital Signs: T98.1 BP 102 / 55 73 18 96 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: tachycardic, regular. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Decreased breath sounds in RLL, otherwise clear to auscultation bilaterally, no wheezes, rales, rhonchi. Posterior chest wall tender to palpation Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: ADMISSION LABS ============== ___ 03:15PM BLOOD WBC-9.4# RBC-4.69 Hgb-14.1 Hct-42.4 MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 RDWSD-42.5 Plt ___ ___ 03:15PM BLOOD Neuts-59.3 ___ Monos-11.9 Eos-0.1* Baso-0.4 Im ___ AbsNeut-5.55 AbsLymp-2.61 AbsMono-1.12* AbsEos-0.01* AbsBaso-0.04 ___ 03:15PM BLOOD ___ PTT-26.6 ___ ___ 03:15PM BLOOD Glucose-102* UreaN-12 Creat-0.8 Na-139 K-4.1 Cl-101 HCO3-22 AnGap-20 ___ 03:15PM BLOOD ALT-32 AST-40 AlkPhos-64 TotBili-0.6 ___ 03:15PM BLOOD Lipase-24 ___ 03:15PM BLOOD cTropnT-<0.01 proBNP-111 ___ 03:30PM BLOOD D-Dimer-740* IMAGING ========= CTA chest ___: 1. Segmental and subsegmental pulmonary emboli within the right lower lobe associated with pulmonary infarction in the peripheral anterior aspect of the right lower lobe. No CT evidence for right heart strain. 2. Small right pleural effusion. CXR ___: Wedge-shaped opacity within the periphery of the right lower lobe concerning for pulmonary infarction and further assessment with chest CTA is recommended to evaluate for pulmonary embolism. No pneumothorax. DISCHARGE LABS ============= ___ 03:15PM BLOOD WBC-9.4# RBC-4.69 Hgb-14.1 Hct-42.4 MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 RDWSD-42.5 Plt ___ ___ 06:10AM BLOOD ___ PTT-29.0 ___ ___ 06:10AM BLOOD Glucose-83 UreaN-11 Creat-0.7 Na-139 K-3.5 Cl-101 HCO3-26 AnGap-16 ___ 06:10AM BLOOD ALT-26 AST-24 LD(LDH)-179 AlkPhos-59 TotBili-0.8 ___ 06:10AM BLOOD cTropnT-<0.01 ___ 06:10AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.1 Mg-2.2 ___ 06:10AM BLOOD TSH-1.5 Brief Hospital Course: Mrs. ___ is a ___ year old female with a history of papillary thyroid carcinoma s/p partial thyroidectomy in ___, GERD and hiatal hernia who presented to the ___ ED with RUQ abdominal/flank and right-sided posterior chest wall pleuritic pain, found to have RLL segmental and subsegmental PEs, with associated RLL pulmonary infarction. ACTIVE ISSUES: # Segmental and subsegmental PEs: Patient presented with RUQ and right posterior chest wall pain, which was noted to be pleuritic in nature and worsened with inspiration. Initial CXR was concerning for a wedge like opacity within the periphery of the right lower lobe concerning for pulmonary infarction. CTA chest revealed segmental and subsegmental PEs in the right lower lobe, accompanied with pulmonary infarction in the peripheral anterior aspect of the right lower lobe. Patient had no evidence of right heart strain and cardiac markers (troponin and BNP) were negative. Underlying etiology of forming a VTE is unclear at this time. Patient does not endorse recent history of being immobile, and further denies any medications associated with formation of PE. She has a history of papillary thyroid cancer ___ years prior) but is s/p thyroidectomy. Her age-appropriate cancer screening includes regular colonoscopies with a known history of polyps, but last colonoscopy in ___ was within normal (pt was recommended f/u in ___ years), also up to date on mammography and pap smears. Patient was treated as an unprovoked PE, and was initiated on lovenox therapy, and transitioned to Rivaroxaban for 6 month course for unprovoked PE. She will be seen as an outpatient by hematology/oncology to assess etiology of PE and complete a hypercoagulable workup. TRANSITIONAL ISSUES: ==================== [] Pt was started on a 6 month course of Rivaroxaban for unprovoked segmental and subsegmental PE, with associated pulmonary infarct. Patient will take Rivaroxaban 15mg BID for 21 days (start date ___, end date ___, and then transition to Rivaroxaban 20mg once daily for 6 months (end date ___. She will further followup with her PCP and outpatient hematologist for further hypercoagulable workup to guide length of therapy. [] Please readdress the length of anticoagulation required with Rivaroxaban pending outpatient workup with hem/onc. [] Please ensure patient is compliant with taking Rivaroxaban daily to prevent future blood clots [] Pt will benefit from f/u with endocrinologist to consider repeat thyroid imaging including thyroid U/S as well as TSH/FT4 to ensure no evidence of recurrence of her thyroid ca, and to determine if patients thyroid cancer history is related to development of a PE . [] Pt had incidentally found cholelithiasis noted on CT imaging, however had normal LFTs on this admission. Pt will benefit from repeating LFTs if pt becomes symptomatic in the future. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO DAILY 2. Simvastatin 10 mg PO QPM 3. Levothyroxine Sodium 125 mcg PO DAILY 4. ALPRAZolam 0.25 mg PO QHS:PRN anxiety, insomnia Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild RX acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp #60 Tablet Refills:0 2. Rivaroxaban 15 mg PO BID Duration: 21 Days Dose #1 of 2: Please take 15mg twice daily for 3 weeks, then switch to Dose #2 of 2 RX rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice daily Disp #42 Tablet Refills:0 3. Rivaroxaban 20 mg PO DAILY Dose #2 of 2: Please start 20mg daily after ___ complete 3 weeks of 15mg twice daily RX rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 4. ALPRAZolam 0.25 mg PO QHS:PRN anxiety, insomnia 5. Famotidine 20 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Pulmonary Embolism (segmental and subsegmental PE) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ presented to the ___ ED with right flank and right upper abdominal pain, accompanied with right-sided posterior chest wall pain that worsened with inspiration. ___ were assessed with labs and imaging, and a CT scan of your chest showed several pulmonary emboli as well as an associated pulmonary infarction (a damaged area of the lung due to lack of blood flow). Due to the above finding of a pulmonary embolism and pulmonary infarction, ___ were admitted to the inpatient service, where ___ were assessed with labs and monitored on telemetry. ___ had no difficulty maintaining your oxygen saturation, and your pain was well controlled while admitted to the inpatient service. ___ were transitioned from Lovenox to Rivaroxaban, a medication to prevent further development of blood clots in your lungs or elsewhere in your body. ___ will readdress how long ___ need to be on your Rivaroxaban with your outpatient primary care physician and outpatient hematologist, however ___ will likely continue Rivaroxaban for a minimum of 6 months. Please ensure that ___ take your prescribed medications as instructed below, and ensure that ___ take this medication every day to prevent future clots. Please also followup at the appointments noted below that have been arranged on your behalf. It was a pleasure being involved in your care. Your ___ care team Followup Instructions: ___	[ "I2699", "E039", "E785", "G4700", "F419", "R1013", "K219", "K449", "Z85850" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: RUQ abdominal/flank pain, R pleuritic chest pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with GERD, hiatal hernia, h/o thyroid Ca s/p thyroidectomy [MASKED] years ago who presents with RUQ/lower R chest pain since [MASKED]. Patient reports pain started suddenly and was initially concerned that it was muscle pull or reflux. She took pepcid without benefit. Unable to sleep given pain. Took 6 tabs ibuprofen without relief. Pain was worse with inspiration, worse when lying on affected side. Denies chest pain, denies SOB, denies lightheadedness, denies [MASKED] edema. Not affected by eating (pt does have a h/o gallstones). No f/c, N/V/D. In the ED, initial vitals were: 97.9 111 139/60 8 97% RA - Exam notable for: Tachy to 111, otherwise VSS Gen: well-appearing CV: RRR, no M/R/G Resp: unable to take deep breath, CTAB Chest wall: no TTP Abd: non-distended, soft, non-tender. Neg [MASKED] sign Ext: no swelling, no calf tenderness - Labs notable for: DDimer 770 - Imaging was notable for: CTA chest: 1. Segmental and subsegmental pulmonary emboli within the right lower lobe associated with pulmonary infarction in the peripheral anterior aspect of the right lower lobe. No CT evidence for right heart strain. 2. Small right pleural effusion. CXR: Wedge-shaped opacity within the periphery of the right lower lobe concerning for pulmonary infarction and further assessment with chest CTA is recommended to evaluate for pulmonary embolism. No pneumothorax. - Patient was given: lovenox 70 mg SQ - Vitals prior to transfer: 98.1 97 116/67 14 98% RA Upon arrival to the floor, patient reports pain is persistent, worse with inspiration, worse when lying on affected side. Denies palpitations, lightheadedness, chest tightness, chest pain. Notably, denies long plane [MASKED] car rides, recent surgery or immobility. Last [MASKED] within the year, had breast bx that was negative for malignancy per pt report. Last pap smear [MASKED] years ago, wnl per pt. No prior cervical bx. No weight loss, fevers, chills, night sweats. Follows with endocrinologist at [MASKED] for her hypothyroidism (s/p thyroidectomy), had bone scan notable for osteoporosis. Does not have routine imaging for thyroid malignancy follow up. No hormonal use. Never smoker REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: - GERD, hiatal hernia -macular degeneration -papillary thyroid Ca s/p partial thyroidectomy [MASKED] -Hypothyroidism -high cholesterol Social History: [MASKED] Family History: father had [MASKED] disease. Mother had breast cancer ([MASKED]) and dementia. One daughter has primary biliary cholangitis. No [MASKED] blood clots, PE, DVT. Father was on [MASKED] for unknown indication Physical Exam: ADMISSION EXAM: Vital Signs: 99.8 103/59 109 20 94 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: tachycardic, regular. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. No chest wall tenderness Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE EXAM: Vital Signs: T98.1 BP 102 / 55 73 18 96 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: tachycardic, regular. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Decreased breath sounds in RLL, otherwise clear to auscultation bilaterally, no wheezes, rales, rhonchi. Posterior chest wall tender to palpation Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: ADMISSION LABS ============== [MASKED] 03:15PM BLOOD WBC-9.4# RBC-4.69 Hgb-14.1 Hct-42.4 MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 RDWSD-42.5 Plt [MASKED] [MASKED] 03:15PM BLOOD Neuts-59.3 [MASKED] Monos-11.9 Eos-0.1* Baso-0.4 Im [MASKED] AbsNeut-5.55 AbsLymp-2.61 AbsMono-1.12* AbsEos-0.01* AbsBaso-0.04 [MASKED] 03:15PM BLOOD [MASKED] PTT-26.6 [MASKED] [MASKED] 03:15PM BLOOD Glucose-102* UreaN-12 Creat-0.8 Na-139 K-4.1 Cl-101 HCO3-22 AnGap-20 [MASKED] 03:15PM BLOOD ALT-32 AST-40 AlkPhos-64 TotBili-0.6 [MASKED] 03:15PM BLOOD Lipase-24 [MASKED] 03:15PM BLOOD cTropnT-<0.01 proBNP-111 [MASKED] 03:30PM BLOOD D-Dimer-740* IMAGING ========= CTA chest [MASKED]: 1. Segmental and subsegmental pulmonary emboli within the right lower lobe associated with pulmonary infarction in the peripheral anterior aspect of the right lower lobe. No CT evidence for right heart strain. 2. Small right pleural effusion. CXR [MASKED]: Wedge-shaped opacity within the periphery of the right lower lobe concerning for pulmonary infarction and further assessment with chest CTA is recommended to evaluate for pulmonary embolism. No pneumothorax. DISCHARGE LABS ============= [MASKED] 03:15PM BLOOD WBC-9.4# RBC-4.69 Hgb-14.1 Hct-42.4 MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 RDWSD-42.5 Plt [MASKED] [MASKED] 06:10AM BLOOD [MASKED] PTT-29.0 [MASKED] [MASKED] 06:10AM BLOOD Glucose-83 UreaN-11 Creat-0.7 Na-139 K-3.5 Cl-101 HCO3-26 AnGap-16 [MASKED] 06:10AM BLOOD ALT-26 AST-24 LD(LDH)-179 AlkPhos-59 TotBili-0.8 [MASKED] 06:10AM BLOOD cTropnT-<0.01 [MASKED] 06:10AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.1 Mg-2.2 [MASKED] 06:10AM BLOOD TSH-1.5 Brief Hospital Course: Mrs. [MASKED] is a [MASKED] year old female with a history of papillary thyroid carcinoma s/p partial thyroidectomy in [MASKED], GERD and hiatal hernia who presented to the [MASKED] ED with RUQ abdominal/flank and right-sided posterior chest wall pleuritic pain, found to have RLL segmental and subsegmental PEs, with associated RLL pulmonary infarction. ACTIVE ISSUES: # Segmental and subsegmental PEs: Patient presented with RUQ and right posterior chest wall pain, which was noted to be pleuritic in nature and worsened with inspiration. Initial CXR was concerning for a wedge like opacity within the periphery of the right lower lobe concerning for pulmonary infarction. CTA chest revealed segmental and subsegmental PEs in the right lower lobe, accompanied with pulmonary infarction in the peripheral anterior aspect of the right lower lobe. Patient had no evidence of right heart strain and cardiac markers (troponin and BNP) were negative. Underlying etiology of forming a VTE is unclear at this time. Patient does not endorse recent history of being immobile, and further denies any medications associated with formation of PE. She has a history of papillary thyroid cancer [MASKED] years prior) but is s/p thyroidectomy. Her age-appropriate cancer screening includes regular colonoscopies with a known history of polyps, but last colonoscopy in [MASKED] was within normal (pt was recommended f/u in [MASKED] years), also up to date on mammography and pap smears. Patient was treated as an unprovoked PE, and was initiated on lovenox therapy, and transitioned to Rivaroxaban for 6 month course for unprovoked PE. She will be seen as an outpatient by hematology/oncology to assess etiology of PE and complete a hypercoagulable workup. TRANSITIONAL ISSUES: ==================== [] Pt was started on a 6 month course of Rivaroxaban for unprovoked segmental and subsegmental PE, with associated pulmonary infarct. Patient will take Rivaroxaban 15mg BID for 21 days (start date [MASKED], end date [MASKED], and then transition to Rivaroxaban 20mg once daily for 6 months (end date [MASKED]. She will further followup with her PCP and outpatient hematologist for further hypercoagulable workup to guide length of therapy. [] Please readdress the length of anticoagulation required with Rivaroxaban pending outpatient workup with hem/onc. [] Please ensure patient is compliant with taking Rivaroxaban daily to prevent future blood clots [] Pt will benefit from f/u with endocrinologist to consider repeat thyroid imaging including thyroid U/S as well as TSH/FT4 to ensure no evidence of recurrence of her thyroid ca, and to determine if patients thyroid cancer history is related to development of a PE . [] Pt had incidentally found cholelithiasis noted on CT imaging, however had normal LFTs on this admission. Pt will benefit from repeating LFTs if pt becomes symptomatic in the future. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO DAILY 2. Simvastatin 10 mg PO QPM 3. Levothyroxine Sodium 125 mcg PO DAILY 4. ALPRAZolam 0.25 mg PO QHS:PRN anxiety, insomnia Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild RX acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp #60 Tablet Refills:0 2. Rivaroxaban 15 mg PO BID Duration: 21 Days Dose #1 of 2: Please take 15mg twice daily for 3 weeks, then switch to Dose #2 of 2 RX rivaroxaban [[MASKED]] 15 mg 1 tablet(s) by mouth twice daily Disp #42 Tablet Refills:0 3. Rivaroxaban 20 mg PO DAILY Dose #2 of 2: Please start 20mg daily after [MASKED] complete 3 weeks of 15mg twice daily RX rivaroxaban [[MASKED]] 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 4. ALPRAZolam 0.25 mg PO QHS:PRN anxiety, insomnia 5. Famotidine 20 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Pulmonary Embolism (segmental and subsegmental PE) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] presented to the [MASKED] ED with right flank and right upper abdominal pain, accompanied with right-sided posterior chest wall pain that worsened with inspiration. [MASKED] were assessed with labs and imaging, and a CT scan of your chest showed several pulmonary emboli as well as an associated pulmonary infarction (a damaged area of the lung due to lack of blood flow). Due to the above finding of a pulmonary embolism and pulmonary infarction, [MASKED] were admitted to the inpatient service, where [MASKED] were assessed with labs and monitored on telemetry. [MASKED] had no difficulty maintaining your oxygen saturation, and your pain was well controlled while admitted to the inpatient service. [MASKED] were transitioned from Lovenox to Rivaroxaban, a medication to prevent further development of blood clots in your lungs or elsewhere in your body. [MASKED] will readdress how long [MASKED] need to be on your Rivaroxaban with your outpatient primary care physician and outpatient hematologist, however [MASKED] will likely continue Rivaroxaban for a minimum of 6 months. Please ensure that [MASKED] take your prescribed medications as instructed below, and ensure that [MASKED] take this medication every day to prevent future clots. Please also followup at the appointments noted below that have been arranged on your behalf. It was a pleasure being involved in your care. Your [MASKED] care team Followup Instructions: [MASKED]	[]	[ "E039", "E785", "G4700", "F419", "K219" ]	[ "I2699: Other pulmonary embolism without acute cor pulmonale", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "G4700: Insomnia, unspecified", "F419: Anxiety disorder, unspecified", "R1013: Epigastric pain", "K219: Gastro-esophageal reflux disease without esophagitis", "K449: Diaphragmatic hernia without obstruction or gangrene", "Z85850: Personal history of malignant neoplasm of thyroid" ]
10,043,039	24,987,075	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Imitrex / Penicillins Attending: ___. Chief Complaint: Right tibial plateau fracture Major Surgical or Invasive Procedure: Right tibial plateau ORIF ___, ___ History of Present Illness: ___ male history hypertension, anxiety, depression, ADD, alcohol abuse who presents with right knee pain status post fall while ice skating yesterday. Denies head strike or loss of consciousness. Unable to ambulate today which prompted his visit to urgent care. unable to take an x-ray at urgent care due to severe pain, so transferred here for further workup. Noted to have a cold foot with weak ___ pulse, so vascular surgery consulted and CTA of the right leg performed. Denies numbness or tingling. Past Medical History: HYPERTENSION ANXIETY DEPRESSION ATTENTION DEFICIT DISORDER WITHOUT HYPERACTIVITY ALCOHOL ABUSE PSYCHIATRIST Social History: ___ Family History: nc Physical Exam: Discharge PE: 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: * dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right tibial plateau ORIF which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with home ___ was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touchdown weightbearing in the right lower extremity, and will be discharged on Lovenox 40 mg 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: ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs inhaled every 4 hours as needed for cough, wheeze, sob CODEINE-GUAIFENESIN - codeine 10 mg-guaifenesin 100 mg/5 mL oral liquid. 10 ml by mouth twice daily as needed for cough DEXTROAMPHETAMINE-AMPHETAMINE - dextroamphetamine-amphetamine 15 mg tablet. 1 tablet(s) by mouth two times per day as needed for concentration HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1 tablet(s) by mouth once a day LISINOPRIL - lisinopril 10 mg tablet. TAKE 1 TABLET BY MOUTH DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 5. Senna 8.6 mg PO BID 6. Amphetamine-Dextroamphetamine 15 mg PO BID 7. Hydrochlorothiazide 25 mg PO DAILY 8. Lisinopril 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right tibial plateau fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Touchdown weightbearing right lower extremity in an unlocked ___ MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox 40 mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. -You may take down your Ace wrap once home. You may change your dressing if saturated in place a new clean gauze if draining - 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 > 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 FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. 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. Physical Therapy: Touchdown weightbearing right lower extremity in an unlocked ___, range of motion as tolerated Treatments Frequency: Remove ace wrap once home Change dressings if saturated, apply dry sterile dressing daily if needed after primary dressing removed if not draining leave open to air wound checks staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: ___	[ "S82141A", "V00211A", "Y9321", "Y92330", "Y998", "I10", "F419", "R55", "I4519", "F1010", "F329", "Z23", "Z87891", "I493", "R000" ]	Allergies: Imitrex / Penicillins Chief Complaint: Right tibial plateau fracture Major Surgical or Invasive Procedure: Right tibial plateau ORIF [MASKED], [MASKED] History of Present Illness: [MASKED] male history hypertension, anxiety, depression, ADD, alcohol abuse who presents with right knee pain status post fall while ice skating yesterday. Denies head strike or loss of consciousness. Unable to ambulate today which prompted his visit to urgent care. unable to take an x-ray at urgent care due to severe pain, so transferred here for further workup. Noted to have a cold foot with weak [MASKED] pulse, so vascular surgery consulted and CTA of the right leg performed. Denies numbness or tingling. Past Medical History: HYPERTENSION ANXIETY DEPRESSION ATTENTION DEFICIT DISORDER WITHOUT HYPERACTIVITY ALCOHOL ABUSE PSYCHIATRIST Social History: [MASKED] Family History: nc Physical Exam: Discharge PE: 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: * dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for right tibial plateau ORIF which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home with home [MASKED] 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 touchdown weightbearing in the right lower extremity, and will be discharged on Lovenox 40 mg 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: ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs inhaled every 4 hours as needed for cough, wheeze, sob CODEINE-GUAIFENESIN - codeine 10 mg-guaifenesin 100 mg/5 mL oral liquid. 10 ml by mouth twice daily as needed for cough DEXTROAMPHETAMINE-AMPHETAMINE - dextroamphetamine-amphetamine 15 mg tablet. 1 tablet(s) by mouth two times per day as needed for concentration HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1 tablet(s) by mouth once a day LISINOPRIL - lisinopril 10 mg tablet. TAKE 1 TABLET BY MOUTH DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain 5. Senna 8.6 mg PO BID 6. Amphetamine-Dextroamphetamine 15 mg PO BID 7. Hydrochlorothiazide 25 mg PO DAILY 8. Lisinopril 10 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Right tibial plateau fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Touchdown weightbearing right lower extremity in an unlocked [MASKED] MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox 40 mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. -You may take down your Ace wrap once home. You may change your dressing if saturated in place a new clean gauze if draining - 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 > 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 FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. [MASKED]. 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. Physical Therapy: Touchdown weightbearing right lower extremity in an unlocked [MASKED], range of motion as tolerated Treatments Frequency: Remove ace wrap once home Change dressings if saturated, apply dry sterile dressing daily if needed after primary dressing removed if not draining leave open to air wound checks staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: [MASKED]	[]	[ "I10", "F419", "F329", "Z87891" ]	[ "S82141A: Displaced bicondylar fracture of right tibia, initial encounter for closed fracture", "V00211A: Fall from ice-skates, initial encounter", "Y9321: Activity, ice skating", "Y92330: Ice skating rink (indoor) (outdoor) as the place of occurrence of the external cause", "Y998: Other external cause status", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "R55: Syncope and collapse", "I4519: Other right bundle-branch block", "F1010: Alcohol abuse, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "Z23: Encounter for immunization", "Z87891: Personal history of nicotine dependence", "I493: Ventricular premature depolarization", "R000: Tachycardia, unspecified" ]
10,043,305	23,614,590	Name: ___ Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: ___ Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "I wasn't thinking clearly." Major Surgical or Invasive Procedure: None History of Present Illness: Per admitting physician: "Ms. ___ is a ___ year old pregnant female (gestational age of ___ 2days) with history of bipolar II disorder, anxiety, and trauma, with one prior psychiatric hospitalization ___ years ago in setting of suicide attempt by ___, who was brought in to the ___ ED on a ___ from her outpatient psychiatrist's office due to SI with plan to overdose on OTC medications. . Ms. ___ reports worsening depression and anxiety due to numerous psychosocial stressors. She described her pregnancy as a big stressor, because she is not able to return to school to finish her Associate's Degree. She described additional stress from working for a ___ and having a very high workload with long hours; she does not feel supported by the staff at the ___. Furthermore, she has had daily nausea and vomiting since becoming pregnant with inability to eat or even take dietary supplements. Overall, she stated that she feels the pregnancy is "a step back" in her life. She reports experiencing severe hopelessness and SI with plan to overdose on naproxen yesterday and today. Upon further discussion, she expressed HI towards the fetus "I thought that if I do that, the baby will go away". She reports that she is still experiencing those thoughts and that she was worried about acting on them ("I don't want to make a mistake"). She described that she avoids keeping medications in the house due to fear of attempting suicide - the fear is related to her mother's history of multiple SAs and patient's own SA from ___ years ago. She describes that she has bottle of naproxen at home. . Ms. ___ described that her SI was worsened significantly by a conflict with her mother yesterday when her mother "said some hurtful things which triggered me to back when I was suicidal". Also described stress from needing to move to a new apartment in ___. . Patient describes ___ weeks of not being able to fall asleep until ___ AM (ruminating about whether she would finish school, if she would be a good mother), feeling tired, with amotivation, poor concentration, and inability to go to work: not been at work since ___. Had other work interruptions in past ___ weeks. She also reports anhedonia, stating that the only thing that she looks forward to is finishing her associate's degree, does not enjoy anything anymore, and is not looking forward to having her baby. She also reported poor appetite, saying she eats "because I have to eat". . She describes losing 45lbs (from 145lbs to 100lbs) ___ years ago due to depression while being in an abusive relationship. Denies significant weight loss currently, stating that she weighs 115lbs and that her OBGYN is not concerned about the weight. She described repeated visits to ___ for IV fluids due to significant nausea and vomiting throughout the 11 weeks of pregnancy. . However, patient also reported that yesterday she was she was "happy, energetic, was around family, had a photo shoot" to announce her pregnancy. Then she went home yesterday, had the fight with her mother, and began experiencing SI/HI." . In the ED, Ms. ___ received the following medications: . ___ 21:47 Lorazepam 0.25mg PO ___ 08:59 Prenatal 1 tab PO ___ 08:59 pyridoxine 25mg PO ___ 08:59 folic acid 1mg PO . On interview today, the pt states that she has been feeling better since arrival in the ED. Of arrival she says, "yesterday I came in because I was thinking of taking a bottle of naproxen, I didn't know if it would hurt me more or the baby." She says she didn't care who she hurt, "I just knew I wasn't safe, because I was going to hurt one of us." She says she feels better in the hospital because, "people are taking care of me." In her day-to day life she feels she takes care of everyone else, her mother, her boyfriend, and people at the ___ where she works. "It feels good to be taking care of." She cites a stressful conversation with her mother yesterday that made her feel, "really bad," when her mother said she would never see her unborn child and that she would never act as its grandmother. "It really hurt." She has also been stressed about the baby and the impact it will have on her schooling. "I worry all the time about how I will do internships and finish my classes, I have put so much time into it." The pt currently denies SI and desire to hurt her baby. "Seeing the ultrasound today made me feel better, seeing the baby moving around." She denies current symptoms of mania, AH, VH, or paranoia. . She does endorse a sense of hypervigilance on the unit. "I'm just really aware of what is going on and what people are doing. I had bad things happen to me at ___, and I've heard my mom talk about things that happened to her." She says while at ___, she had issues with roommate smuggling in drugs. She told staff at the time and being in that position made her feel unsafe. She says that she feels comfortable going to staff with any issues that come up while she is here. She endorses 1.5 months of decreased sleep, fatigue, anhedonia, and decreased concentration prior to hospitalization." Past Medical History: -Prior diagnoses: Bipolar II disorder, anxiety, trichotillomania -Hospitalizations: ___ ___ years ago -Partial hospitalizations: ___ ___ years ago after discharge from inpatient unit at ___. Another PHP in ___ a few months later due to recurrent depression. -Psychiatrist: Had first appointment with psychiatry at ___ on ___ with Dr. ___, whom she saw again today before being sent to the ___ ED. She reports that last week (on ___, ___ olanzapine, but patient was reluctant due to pregnancy. She called him again yesterday when she became concerned about her safety. Prior to that used to see ___ at ___ in ___ - last saw in ___. -Therapist: ___ at ___ in ___ - last saw in ___ - had to switch providers to ___ because she lost ___ insurance due to her income increasing;she found the therapy very helpful in the past and states that it contributed to her maintaining stable mood. -Medication trials: Patient reports trialing psychiatric medications in the past (can only remember olanzapine) but always discontinues them due to side-effects. Last time she trialed psychotropic medications was in ___: olanzapine, she discontinued it due to sedation. -___ trials: Denies -Suicide attempts: At age ___, cut right wrist with kitchen knife, but was superficial cut. Called BEST team the next day and went to ___, where she also attended ___ after discharge. Since then, has been keeping herself very busy which prevents her from thinking. -Self-injurious behavior: -Harm to others: Denies -Trauma: Abusive relationship ___ years ago with past-boyfriend, including emotional, physical, and sexual trauma. Also described being kicked out of mother's home at age ___ and being homeless for some time. -Access to weapons: Denies Social History: -Born/Raised: Born in ___, moved to ___ at 11 months and with her mother and oldest sister (who is ___ year older). -Relationship status/Children: Currently in a relationship with her boyfriend (the father of the child). -Primary Supports: Mother, though they have a strained relationship. Has other supports (older sister, grandfather, stepfather, friends) but none of them are as close as her mother. -___: Lives in own apartment in ___. Used to live with boyfriend, but asked him to move out a few months ago because "I needed my space" (he now lives with his own mother). Patient lived with mother until age ___, then mother kicked her out so patient lived in a shelter, then got her own apartment. -Education: Graduated high school and was enrolled at ___ ___ for Associate's degree in human services, but had to put studies on hold ___ years ago because of her depression and "to take care of family" (she reports that she needs to live close to her mother because she worries her mother will attempt suicide again). She still enjoys school, has 2 semesters left to complete her degree at ___, plans to pursue ___ bachelor's and PhD after that and to become a ___. -___: Currently works in ___ at the ___ in ___. Worked at the ___ prior to that. -Spiritual: identifies as Catholic, but says that "I stopped going to Church a long time ago" - explained that this was ___ years ago when she was in the abusive relationship Family History: -Psychiatric Diagnoses: Mother with bipolar disorder, older sister with depression -___ Use Disorders: Father with alcohol and substance use -Suicide Attempts/Completed Suicides: Mother attempted suicide multiple times via OD, cutting, multiple inpatient hospitalizations for mother Physical ___: GENERAL - HEENT: - normocephalic, atraumatic - dry mucous membranes, oropharynx clear, supple neck - ___ scleral icterus - Cardiovascular: - regular rate and rhythm, S1/S2 heard, ___ murmurs/rubs/gallops - distal pulses intact throughout - Pulmonary: - ___ increased work of breathing - lungs clear to auscultation bilaterally - ___ wheezes/rhonchi/rales - Abdominal: - pregnant, non-distended, bowel sounds normoactive - ___ tenderness to palpation in all quadrants - ___ guarding, ___ rebound tenderness - Extremities: - warm and well-perfused - ___ edema of the limbs - Skin: - ___ rashes or lesions noted NEUROLOGICAL - Cranial Nerves: - I: olfaction not tested - II: PERRL 3 to 2 mm, both directly and consentually; brisk bilaterally, VFF to confrontation - III, IV, VI: EOMI without nystagmus - VII: ___ 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 - ___ abnormal movements, ___ tremor - strength ___ throughout - Sensory: - ___ deficits to fine touch throughout - 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: - MOYb with 0 errors - Orientation: - oriented to person, time, place ___, psych unit), situation - Executive function ___ go, Luria, trails, FAS): - not tested - Memory: - ___ registration - ___ spontaneous recall after 5 min - long-term grossly intact - Fund of knowledge: - consistent with education - intact to last 3 presidents - Calculations: - $1.75 = 7 quarters (thinks about for a minute and calculates on fingers) - Abstraction: - "Don't judge a book by its cover" = "you have to get to know someone before you judge them." - Visuospatial: - not assessed - Language: - fluent ___ speaker, ___ paraphasic errors, appropriate to conversation MENTAL STATUS - Appearance: - appears stated age, well groomed, wearing hospital gown, long, ___ artificial fingernails - Behavior: - sitting in chair, appropriate eye contact, psychomotor slowing present - Attitude: - cooperative, engaged, help-seeking - Mood: - "I'm feeling better. I don't know how I feel." - Affect: - mood-congruent, blunted, dysthymic, appropriate to situation - Speech: - normal rate, muted volume, and normal prosody - Thought process: - linear, coherent, goal-oriented, ___ loose associations - Thought Content: - Safety: Denies current SI/HI - Delusions: ___ evidence of paranoia, etc. - Obsessions/Compulsions: ___ evidence based on current encounter - Hallucinations: Denies AVH, not appearing to be attending to internal stimuli - Insight: - limited, though pt is able to name ___ number of stressors and elements of current situation that have made her feel safer - Judgment: - limited, thoughts of hurting self and baby yesterday, but help-seeking, called psychiatrist Pertinent Results: ___ 05:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 04:20PM GLUCOSE-86 UREA N-11 CREAT-0.6 SODIUM-135 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-12 ___ 04:20PM WBC-8.4 RBC-4.05 HGB-12.7 HCT-37.5 MCV-93 MCH-31.4 MCHC-33.9 RDW-12.3 RDWSD-42.2 ___ 04:20PM NEUTS-66.5 ___ MONOS-6.4 EOS-2.3 BASOS-0.4 IM ___ AbsNeut-5.59 AbsLymp-2.01 AbsMono-0.54 AbsEos-0.19 AbsBaso-0.03 ___ 04:20PM PLT COUNT-344 ___ 07:12AM BLOOD Triglyc-86 HDL-84 CHOL/HD-2.7 LDLcalc-125 ___ 07:12AM BLOOD %HbA1c-5.4 eAG-___. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) on ___ and remained on that status throughout their admission. At that time patient was deemed to be at risk of harm to self/others due to suicidal thoughts and worsening depressed mood, anhedonia, and neurovegetative symptoms. She was placed on 15-minute check status on admission and remained on that level of observation throughout while being unit restricted. Upon suicide risk assessment evaluation, SAFE-T risk was deemed moderate to low once patient retracted all suicidal statements, appeared future oriented, help seeking, and was medication adherent. . 2. PSYCHIATRIC: #) Bipolar II Disorder, current episode depressed #) Unspecified anxiety disorder Ms. ___ is a ___ year old pregnant female (G1P0, gestational age of ~___ weeks), with hx bipolar II disorder and family hx BPAD, anxiety, trauma, with one prior psychiatric hospitalization ___ years ago in setting of suicide attempt by cutting, who was brought in to the ___ ED on a ___ from her outpatient psychiatrist's office due to SI with plan to overdose on NSAIDs. Patient endorsed depressed mood with intrusive egodystonic suicidal thoughts in the setting of various psychosocial stressors including physical discomfort secondary to pregnancy (vomiting), financial stressors, work related stressors, impact upon her academics (and subsequent academic stressors from performing poorly in school), and interpersonal conflict with her mother (in context of hx of physical and emotional abuse from her mother). . On initial presentation, patient appeared to be isolative, was not seen often participating in other OT lead group sessions or within the milieu. Her isolated behavior was also associated with severe anxiety, impaired sleep, poor appetite, and frequent anxious ruminative thoughts that were distressing and often oriented around her future. However, during the course of this admission, patient started leaving her room more frequently, was more visible in the milieu, and was willing to develop new coping mechanisms that she had learned during group therapy sessions. She expressed interest in continuing therapy in the outpatient setting and wanted to utilize her admission as an opportunity to start new medications while developing new coping mechanisms. As such, patient was started on Abilify 2 mg nightly, which she tolerated with ___ reported adverse effects. She was additionally offered vistaril 25 mg Q4H:PRN for anxiety and nausea, as she suffered from hyperemesis gravidarum and had difficulty tolerating her perenatal vitamins/folic acid supplementation. . While admitted, patient additionally reported that her mood had improved and she appeared more future oriented with an intact sense of self-worth. She did note that she had multiple conversations with her boyfriend who reported that he would help support her financially so that she would not have to return to work if she decided that would be most beneficial to her. She reported that work was a major stressor for her given perceived lack of support from the administration. Mental status exam initially was significant for monotonous, soft speech, dysthymic and constricted (though reactive) affect, with psychomotor slowing concerning for neurovegative symptoms. Patient reported impaired sleep and concentration though cognitive exam was intact. Prior to discharge, patient reported improved Ms. ___ endorses improvement in mood, appetite, and resolution of suicidal thoughts. She is future oriented and demonstrates a number of protective factors including interest in parenting/pregnancy preparedness classes, continued follow up with outpatient psychiatrist, and treatment with aripiprazole. While she continues to have a strained relationship with her mother, she identifies her sister and boyfriend as strong social supports. . Diagnostically, presentation is concerning for bipolar II disorder, current episode depressed, severe. Patient's presentation is further complicated by pregnancy. Patient of note initially presented with active suicidal ideation with plan to harm herself, but has since retracted initial suicidal statements, appears more future oriented and willing to develop new coping strategies. She appears help seeking and would benefit from continued outpatient therapy and medication management. We arranged for outpatient partial program treatment at ___. . 3. SUBSTANCE USE DISORDERS: Patient has hx of cannabis use, but stopped smoking cannabis when she found out she was pregnant. ___ longer actively uses substances. We encouraged development and maintenance of positive coping mechanisms in lieu of substance use. Follow up with PCP and ___ program for continued substance use counseling. . 4. MEDICAL #R flank pain- Resolved prior to discharge. - Patient reported right sided flank pain with soreness worsened by cough and improved with Tylenol and heating pad administration. ___ focal concerns on exam, ___ CVA tenderness. Treated with Tylenol ___ mg Q6H:PRN for moderate to severe pain Heating pad PRN. . #Viral upper respiratory infection - Patient reported cough and congestion x1 week - Offered saline spray PRN for nasal congestion - Offered cepecol lozenges PRN and guanfesein PRN . #Vomiting Pt states that she vomited in ED and continues to experience nausea. BMP ordered to monitor for signs of metabolic derangement which was within normal limits. Intermittent association with food and water. Continues to occur with Folate and B6. Does not appear to be consistent with hyperemesis gravidarum and appears more anxiety related. Provided IV fluids and anti-nausea medications which improved allowing patient to tolerate food prior to discharge. OB to continue to monitor weight and appetite on discharge. #Pregnancy -Per OB note, regular fetal monitoring was not required -Continued Folic acid ___ PO daily -Continued prenatal vitamins -Next ultrasound for ___ at ___ appointment. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. Initially patient was minimally interactive in group sessions. She exhibited isolative and avoidant behaviors, secondary to hypersomnolence, pain, and discomfort along with anhedonic sx. During the course of her hospitalization however patient eventually began participating more frequently in group sessions. She demonstrated improvement in insight, participated more often in coping skills group, and her affect appeared brighter. . #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT Patient has a Case Manger ___ (___) from ___ through ___ to discuss resources/support upon discharge. . #) INTERVENTIONS - Medications: Aripiprazole - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: PHP Referral: ___ - Partial Hospital Program (Women's Program) ___ P: ___ F: ___ Start date: ___ at 8:15am Program hours: M-F from 10:00 a.m. to 3:15 p.m. Breakfast and lunch are provided. - Behavioral Interventions: Group therapy, coping skills -Guardianships: None PCP ___ MMF ___ Aripiprazole INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication (*Would consider specifically mention discussing black box warnings/very dangerous side effects), and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT & PROGNOSIS On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon active suicidal ideation. Her static factors noted at that time include: - History of suicide attempts - History of abuse - Chronic mental illness - Age - Marital status (single) - Family history of suicide attempt. We addressed the following modifiable risk factors with daily motivational interviewing, encouragement of therapy led groups, medication adjustment, and arrangement of ___ with outpatient providers with resolution of the following: - Suicidal ideation - Medication noncompliance - Poorly controlled mental illness - Hopelessness - Limited social supports - Feeling trapped Patient has the following protective factors which decrease risk of harm to self: Protective Factors - Help-seeking nature - Sense of responsibility to family - Pregnancy - ___ irritability/agitation - ___ rage/anger/revenge - Good problem-solving skills - Positive therapeutic relationship with outpatient providers - ___ history of substance use disorder Overall, based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY 2. Pyridoxine 25 mg PO TID nausea/vomiting 3. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. ARIPiprazole 2 mg PO QHS mood disorder RX aripiprazole [Abilify] 2 mg 1 tablet(s) by mouth at bedtime Disp #14 Tablet Refills:0 3. HydrOXYzine 10 mg PO Q4H:PRN anxiety, nausea RX hydroxyzine HCl 10 mg 10 mg by mouth every 4 hours as needed Disp #20 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 5. Pyridoxine 25 mg PO TID:PRN nausea/vomiting 6. FoLIC Acid 1 mg PO DAILY 7. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Bipolar Disorder Type II, current episode depressed Unspecified Anxiety Disorder Discharge Condition: Mental Status: -Appearance: female appearing slightly older than stated age, well groomed, good hygiene, appropriate eye contact, ___ psychomotor agitation or retardation -Attitude: Cooperative, engaged, friendly -Mood: 'better' -Affect: congruent, euthymic, constricted, reactive, tearful at times, appropriate to situation -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, ___ loose associations. Rumination on vomiting. -Thought Content: ---Safety: Denies SI/HI ---Delusions: ___ evidence of paranoia, etc. ---Obsessions/Compulsions: ___ evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: fair Cognition: -Wakefulness/alertness: Awake and alert -Attention: Not formally assessed but attentive to interview -Orientation: Oriented to person, time, place, situation -Executive function: Not assessed -Memory: Not formally assessed but intact to interview -Language: Native ___ speaker, ___ paraphasic errors, appropriate to conversation Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: ___	[ "O99341", "F3181", "R45851", "Z3A11", "F4322", "F1211", "R109", "O99511", "J069", "O218", "Z818", "R4584", "Z811" ]	Allergies: [MASKED] Known Allergies / Adverse Drug Reactions Chief Complaint: "I wasn't thinking clearly." Major Surgical or Invasive Procedure: None History of Present Illness: Per admitting physician: "Ms. [MASKED] is a [MASKED] year old pregnant female (gestational age of [MASKED] 2days) with history of bipolar II disorder, anxiety, and trauma, with one prior psychiatric hospitalization [MASKED] years ago in setting of suicide attempt by [MASKED], who was brought in to the [MASKED] ED on a [MASKED] from her outpatient psychiatrist's office due to SI with plan to overdose on OTC medications. . Ms. [MASKED] reports worsening depression and anxiety due to numerous psychosocial stressors. She described her pregnancy as a big stressor, because she is not able to return to school to finish her Associate's Degree. She described additional stress from working for a [MASKED] and having a very high workload with long hours; she does not feel supported by the staff at the [MASKED]. Furthermore, she has had daily nausea and vomiting since becoming pregnant with inability to eat or even take dietary supplements. Overall, she stated that she feels the pregnancy is "a step back" in her life. She reports experiencing severe hopelessness and SI with plan to overdose on naproxen yesterday and today. Upon further discussion, she expressed HI towards the fetus "I thought that if I do that, the baby will go away". She reports that she is still experiencing those thoughts and that she was worried about acting on them ("I don't want to make a mistake"). She described that she avoids keeping medications in the house due to fear of attempting suicide - the fear is related to her mother's history of multiple SAs and patient's own SA from [MASKED] years ago. She describes that she has bottle of naproxen at home. . Ms. [MASKED] described that her SI was worsened significantly by a conflict with her mother yesterday when her mother "said some hurtful things which triggered me to back when I was suicidal". Also described stress from needing to move to a new apartment in [MASKED]. . Patient describes [MASKED] weeks of not being able to fall asleep until [MASKED] AM (ruminating about whether she would finish school, if she would be a good mother), feeling tired, with amotivation, poor concentration, and inability to go to work: not been at work since [MASKED]. Had other work interruptions in past [MASKED] weeks. She also reports anhedonia, stating that the only thing that she looks forward to is finishing her associate's degree, does not enjoy anything anymore, and is not looking forward to having her baby. She also reported poor appetite, saying she eats "because I have to eat". . She describes losing 45lbs (from 145lbs to 100lbs) [MASKED] years ago due to depression while being in an abusive relationship. Denies significant weight loss currently, stating that she weighs 115lbs and that her OBGYN is not concerned about the weight. She described repeated visits to [MASKED] for IV fluids due to significant nausea and vomiting throughout the 11 weeks of pregnancy. . However, patient also reported that yesterday she was she was "happy, energetic, was around family, had a photo shoot" to announce her pregnancy. Then she went home yesterday, had the fight with her mother, and began experiencing SI/HI." . In the ED, Ms. [MASKED] received the following medications: . [MASKED] 21:47 Lorazepam 0.25mg PO [MASKED] 08:59 Prenatal 1 tab PO [MASKED] 08:59 pyridoxine 25mg PO [MASKED] 08:59 folic acid 1mg PO . On interview today, the pt states that she has been feeling better since arrival in the ED. Of arrival she says, "yesterday I came in because I was thinking of taking a bottle of naproxen, I didn't know if it would hurt me more or the baby." She says she didn't care who she hurt, "I just knew I wasn't safe, because I was going to hurt one of us." She says she feels better in the hospital because, "people are taking care of me." In her day-to day life she feels she takes care of everyone else, her mother, her boyfriend, and people at the [MASKED] where she works. "It feels good to be taking care of." She cites a stressful conversation with her mother yesterday that made her feel, "really bad," when her mother said she would never see her unborn child and that she would never act as its grandmother. "It really hurt." She has also been stressed about the baby and the impact it will have on her schooling. "I worry all the time about how I will do internships and finish my classes, I have put so much time into it." The pt currently denies SI and desire to hurt her baby. "Seeing the ultrasound today made me feel better, seeing the baby moving around." She denies current symptoms of mania, AH, VH, or paranoia. . She does endorse a sense of hypervigilance on the unit. "I'm just really aware of what is going on and what people are doing. I had bad things happen to me at [MASKED], and I've heard my mom talk about things that happened to her." She says while at [MASKED], she had issues with roommate smuggling in drugs. She told staff at the time and being in that position made her feel unsafe. She says that she feels comfortable going to staff with any issues that come up while she is here. She endorses 1.5 months of decreased sleep, fatigue, anhedonia, and decreased concentration prior to hospitalization." Past Medical History: -Prior diagnoses: Bipolar II disorder, anxiety, trichotillomania -Hospitalizations: [MASKED] [MASKED] years ago -Partial hospitalizations: [MASKED] [MASKED] years ago after discharge from inpatient unit at [MASKED]. Another PHP in [MASKED] a few months later due to recurrent depression. -Psychiatrist: Had first appointment with psychiatry at [MASKED] on [MASKED] with Dr. [MASKED], whom she saw again today before being sent to the [MASKED] ED. She reports that last week (on [MASKED], [MASKED] olanzapine, but patient was reluctant due to pregnancy. She called him again yesterday when she became concerned about her safety. Prior to that used to see [MASKED] at [MASKED] in [MASKED] - last saw in [MASKED]. -Therapist: [MASKED] at [MASKED] in [MASKED] - last saw in [MASKED] - had to switch providers to [MASKED] because she lost [MASKED] insurance due to her income increasing;she found the therapy very helpful in the past and states that it contributed to her maintaining stable mood. -Medication trials: Patient reports trialing psychiatric medications in the past (can only remember olanzapine) but always discontinues them due to side-effects. Last time she trialed psychotropic medications was in [MASKED]: olanzapine, she discontinued it due to sedation. -[MASKED] trials: Denies -Suicide attempts: At age [MASKED], cut right wrist with kitchen knife, but was superficial cut. Called BEST team the next day and went to [MASKED], where she also attended [MASKED] after discharge. Since then, has been keeping herself very busy which prevents her from thinking. -Self-injurious behavior: -Harm to others: Denies -Trauma: Abusive relationship [MASKED] years ago with past-boyfriend, including emotional, physical, and sexual trauma. Also described being kicked out of mother's home at age [MASKED] and being homeless for some time. -Access to weapons: Denies Social History: -Born/Raised: Born in [MASKED], moved to [MASKED] at 11 months and with her mother and oldest sister (who is [MASKED] year older). -Relationship status/Children: Currently in a relationship with her boyfriend (the father of the child). -Primary Supports: Mother, though they have a strained relationship. Has other supports (older sister, grandfather, stepfather, friends) but none of them are as close as her mother. -[MASKED]: Lives in own apartment in [MASKED]. Used to live with boyfriend, but asked him to move out a few months ago because "I needed my space" (he now lives with his own mother). Patient lived with mother until age [MASKED], then mother kicked her out so patient lived in a shelter, then got her own apartment. -Education: Graduated high school and was enrolled at [MASKED] [MASKED] for Associate's degree in human services, but had to put studies on hold [MASKED] years ago because of her depression and "to take care of family" (she reports that she needs to live close to her mother because she worries her mother will attempt suicide again). She still enjoys school, has 2 semesters left to complete her degree at [MASKED], plans to pursue [MASKED] bachelor's and PhD after that and to become a [MASKED]. -[MASKED]: Currently works in [MASKED] at the [MASKED] in [MASKED]. Worked at the [MASKED] prior to that. -Spiritual: identifies as Catholic, but says that "I stopped going to Church a long time ago" - explained that this was [MASKED] years ago when she was in the abusive relationship Family History: -Psychiatric Diagnoses: Mother with bipolar disorder, older sister with depression -[MASKED] Use Disorders: Father with alcohol and substance use -Suicide Attempts/Completed Suicides: Mother attempted suicide multiple times via OD, cutting, multiple inpatient hospitalizations for mother Physical [MASKED]: GENERAL - HEENT: - normocephalic, atraumatic - dry mucous membranes, oropharynx clear, supple neck - [MASKED] scleral icterus - Cardiovascular: - regular rate and rhythm, S1/S2 heard, [MASKED] murmurs/rubs/gallops - distal pulses intact throughout - Pulmonary: - [MASKED] increased work of breathing - lungs clear to auscultation bilaterally - [MASKED] wheezes/rhonchi/rales - Abdominal: - pregnant, non-distended, bowel sounds normoactive - [MASKED] tenderness to palpation in all quadrants - [MASKED] guarding, [MASKED] rebound tenderness - Extremities: - warm and well-perfused - [MASKED] edema of the limbs - Skin: - [MASKED] rashes or lesions noted NEUROLOGICAL - Cranial Nerves: - I: olfaction not tested - II: PERRL 3 to 2 mm, both directly and consentually; brisk bilaterally, VFF to confrontation - III, IV, VI: EOMI without nystagmus - VII: [MASKED] 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 - [MASKED] abnormal movements, [MASKED] tremor - strength [MASKED] throughout - Sensory: - [MASKED] deficits to fine touch throughout - 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: - MOYb with 0 errors - Orientation: - oriented to person, time, place [MASKED], psych unit), situation - Executive function [MASKED] go, Luria, trails, FAS): - not tested - Memory: - [MASKED] registration - [MASKED] spontaneous recall after 5 min - long-term grossly intact - Fund of knowledge: - consistent with education - intact to last 3 presidents - Calculations: - $1.75 = 7 quarters (thinks about for a minute and calculates on fingers) - Abstraction: - "Don't judge a book by its cover" = "you have to get to know someone before you judge them." - Visuospatial: - not assessed - Language: - fluent [MASKED] speaker, [MASKED] paraphasic errors, appropriate to conversation MENTAL STATUS - Appearance: - appears stated age, well groomed, wearing hospital gown, long, [MASKED] artificial fingernails - Behavior: - sitting in chair, appropriate eye contact, psychomotor slowing present - Attitude: - cooperative, engaged, help-seeking - Mood: - "I'm feeling better. I don't know how I feel." - Affect: - mood-congruent, blunted, dysthymic, appropriate to situation - Speech: - normal rate, muted volume, and normal prosody - Thought process: - linear, coherent, goal-oriented, [MASKED] loose associations - Thought Content: - Safety: Denies current SI/HI - Delusions: [MASKED] evidence of paranoia, etc. - Obsessions/Compulsions: [MASKED] evidence based on current encounter - Hallucinations: Denies AVH, not appearing to be attending to internal stimuli - Insight: - limited, though pt is able to name [MASKED] number of stressors and elements of current situation that have made her feel safer - Judgment: - limited, thoughts of hurting self and baby yesterday, but help-seeking, called psychiatrist Pertinent Results: [MASKED] 05:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 04:20PM GLUCOSE-86 UREA N-11 CREAT-0.6 SODIUM-135 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-12 [MASKED] 04:20PM WBC-8.4 RBC-4.05 HGB-12.7 HCT-37.5 MCV-93 MCH-31.4 MCHC-33.9 RDW-12.3 RDWSD-42.2 [MASKED] 04:20PM NEUTS-66.5 [MASKED] MONOS-6.4 EOS-2.3 BASOS-0.4 IM [MASKED] AbsNeut-5.59 AbsLymp-2.01 AbsMono-0.54 AbsEos-0.19 AbsBaso-0.03 [MASKED] 04:20PM PLT COUNT-344 [MASKED] 07:12AM BLOOD Triglyc-86 HDL-84 CHOL/HD-2.7 LDLcalc-125 [MASKED] 07:12AM BLOOD %HbA1c-5.4 eAG-[MASKED]. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) on [MASKED] and remained on that status throughout their admission. At that time patient was deemed to be at risk of harm to self/others due to suicidal thoughts and worsening depressed mood, anhedonia, and neurovegetative symptoms. She was placed on 15-minute check status on admission and remained on that level of observation throughout while being unit restricted. Upon suicide risk assessment evaluation, SAFE-T risk was deemed moderate to low once patient retracted all suicidal statements, appeared future oriented, help seeking, and was medication adherent. . 2. PSYCHIATRIC: #) Bipolar II Disorder, current episode depressed #) Unspecified anxiety disorder Ms. [MASKED] is a [MASKED] year old pregnant female (G1P0, gestational age of ~[MASKED] weeks), with hx bipolar II disorder and family hx BPAD, anxiety, trauma, with one prior psychiatric hospitalization [MASKED] years ago in setting of suicide attempt by cutting, who was brought in to the [MASKED] ED on a [MASKED] from her outpatient psychiatrist's office due to SI with plan to overdose on NSAIDs. Patient endorsed depressed mood with intrusive egodystonic suicidal thoughts in the setting of various psychosocial stressors including physical discomfort secondary to pregnancy (vomiting), financial stressors, work related stressors, impact upon her academics (and subsequent academic stressors from performing poorly in school), and interpersonal conflict with her mother (in context of hx of physical and emotional abuse from her mother). . On initial presentation, patient appeared to be isolative, was not seen often participating in other OT lead group sessions or within the milieu. Her isolated behavior was also associated with severe anxiety, impaired sleep, poor appetite, and frequent anxious ruminative thoughts that were distressing and often oriented around her future. However, during the course of this admission, patient started leaving her room more frequently, was more visible in the milieu, and was willing to develop new coping mechanisms that she had learned during group therapy sessions. She expressed interest in continuing therapy in the outpatient setting and wanted to utilize her admission as an opportunity to start new medications while developing new coping mechanisms. As such, patient was started on Abilify 2 mg nightly, which she tolerated with [MASKED] reported adverse effects. She was additionally offered vistaril 25 mg Q4H:PRN for anxiety and nausea, as she suffered from hyperemesis gravidarum and had difficulty tolerating her perenatal vitamins/folic acid supplementation. . While admitted, patient additionally reported that her mood had improved and she appeared more future oriented with an intact sense of self-worth. She did note that she had multiple conversations with her boyfriend who reported that he would help support her financially so that she would not have to return to work if she decided that would be most beneficial to her. She reported that work was a major stressor for her given perceived lack of support from the administration. Mental status exam initially was significant for monotonous, soft speech, dysthymic and constricted (though reactive) affect, with psychomotor slowing concerning for neurovegative symptoms. Patient reported impaired sleep and concentration though cognitive exam was intact. Prior to discharge, patient reported improved Ms. [MASKED] endorses improvement in mood, appetite, and resolution of suicidal thoughts. She is future oriented and demonstrates a number of protective factors including interest in parenting/pregnancy preparedness classes, continued follow up with outpatient psychiatrist, and treatment with aripiprazole. While she continues to have a strained relationship with her mother, she identifies her sister and boyfriend as strong social supports. . Diagnostically, presentation is concerning for bipolar II disorder, current episode depressed, severe. Patient's presentation is further complicated by pregnancy. Patient of note initially presented with active suicidal ideation with plan to harm herself, but has since retracted initial suicidal statements, appears more future oriented and willing to develop new coping strategies. She appears help seeking and would benefit from continued outpatient therapy and medication management. We arranged for outpatient partial program treatment at [MASKED]. . 3. SUBSTANCE USE DISORDERS: Patient has hx of cannabis use, but stopped smoking cannabis when she found out she was pregnant. [MASKED] longer actively uses substances. We encouraged development and maintenance of positive coping mechanisms in lieu of substance use. Follow up with PCP and [MASKED] program for continued substance use counseling. . 4. MEDICAL #R flank pain- Resolved prior to discharge. - Patient reported right sided flank pain with soreness worsened by cough and improved with Tylenol and heating pad administration. [MASKED] focal concerns on exam, [MASKED] CVA tenderness. Treated with Tylenol [MASKED] mg Q6H:PRN for moderate to severe pain Heating pad PRN. . #Viral upper respiratory infection - Patient reported cough and congestion x1 week - Offered saline spray PRN for nasal congestion - Offered cepecol lozenges PRN and guanfesein PRN . #Vomiting Pt states that she vomited in ED and continues to experience nausea. BMP ordered to monitor for signs of metabolic derangement which was within normal limits. Intermittent association with food and water. Continues to occur with Folate and B6. Does not appear to be consistent with hyperemesis gravidarum and appears more anxiety related. Provided IV fluids and anti-nausea medications which improved allowing patient to tolerate food prior to discharge. OB to continue to monitor weight and appetite on discharge. #Pregnancy -Per OB note, regular fetal monitoring was not required -Continued Folic acid [MASKED] PO daily -Continued prenatal vitamins -Next ultrasound for [MASKED] at [MASKED] appointment. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. Initially patient was minimally interactive in group sessions. She exhibited isolative and avoidant behaviors, secondary to hypersomnolence, pain, and discomfort along with anhedonic sx. During the course of her hospitalization however patient eventually began participating more frequently in group sessions. She demonstrated improvement in insight, participated more often in coping skills group, and her affect appeared brighter. . #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT Patient has a Case Manger [MASKED] ([MASKED]) from [MASKED] through [MASKED] to discuss resources/support upon discharge. . #) INTERVENTIONS - Medications: Aripiprazole - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: PHP Referral: [MASKED] - Partial Hospital Program (Women's Program) [MASKED] P: [MASKED] F: [MASKED] Start date: [MASKED] at 8:15am Program hours: M-F from 10:00 a.m. to 3:15 p.m. Breakfast and lunch are provided. - Behavioral Interventions: Group therapy, coping skills -Guardianships: None PCP [MASKED] MMF [MASKED] Aripiprazole INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication (*Would consider specifically mention discussing black box warnings/very dangerous side effects), and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT & PROGNOSIS On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon active suicidal ideation. Her static factors noted at that time include: - History of suicide attempts - History of abuse - Chronic mental illness - Age - Marital status (single) - Family history of suicide attempt. We addressed the following modifiable risk factors with daily motivational interviewing, encouragement of therapy led groups, medication adjustment, and arrangement of [MASKED] with outpatient providers with resolution of the following: - Suicidal ideation - Medication noncompliance - Poorly controlled mental illness - Hopelessness - Limited social supports - Feeling trapped Patient has the following protective factors which decrease risk of harm to self: Protective Factors - Help-seeking nature - Sense of responsibility to family - Pregnancy - [MASKED] irritability/agitation - [MASKED] rage/anger/revenge - Good problem-solving skills - Positive therapeutic relationship with outpatient providers - [MASKED] history of substance use disorder Overall, based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY 2. Pyridoxine 25 mg PO TID nausea/vomiting 3. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. ARIPiprazole 2 mg PO QHS mood disorder RX aripiprazole [Abilify] 2 mg 1 tablet(s) by mouth at bedtime Disp #14 Tablet Refills:0 3. HydrOXYzine 10 mg PO Q4H:PRN anxiety, nausea RX hydroxyzine HCl 10 mg 10 mg by mouth every 4 hours as needed Disp #20 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 5. Pyridoxine 25 mg PO TID:PRN nausea/vomiting 6. FoLIC Acid 1 mg PO DAILY 7. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Bipolar Disorder Type II, current episode depressed Unspecified Anxiety Disorder Discharge Condition: Mental Status: -Appearance: female appearing slightly older than stated age, well groomed, good hygiene, appropriate eye contact, [MASKED] psychomotor agitation or retardation -Attitude: Cooperative, engaged, friendly -Mood: 'better' -Affect: congruent, euthymic, constricted, reactive, tearful at times, appropriate to situation -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, [MASKED] loose associations. Rumination on vomiting. -Thought Content: ---Safety: Denies SI/HI ---Delusions: [MASKED] evidence of paranoia, etc. ---Obsessions/Compulsions: [MASKED] evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: fair Cognition: -Wakefulness/alertness: Awake and alert -Attention: Not formally assessed but attentive to interview -Orientation: Oriented to person, time, place, situation -Executive function: Not assessed -Memory: Not formally assessed but intact to interview -Language: Native [MASKED] speaker, [MASKED] paraphasic errors, appropriate to conversation Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED]	[]	[]	[ "O99341: Other mental disorders complicating pregnancy, first trimester", "F3181: Bipolar II disorder", "R45851: Suicidal ideations", "Z3A11: 11 weeks gestation of pregnancy", "F4322: Adjustment disorder with anxiety", "F1211: Cannabis abuse, in remission", "R109: Unspecified abdominal pain", "O99511: Diseases of the respiratory system complicating pregnancy, first trimester", "J069: Acute upper respiratory infection, unspecified", "O218: Other vomiting complicating pregnancy", "Z818: Family history of other mental and behavioral disorders", "R4584: Anhedonia", "Z811: Family history of alcohol abuse and dependence" ]
10,043,622	23,527,228	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP Pertinent Results: ___ 05:44PM WBC-9.3 RBC-4.38 HGB-12.9 HCT-37.9 MCV-87 MCH-29.5 MCHC-34.0 RDW-13.4 RDWSD-41.7 ___ 05:44PM NEUTS-59.2 ___ MONOS-10.3 EOS-0.9* BASOS-0.2 IM ___ AbsNeut-5.53# AbsLymp-2.67 AbsMono-0.96* AbsEos-0.08 AbsBaso-0.02 ___ 05:44PM PLT COUNT-253 ___ 10:00PM ___ PO2-28* PCO2-42 PH-7.41 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA ___ 10:00PM LACTATE-1.6 ___ 09:21PM GLUCOSE-254* UREA N-17 CREAT-0.6 SODIUM-136 POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-24 ANION GAP-19 ___ 09:21PM estGFR-Using this ___ 09:21PM WBC-15.9* RBC-4.26 HGB-13.0 HCT-37.1 MCV-87 MCH-30.5 MCHC-35.0 RDW-13.3 RDWSD-41.5 ___ 09:21PM PLT COUNT-269 ___ 08:20PM URINE HOURS-RANDOM ___ 08:20PM URINE UCG-NEGATIVE ___ 08:20PM URINE UHOLD-HOLD ___ 08:20PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 08:20PM URINE RBC-6* WBC-<1 BACTERIA-NONE YEAST-MOD EPI-3 ___ 08:20PM URINE MUCOUS-RARE Brief Hospital Course: On ___ MS. ___ was admitted to the Gynecology service from the Emergency Department. She received IV morphine in the ED for pain control. A UA was negative for infection however showed red blood cells. An initial pelvic ultrasound showed "Impression: Asymmetric enlargement of the left ovary compared to the right without detection of vascular flow, concerning for ovarian torsion. Small amount of simple left adnexal free fluid." A chest Xray showed was negative. A CT scan showed "Impression: 1. No nephrolithiasis or ureterolithiasis. 2. Asymmetric enlargement and hypodensity of the left ovary is also seen on pelvic ultrasound from the same day, and may reflect non vascularity seen on that exam." A repeat pelvic ultrasound on ___ showed "Impression: Essentially unchanged exam compared to the pelvic ultrasound from 6 hours prior, with asymmetry of the ovaries. No detectable left ovarian vascularity. Given no interval change, suspicion for torsion is low. Additionally, the ovary does not look particularly edematous, and decreased or undetectable ovarian blood flow can be seen in postmenopausal woman. I think that torsion is unlikely though not entirely excluded." Her WBC count was initial 15.9, however downtrended to 9.3. For her diabetes, she was placed on an insulin sliding scale and her blood glucose was monitored. Her pain was controlled with Tylenol and toradol. She was initially kept NPO for possible procedure, however her vital signs remained stable and her pain remained well controlled. On hospital day 1 her diet was advanced and she tolerated this well. She was discharged to home in stable condition with outpatient follow-up as scheduled. Medications on Admission: Lantus 20 QHS, pioglitazone, glimpiride Discharge Medications: 1. Acetaminophen ___ mg PO Q6H Do not exceed 4,000mg in 24 hours. RX acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #50 Tablet Refills:1 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Take with food or milk. RX ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #50 Tablet Refills:1 Discharge Disposition: Home Discharge Diagnosis: abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to the gynecology service. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___	[ "R1032", "M549", "E119", "Z794" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP Pertinent Results: [MASKED] 05:44PM WBC-9.3 RBC-4.38 HGB-12.9 HCT-37.9 MCV-87 MCH-29.5 MCHC-34.0 RDW-13.4 RDWSD-41.7 [MASKED] 05:44PM NEUTS-59.2 [MASKED] MONOS-10.3 EOS-0.9* BASOS-0.2 IM [MASKED] AbsNeut-5.53# AbsLymp-2.67 AbsMono-0.96* AbsEos-0.08 AbsBaso-0.02 [MASKED] 05:44PM PLT COUNT-253 [MASKED] 10:00PM [MASKED] PO2-28* PCO2-42 PH-7.41 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA [MASKED] 10:00PM LACTATE-1.6 [MASKED] 09:21PM GLUCOSE-254* UREA N-17 CREAT-0.6 SODIUM-136 POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-24 ANION GAP-19 [MASKED] 09:21PM estGFR-Using this [MASKED] 09:21PM WBC-15.9* RBC-4.26 HGB-13.0 HCT-37.1 MCV-87 MCH-30.5 MCHC-35.0 RDW-13.3 RDWSD-41.5 [MASKED] 09:21PM PLT COUNT-269 [MASKED] 08:20PM URINE HOURS-RANDOM [MASKED] 08:20PM URINE UCG-NEGATIVE [MASKED] 08:20PM URINE UHOLD-HOLD [MASKED] 08:20PM URINE COLOR-Yellow APPEAR-Hazy SP [MASKED] [MASKED] 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 08:20PM URINE RBC-6* WBC-<1 BACTERIA-NONE YEAST-MOD EPI-3 [MASKED] 08:20PM URINE MUCOUS-RARE Brief Hospital Course: On [MASKED] MS. [MASKED] was admitted to the Gynecology service from the Emergency Department. She received IV morphine in the ED for pain control. A UA was negative for infection however showed red blood cells. An initial pelvic ultrasound showed "Impression: Asymmetric enlargement of the left ovary compared to the right without detection of vascular flow, concerning for ovarian torsion. Small amount of simple left adnexal free fluid." A chest Xray showed was negative. A CT scan showed "Impression: 1. No nephrolithiasis or ureterolithiasis. 2. Asymmetric enlargement and hypodensity of the left ovary is also seen on pelvic ultrasound from the same day, and may reflect non vascularity seen on that exam." A repeat pelvic ultrasound on [MASKED] showed "Impression: Essentially unchanged exam compared to the pelvic ultrasound from 6 hours prior, with asymmetry of the ovaries. No detectable left ovarian vascularity. Given no interval change, suspicion for torsion is low. Additionally, the ovary does not look particularly edematous, and decreased or undetectable ovarian blood flow can be seen in postmenopausal woman. I think that torsion is unlikely though not entirely excluded." Her WBC count was initial 15.9, however downtrended to 9.3. For her diabetes, she was placed on an insulin sliding scale and her blood glucose was monitored. Her pain was controlled with Tylenol and toradol. She was initially kept NPO for possible procedure, however her vital signs remained stable and her pain remained well controlled. On hospital day 1 her diet was advanced and she tolerated this well. She was discharged to home in stable condition with outpatient follow-up as scheduled. Medications on Admission: Lantus 20 QHS, pioglitazone, glimpiride Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H Do not exceed 4,000mg in 24 hours. RX acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hours Disp #50 Tablet Refills:1 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Take with food or milk. RX ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #50 Tablet Refills:1 Discharge Disposition: Home Discharge Diagnosis: abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were admitted to the gynecology service. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. [MASKED] office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]	[]	[ "E119", "Z794" ]	[ "R1032: Left lower quadrant pain", "M549: Dorsalgia, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin" ]
10,043,967	20,396,288	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: almonds Attending: ___ Chief Complaint: left knee arthrofibrosis Major Surgical or Invasive Procedure: ___: left knee manipulation under anesthesia History of Present Illness: ___ year old male with history of L TKA ___, ___ with left knee arthrofibrosis who presents for left knee manipulation under anesthesia. Past Medical History: Dyslipidemia, OSA (tested positive ___ years ago), seasonal allergies, headaches (occasional), h/o kidney stones, BPH (w/elevated PSA), BCC, s/p right knee meniscectomy (___), left knee meniscectomy (___), right L4-5 discectomy (___), L5-S1 laminectomy & fusion (___), right shoulder surgery (___), lithotripsy, vasectomy (___), tonsillectomy (age ___ Social History: ___ Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision stable * Thigh soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Postoperative course was remarkable Otherwise, pain was controlled with an epidural post-operatively. It was discontinued on POD#1 and he was transitioned to oral pain medications. The foley was discontinued on POD#1 and the patient was able to void independently. The patient was seen by physical therapy. 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 pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Wean assistive devices as able. Mr. ___ is discharged to home with outpatient physical therapy in stable condition. Medications on Admission: 1. Tamsulosin 0.4 mg PO BID 2. Atorvastatin 10 mg PO QPM 3. Vitamin D ___ UNIT PO DAILY 4. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp #100 Tablet Refills:0 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate no drinking alcohol or driving while taking this medication RX oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #84 Tablet Refills:0 3. Atorvastatin 10 mg PO QPM 4. Multivitamins 1 TAB PO DAILY 5. Tamsulosin 0.4 mg PO BID 6. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: left knee arthrofibrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Wean assistive device as able. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Followup Instructions: ___	[ "M24662", "Z96652", "G8918", "Z85828", "R319", "E669", "Z6837", "Z87891", "E785", "G4733", "Z87442", "N400" ]	Allergies: almonds Chief Complaint: left knee arthrofibrosis Major Surgical or Invasive Procedure: [MASKED]: left knee manipulation under anesthesia History of Present Illness: [MASKED] year old male with history of L TKA [MASKED], [MASKED] with left knee arthrofibrosis who presents for left knee manipulation under anesthesia. Past Medical History: Dyslipidemia, OSA (tested positive [MASKED] years ago), seasonal allergies, headaches (occasional), h/o kidney stones, BPH (w/elevated PSA), BCC, s/p right knee meniscectomy ([MASKED]), left knee meniscectomy ([MASKED]), right L4-5 discectomy ([MASKED]), L5-S1 laminectomy & fusion ([MASKED]), right shoulder surgery ([MASKED]), lithotripsy, vasectomy ([MASKED]), tonsillectomy (age [MASKED] Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision stable * Thigh soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Postoperative course was remarkable Otherwise, pain was controlled with an epidural post-operatively. It was discontinued on POD#1 and he was transitioned to oral pain medications. The foley was discontinued on POD#1 and the patient was able to void independently. The patient was seen by physical therapy. 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 pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Wean assistive devices as able. Mr. [MASKED] is discharged to home with outpatient physical therapy in stable condition. Medications on Admission: 1. Tamsulosin 0.4 mg PO BID 2. Atorvastatin 10 mg PO QPM 3. Vitamin D [MASKED] UNIT PO DAILY 4. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp #100 Tablet Refills:0 2. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate no drinking alcohol or driving while taking this medication RX oxycodone 5 mg [MASKED] tablet(s) by mouth every 4 hours Disp #84 Tablet Refills:0 3. Atorvastatin 10 mg PO QPM 4. Multivitamins 1 TAB PO DAILY 5. Tamsulosin 0.4 mg PO BID 6. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: left knee arthrofibrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Wean assistive device as able. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Followup Instructions: [MASKED]	[]	[ "E669", "Z87891", "E785", "G4733", "N400" ]	[ "M24662: Ankylosis, left knee", "Z96652: Presence of left artificial knee joint", "G8918: Other acute postprocedural pain", "Z85828: Personal history of other malignant neoplasm of skin", "R319: Hematuria, unspecified", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z87442: Personal history of urinary calculi", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms" ]
10,043,967	27,111,422	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: almonds Attending: ___ Chief Complaint: left knee osteoarthritis/pain Major Surgical or Invasive Procedure: ___: left total knee arthroplasty History of Present Illness: ___ year old male w/left knee osteoarthritis/pain who failed conservative measures, now admitted for left total knee arthroplasty. Past Medical History: Dyslipidemia, OSA (tested positive ___ years ago), seasonal allergies, headaches (occasional), h/o kidney stones, BPH (w/elevated PSA), BCC, s/p right knee meniscectomy (___), left knee meniscectomy (___), right L4-5 discectomy (___), L5-S1 laminectomy & fusion (___), right shoulder surgery (___), lithotripsy, vasectomy (___), tonsillectomy (age ___ Social History: ___ Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 06:36AM BLOOD WBC-11.1* RBC-3.46* Hgb-10.3* Hct-31.2* MCV-90 MCH-29.8 MCHC-33.0 RDW-12.5 RDWSD-41.2 Plt ___ ___ 06:45AM BLOOD WBC-11.0* RBC-3.69* Hgb-11.0* Hct-34.0* MCV-92 MCH-29.8 MCHC-32.4 RDW-12.6 RDWSD-42.3 Plt ___ ___ 06:28AM BLOOD WBC-12.3# RBC-4.18 Hgb-12.6* Hct-38.2* MCV-91 MCH-30.1 MCHC-33.0 RDW-12.4 RDWSD-41.6 Plt ___ ___ 06:28AM BLOOD Glucose-122* UreaN-16 Creat-1.1 Na-143 K-5.0 Cl-103 HCO3-27 AnGap-13 ___ 06:28AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was unremarkable. 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. Please use walker or 2 crutches, wean as able. Mr. ___ is discharged to home with services in stable condition. Medications on Admission: 1. Atorvastatin 10 mg PO QPM 2. Tamsulosin 0.4 mg PO QHS 3. Vitamin D 1000 UNIT PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO BID 5. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 5. Pantoprazole 40 mg PO Q24H 6. Senna 8.6 mg PO BID 7. Atorvastatin 10 mg PO QPM 8. Multivitamins 1 TAB PO DAILY 9. Tamsulosin 0.4 mg PO QHS 10. Vitamin D 1000 UNIT PO DAILY 11. HELD- Fish Oil (Omega 3) 1000 mg PO BID This medication was held. Do not restart Fish Oil (Omega 3) until Aspirin course completed. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left knee osteoarthritis/pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 325 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). 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 2 weeks after surgery. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker. Wean assistive device as able. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Wean assistive device as able Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips (at follow up visit) Followup Instructions: ___	[ "M1712", "E6601", "Z6838", "E785", "Z23", "N400", "G4733" ]	Allergies: almonds Chief Complaint: left knee osteoarthritis/pain Major Surgical or Invasive Procedure: [MASKED]: left total knee arthroplasty History of Present Illness: [MASKED] year old male w/left knee osteoarthritis/pain who failed conservative measures, now admitted for left total knee arthroplasty. Past Medical History: Dyslipidemia, OSA (tested positive [MASKED] years ago), seasonal allergies, headaches (occasional), h/o kidney stones, BPH (w/elevated PSA), BCC, s/p right knee meniscectomy ([MASKED]), left knee meniscectomy ([MASKED]), right L4-5 discectomy ([MASKED]), L5-S1 laminectomy & fusion ([MASKED]), right shoulder surgery ([MASKED]), lithotripsy, vasectomy ([MASKED]), tonsillectomy (age [MASKED] Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:36AM BLOOD WBC-11.1* RBC-3.46* Hgb-10.3* Hct-31.2* MCV-90 MCH-29.8 MCHC-33.0 RDW-12.5 RDWSD-41.2 Plt [MASKED] [MASKED] 06:45AM BLOOD WBC-11.0* RBC-3.69* Hgb-11.0* Hct-34.0* MCV-92 MCH-29.8 MCHC-32.4 RDW-12.6 RDWSD-42.3 Plt [MASKED] [MASKED] 06:28AM BLOOD WBC-12.3# RBC-4.18 Hgb-12.6* Hct-38.2* MCV-91 MCH-30.1 MCHC-33.0 RDW-12.4 RDWSD-41.6 Plt [MASKED] [MASKED] 06:28AM BLOOD Glucose-122* UreaN-16 Creat-1.1 Na-143 K-5.0 Cl-103 HCO3-27 AnGap-13 [MASKED] 06:28AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was unremarkable. 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. Please use walker or 2 crutches, wean as able. Mr. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. Atorvastatin 10 mg PO QPM 2. Tamsulosin 0.4 mg PO QHS 3. Vitamin D 1000 UNIT PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO BID 5. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain 5. Pantoprazole 40 mg PO Q24H 6. Senna 8.6 mg PO BID 7. Atorvastatin 10 mg PO QPM 8. Multivitamins 1 TAB PO DAILY 9. Tamsulosin 0.4 mg PO QHS 10. Vitamin D 1000 UNIT PO DAILY 11. HELD- Fish Oil (Omega 3) 1000 mg PO BID This medication was held. Do not restart Fish Oil (Omega 3) until Aspirin course completed. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: left knee osteoarthritis/pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 325 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). 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 2 weeks after surgery. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker. Wean assistive device as able. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Wean assistive device as able Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips (at follow up visit) Followup Instructions: [MASKED]	[]	[ "E785", "N400", "G4733" ]	[ "M1712: Unilateral primary osteoarthritis, left knee", "E6601: Morbid (severe) obesity due to excess calories", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "E785: Hyperlipidemia, unspecified", "Z23: Encounter for immunization", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "G4733: Obstructive sleep apnea (adult) (pediatric)" ]
10,044,439	22,675,571	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Cipro / Ceclor / Reglan / Toradol / morphine Attending: ___ Chief Complaint: pre-term labor/abruption Major Surgical or Invasive Procedure: Low transverse c/section Physical Exam: Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm, incision c/d/i Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema Pertinent Results: ___ 09:22AM WBC-13.4* RBC-3.30* HGB-9.6* HCT-28.7* MCV-87 MCH-29.1 MCHC-33.4 RDW-13.5 RDWSD-42.1 ___ 09:22AM PLT COUNT-352 ___ 09:22AM ___ PTT-24.6* ___ ___ 09:22AM ___ ___ 12:14AM WBC-12.3* RBC-3.29* HGB-9.6* HCT-28.1* MCV-85 MCH-29.2 MCHC-34.2 RDW-13.4 RDWSD-41.1 ___ 12:14AM PLT COUNT-331 ___ 10:38PM OTHER BODY FLUID FETALFN-POSITIVE ___ 10:15PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 10:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 10:15PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 ___ 10:15PM URINE AMORPH-RARE ___ 10:15PM URINE MUCOUS-RARE Brief Hospital Course: On ___, Ms. ___ was admitted to Antepartum service for pre-term labor and placental abruption. She underwent a low transverse cesarean section, with an estimated blood loss and her hematocrit was monitored closely. Post-operatively her pain was controlled with Dilaudid PCA, which was transitioned to oral Dilaudid, acetaminophen and ibuprofen. She was also seen by the chronic pain service during her hospitalization. She was continued on her home levothyroxine during her hospitalization. She was offered her home Subutex but declined. 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. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Buprenorphine 4 mg SL DAILY 2. Prenatal Vitamins 1 TAB PO DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY 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 #30 Capsule Refills:0 2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe pain RX hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q 6 hr Disp #25 Tablet Refills:0 3. Ibuprofen 600 mg PO Q6H RX ibuprofen 600 mg 1 tablet(s) by mouth Q 6 hours Disp #40 Tablet Refills:0 4. LORazepam 1 mg PO Q6H:PRN muscle spasm RX lorazepam [Ativan] 1 mg 1 by mouth Q 8 Disp #20 Tablet Refills:0 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Pregnancy delivered Hypothyroid H/O opiate abuse Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Routine post partum Pt was given post op narcotics and told she cannot get refills except from ___ Followup Instructions: ___	[ "O6014X1", "O4593", "O30043", "Z372", "O99324", "F1120", "O6014X2", "O321XX2", "O3421", "Z3A29", "O99344", "F419", "O99283", "E039" ]	Allergies: Cipro / Ceclor / Reglan / Toradol / morphine Chief Complaint: pre-term labor/abruption Major Surgical or Invasive Procedure: Low transverse c/section Physical Exam: Physical Exam on Discharge: VS: Afebrile, VSS Neuro/Psych: NAD, Oriented x3, Affect Normal Heart: RRR Lungs: CTA b/l Abdomen: soft, appropriately tender, fundus firm, incision c/d/i Pelvis: minimal bleeding Extremities: warm and well perfused, no calf tenderness, no edema Pertinent Results: [MASKED] 09:22AM WBC-13.4* RBC-3.30* HGB-9.6* HCT-28.7* MCV-87 MCH-29.1 MCHC-33.4 RDW-13.5 RDWSD-42.1 [MASKED] 09:22AM PLT COUNT-352 [MASKED] 09:22AM [MASKED] PTT-24.6* [MASKED] [MASKED] 09:22AM [MASKED] [MASKED] 12:14AM WBC-12.3* RBC-3.29* HGB-9.6* HCT-28.1* MCV-85 MCH-29.2 MCHC-34.2 RDW-13.4 RDWSD-41.1 [MASKED] 12:14AM PLT COUNT-331 [MASKED] 10:38PM OTHER BODY FLUID FETALFN-POSITIVE [MASKED] 10:15PM URINE COLOR-Yellow APPEAR-Hazy SP [MASKED] [MASKED] 10:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [MASKED] 10:15PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-<1 [MASKED] 10:15PM URINE AMORPH-RARE [MASKED] 10:15PM URINE MUCOUS-RARE Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to Antepartum service for pre-term labor and placental abruption. She underwent a low transverse cesarean section, with an estimated blood loss and her hematocrit was monitored closely. Post-operatively her pain was controlled with Dilaudid PCA, which was transitioned to oral Dilaudid, acetaminophen and ibuprofen. She was also seen by the chronic pain service during her hospitalization. She was continued on her home levothyroxine during her hospitalization. She was offered her home Subutex but declined. 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. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Buprenorphine 4 mg SL DAILY 2. Prenatal Vitamins 1 TAB PO DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY 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 #30 Capsule Refills:0 2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe pain RX hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q 6 hr Disp #25 Tablet Refills:0 3. Ibuprofen 600 mg PO Q6H RX ibuprofen 600 mg 1 tablet(s) by mouth Q 6 hours Disp #40 Tablet Refills:0 4. LORazepam 1 mg PO Q6H:PRN muscle spasm RX lorazepam [Ativan] 1 mg 1 by mouth Q 8 Disp #20 Tablet Refills:0 5. Levothyroxine Sodium 100 mcg PO DAILY 6. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Pregnancy delivered Hypothyroid H/O opiate abuse Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Routine post partum Pt was given post op narcotics and told she cannot get refills except from [MASKED] Followup Instructions: [MASKED]	[]	[ "F419", "E039" ]	[ "O6014X1: Preterm labor third trimester with preterm delivery third trimester, fetus 1", "O4593: Premature separation of placenta, unspecified, third trimester", "O30043: Twin pregnancy, dichorionic/diamniotic, third trimester", "Z372: Twins, both liveborn", "O99324: Drug use complicating childbirth", "F1120: Opioid dependence, uncomplicated", "O6014X2: Preterm labor third trimester with preterm delivery third trimester, fetus 2", "O321XX2: Maternal care for breech presentation, fetus 2", "O3421: Maternal care for scar from previous cesarean delivery", "Z3A29: 29 weeks gestation of pregnancy", "O99344: Other mental disorders complicating childbirth", "F419: Anxiety disorder, unspecified", "O99283: Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester", "E039: Hypothyroidism, unspecified" ]
10,044,439	28,804,415	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Cipro / Ceclor / Reglan / Toradol / morphine Attending: ___ Chief Complaint: pelvic cramping, rule out reterm labor, rule out short cervix Major Surgical or Invasive Procedure: none History of Present Illness: ___ ___ @ 19w2d with prior history of preterm delivery at 29w3d due to abruption presents with irregular contractions. Patient states that she has been experiencing irregular contractions, lasting one minute for one week. The contractions are associated w/ back pain and pelvic pain which subsides once contractions. This morning she noted pink spotting, thus she decided to present. She denies any recent vaginal intercourse, abdominal trauma, changes in vaginal discharge. Of note, her last TVUS was on ___ which showed a CL=3.3 cm. She endorses +FM and denies VB, LOF. She feels nervous that her cervix is shorter and she is having preterm labor. She denies any HA, F/C, n/v, abdominal pain, rashes. Last meal 2 hours ago All: - Celcor (childhood) - Cipro (itching, throat swelling) - Toradol (rash) - Morphine (choking sensation) Past Medical History: PNC: ___ ___ by IVF dating Labs: A+/Rh neg/RI/RPR neg/HBsAg neg/HIV neg/GBS unk Screening: low risk ERA FFS: N/A GLT: N/A US: N/A Issues: - small subchorionic hematoma noted on 510/19 U/S at 6w5d. No vaginal bleeding. Plan follow up with NT U/S. - Hx preterm delivery with repeat LTCS at 29 weeks for twins. Followed for short cervix, preterm contractions. Both babies are doing very well and meeting milestones. s/p ___ consult. IM Progesterone week ___ for prevention of recurrent preterm birth. However pt opted to start vaginal progesterone @ 12weeks - hx opioid use: on buprenorphine ___ QD - hypothyroidism: levothyroxine 75mcg QD; last TSH 1.96 on ___ - gHSV: [ ] suppression @ 36wks OB: G1 - SAB G2 - C/S at term 38w0d G3 - C/S at 29w3d, abruption, mono-di twins PMH: - Opiate dependence - Anxiety - Hypothyroidism PSH: - c/s x 2 - LSC x 6 (ovarian cystectomy, appendectomy, LOA) - Exploratory laparotomy, ruptured hemorrhagic cyst - Cholecystectomy - Mini laparotomy Social History: ___ Family History: non contributory Physical Exam: Gen: A&O, NAD CV: RRR Resp: CTAB Abd: +BS, soft, NT/ND, no rebound or guarding. Ext: calves nontender bilaterally, no c/c/e Pelvic: normal vulva anatomy, vagina w/ normal discharge, no bleeding noted. Cervix appears visually closed. SVE: pt declined FHT 140s. Bedside TVUS: Cervical length measuring 2.1 cm, unchanged w/ fundal pressure Pertinent Results: ___ 06:08PM OTHER BODY FLUID CT-NEG NG-NEG TRICH-NEG Brief Hospital Course: admitted for observation. lower abdominal cramping resolved. ___ U/S cephalic, normal fluid, cervical length 3.4cm, no evidence abruption ___ follow up U/S prelim read CL 3.7cm per review with Dr ___. discharge instructions reviewed. d/c home with follow up on ___ with primary ___ MD ___ and with ___ U/S. Medications on Admission: Meds: - Levothryxoine 100mcg daily - Subtex 8mg TID - PNV - Vaginal progesterone BID Discharge Medications: 1. Buprenorphine 8 mg SL TID 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: preterm contractions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: per instruction sheet Followup Instructions: ___	[ "O4702", "O3432", "O99322", "F1120", "O99282", "E039", "O99342", "F419", "Z3A19" ]	Allergies: Cipro / Ceclor / Reglan / Toradol / morphine Chief Complaint: pelvic cramping, rule out reterm labor, rule out short cervix Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] [MASKED] @ 19w2d with prior history of preterm delivery at 29w3d due to abruption presents with irregular contractions. Patient states that she has been experiencing irregular contractions, lasting one minute for one week. The contractions are associated w/ back pain and pelvic pain which subsides once contractions. This morning she noted pink spotting, thus she decided to present. She denies any recent vaginal intercourse, abdominal trauma, changes in vaginal discharge. Of note, her last TVUS was on [MASKED] which showed a CL=3.3 cm. She endorses +FM and denies VB, LOF. She feels nervous that her cervix is shorter and she is having preterm labor. She denies any HA, F/C, n/v, abdominal pain, rashes. Last meal 2 hours ago All: - Celcor (childhood) - Cipro (itching, throat swelling) - Toradol (rash) - Morphine (choking sensation) Past Medical History: PNC: [MASKED] [MASKED] by IVF dating Labs: A+/Rh neg/RI/RPR neg/HBsAg neg/HIV neg/GBS unk Screening: low risk ERA FFS: N/A GLT: N/A US: N/A Issues: - small subchorionic hematoma noted on 510/19 U/S at 6w5d. No vaginal bleeding. Plan follow up with NT U/S. - Hx preterm delivery with repeat LTCS at 29 weeks for twins. Followed for short cervix, preterm contractions. Both babies are doing very well and meeting milestones. s/p [MASKED] consult. IM Progesterone week [MASKED] for prevention of recurrent preterm birth. However pt opted to start vaginal progesterone @ 12weeks - hx opioid use: on buprenorphine [MASKED] QD - hypothyroidism: levothyroxine 75mcg QD; last TSH 1.96 on [MASKED] - gHSV: [ ] suppression @ 36wks OB: G1 - SAB G2 - C/S at term 38w0d G3 - C/S at 29w3d, abruption, mono-di twins PMH: - Opiate dependence - Anxiety - Hypothyroidism PSH: - c/s x 2 - LSC x 6 (ovarian cystectomy, appendectomy, LOA) - Exploratory laparotomy, ruptured hemorrhagic cyst - Cholecystectomy - Mini laparotomy Social History: [MASKED] Family History: non contributory Physical Exam: Gen: A&O, NAD CV: RRR Resp: CTAB Abd: +BS, soft, NT/ND, no rebound or guarding. Ext: calves nontender bilaterally, no c/c/e Pelvic: normal vulva anatomy, vagina w/ normal discharge, no bleeding noted. Cervix appears visually closed. SVE: pt declined FHT 140s. Bedside TVUS: Cervical length measuring 2.1 cm, unchanged w/ fundal pressure Pertinent Results: [MASKED] 06:08PM OTHER BODY FLUID CT-NEG NG-NEG TRICH-NEG Brief Hospital Course: admitted for observation. lower abdominal cramping resolved. [MASKED] U/S cephalic, normal fluid, cervical length 3.4cm, no evidence abruption [MASKED] follow up U/S prelim read CL 3.7cm per review with Dr [MASKED]. discharge instructions reviewed. d/c home with follow up on [MASKED] with primary [MASKED] MD [MASKED] and with [MASKED] U/S. Medications on Admission: Meds: - Levothryxoine 100mcg daily - Subtex 8mg TID - PNV - Vaginal progesterone BID Discharge Medications: 1. Buprenorphine 8 mg SL TID 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: preterm contractions Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: per instruction sheet Followup Instructions: [MASKED]	[]	[ "E039", "F419" ]	[ "O4702: False labor before 37 completed weeks of gestation, second trimester", "O3432: Maternal care for cervical incompetence, second trimester", "O99322: Drug use complicating pregnancy, second trimester", "F1120: Opioid dependence, uncomplicated", "O99282: Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester", "E039: Hypothyroidism, unspecified", "O99342: Other mental disorders complicating pregnancy, second trimester", "F419: Anxiety disorder, unspecified", "Z3A19: 19 weeks gestation of pregnancy" ]
10,044,997	25,979,513	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: shellfish derived / iodine Attending: ___. Chief Complaint: Left hand table saw injury Major Surgical or Invasive Procedure: ___: left hand washout of multiple open fractures thumb index middle ring fingers, nerve repair x 1, PIP fusion ring finger, first dorsal metacarpal artery flap for thumb pulp recontruction History of Present Illness: ___ is a ___ year old male with PMH notable for hypertension presents with table saw injury to his left hand. He accidentally caught multiple digits and in the saw. He was seen at an outside ED where he had a digital block performed. He was given tetanus and Ancef. He is right-hand dominant. He sustained multiple serious injuries to the left hand fingers and was sent here for higher level of care. Denies any other injuries. Otherwise asymptomatic. Past Medical History: Hypertension Social History: ___ Family History: Noncontributory Physical Exam: GEN: AOx3 WN, WD in NAD HEENT: NCAT, EOMI, anicteric CV: RRR PULM: unlabored breathing with symmetric chest rise, no respiratory distress EXT: Flap pink, good cap refill, WWP SILT over thumb and all digits, including flap site Flexing/extending thumb IP joint, flap pink and well perfused No erythema, no drainage Brief Hospital Course: The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have multiple injuries to the left hand at all the digits including the thumb except for the small finger and was admitted to the hand surgery service. The patient was taken to the operating room on ___ for procedure as noted above, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with OT who determined that discharge to home with outpatient occupational therapy was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the left upper extremity. 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. amLODIPine 10 mg PO DAILY 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain Partial fill ok. Wean. No driving/heavy machinery. RX oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed Disp #25 Tablet Refills:*0 3. amLODIPine 10 mg PO DAILY 4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Disposition: Home Discharge Diagnosis: Left hand third finger deep laceration, left hand fourth finger partial amputation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER HAND SURGERY: - You were in the hospital for hand surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing left upper extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 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. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB FOLLOW UP: Please follow up with your Hand Surgeon, Dr. ___ one week. 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. Followup Instructions: ___	[ "S62522B", "S62623B", "S62633B", "S61211A", "S66323A", "S66327A", "S63633A", "S61313A", "S68625A", "S64493A", "W312XXA", "Y929", "M19071", "I10" ]	Allergies: shellfish derived / iodine Chief Complaint: Left hand table saw injury Major Surgical or Invasive Procedure: [MASKED]: left hand washout of multiple open fractures thumb index middle ring fingers, nerve repair x 1, PIP fusion ring finger, first dorsal metacarpal artery flap for thumb pulp recontruction History of Present Illness: [MASKED] is a [MASKED] year old male with PMH notable for hypertension presents with table saw injury to his left hand. He accidentally caught multiple digits and in the saw. He was seen at an outside ED where he had a digital block performed. He was given tetanus and Ancef. He is right-hand dominant. He sustained multiple serious injuries to the left hand fingers and was sent here for higher level of care. Denies any other injuries. Otherwise asymptomatic. Past Medical History: Hypertension Social History: [MASKED] Family History: Noncontributory Physical Exam: GEN: AOx3 WN, WD in NAD HEENT: NCAT, EOMI, anicteric CV: RRR PULM: unlabored breathing with symmetric chest rise, no respiratory distress EXT: Flap pink, good cap refill, WWP SILT over thumb and all digits, including flap site Flexing/extending thumb IP joint, flap pink and well perfused No erythema, no drainage Brief Hospital Course: The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have multiple injuries to the left hand at all the digits including the thumb except for the small finger and was admitted to the hand surgery service. The patient was taken to the operating room on [MASKED] for procedure as noted above, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with OT who determined that discharge to home with outpatient occupational therapy was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the left upper extremity. 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. amLODIPine 10 mg PO DAILY 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain Partial fill ok. Wean. No driving/heavy machinery. RX oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed Disp #25 Tablet Refills:*0 3. amLODIPine 10 mg PO DAILY 4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Discharge Disposition: Home Discharge Diagnosis: Left hand third finger deep laceration, left hand fourth finger partial amputation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER HAND SURGERY: - You were in the hospital for hand surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Nonweightbearing left upper extremity MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 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. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever [MASKED] 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE [MASKED] DAYS OF REHAB FOLLOW UP: Please follow up with your Hand Surgeon, Dr. [MASKED] one week. 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. Followup Instructions: [MASKED]	[]	[ "Y929", "I10" ]	[ "S62522B: Displaced fracture of distal phalanx of left thumb, initial encounter for open fracture", "S62623B: Displaced fracture of middle phalanx of left middle finger, initial encounter for open fracture", "S62633B: Displaced fracture of distal phalanx of left middle finger, initial encounter for open fracture", "S61211A: Laceration without foreign body of left index finger without damage to nail, initial encounter", "S66323A: Laceration of extensor muscle, fascia and tendon of left middle finger at wrist and hand level, initial encounter", "S66327A: Laceration of extensor muscle, fascia and tendon of left little finger at wrist and hand level, initial encounter", "S63633A: Sprain of interphalangeal joint of left middle finger, initial encounter", "S61313A: Laceration without foreign body of left middle finger with damage to nail, initial encounter", "S68625A: Partial traumatic transphalangeal amputation of left ring finger, initial encounter", "S64493A: Injury of digital nerve of left middle finger, initial encounter", "W312XXA: Contact with powered woodworking and forming machines, initial encounter", "Y929: Unspecified place or not applicable", "M19071: Primary osteoarthritis, right ankle and foot", "I10: Essential (primary) hypertension" ]
10,045,326	22,999,349	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with history of history of metastatic lung cancer currently on alimta/carboplatin who presents with abdominal pain and constipation. Patient reports severe constipation, last bowel movement about one week ago. He has tried multiple stool softeners, including Colace, senna, milk of magnesia, suppository, and fleet enema without success. He also continues to have back and rib pain. He has been taking oxycodone and valium for pain. He feels very weak and tired. Has had difficulty walking at home recently due to abdominal pain. Not eating well. He was seen at ___ Urgent Care where exam as notable for diffuse abdominal tenderness to palpation. KUB was unremarkable. He had manual disimpaction with removal of small amount of stool. He was referred to ___ ED for further evaluation. On arrival to the ED, initial vitals were 98.4 89 98/59 22 98% RA. Labs were notable for WBC 41.0 (78% PMNs, 8% bands, 4% lymphs), H/H 8.1/25.2, Plt 386, Na 134, BUN/Cr ___, LFTs wnl, UA negative. He had CT abdomen/pelvis which showed worsening metastatic disease and short segment of intussuscepted small bowel. Colorectal surgery was consulted and recommended no urgent surgical interventions. He was given dilaudid 1mg IV, valium 15mg PO, and 1L NS. Prior to transfer vitals were 98.9 78 100/49 16 100% RA. On arrival to the floor, patient reports abdominal pain has improved. Reports ___ back and rib pain. He denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: - ___ PET scan:There is a 2.7 x 1.6 cm left upper lobe irregular soft tissue mass with significant increased FDG uptake, concerning for malignancy, with a few associated mildly avid left axillary lymph nodes. There is a prominent 0.8 cm left cervical level IIA lymph node with increased FDG uptake, concerning for metastatic focus. There is a 1.4 cm FDG avid soft tissue lesion at the level of the kidneys, which may represent either an enlarged left para-aortic lymph node or a left adrenal gland nodule. Recommend further evaluation with additional diagnostic CT imaging. 1.0 cm right adrenal nodule with mildly increased FDG uptake, also incompletely evaluated on this low-dose exam. Sigmoid diverticulosis. Prostamegaly. Renal cysts - ___- cervical node biopsy (FNA)- non-diagnostic - ___- left axillary node biopsy (FNA)- negative - ___- EUS/Adrenal gland core biopsy: Poorly differentiated carcinoma with extensive necrosis. Note: Immunohistochemical stains are performed. The tumor cells are positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20, TTF-1, Napsin, P40 and Inhibin are negative. The findings are not specific for the origin of this tumor. - ___ Head MRI showed no evidence of intracranial metastatic disease at this time. Chronic right thalamic lacunar and left cerebellar infarcts - ___ Admitted to ___ with generalized weakness - ___ He received his first chemotherapy with carboplatin and pemetrexed--took decadron premedication and is on folate supplementation. - ___ Admitted to ___ with right flank and RUQ pain. Imaging with abdominal CT and RUQ US negative except for cholelithiasis. Resolved after 24 hours PAST MEDICAL HISTORY: - History of Alcohol Abuse - History of Substance Abuse - Atrial Septal Defect - Stroke, small vessel in ___ without residual deficits, on aggrenox - Tobacco Dependence - Hypercholesteremia - Insomnia Social History: ___ Family History: No family history of cancer. Physical Exam: ADMISSION EXAM ============== VS: Temp 97.7, BP 100/63, HR 81, RR 18, O2 sat 94% RA. GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, mild diffuse tenderness to palpation without rebound, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. DISCHARGE EXAM ============== VS: 97.8 97/62 91 18 95% RA I/O: x1 BM yesterday and x1 this morning. GENERAL: NAD, lying on his back in bed. Sleepy, but able to open his eyes and converse with me. HEENT: Anicteric sclerae, OP clear. CARDIAC: RRR, normal S1/S2, no M/R/G. LUNG: Clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: NABS. Abdomen is soft, nondistended, mild diffuse tenderness to palpation (worst in the LUQ today) without rebound or guarding. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, moves all four extremities spontaneously. SKIN: No significant rashes. Pertinent Results: ADMISSION LABS ============== ___ 05:30PM URINE HOURS-RANDOM ___ 05:30PM URINE UHOLD-HOLD ___ 05:30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ___ 05:30PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 ___ 05:30PM URINE AMORPH-RARE ___ 05:30PM URINE MUCOUS-RARE ___ 04:30PM GLUCOSE-83 UREA N-12 CREAT-0.7 SODIUM-134 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-25 ANION GAP-15 ___ 04:30PM estGFR-Using this ___ 04:30PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-174* TOT BILI-0.2 ___ 04:30PM LIPASE-49 ___ 04:30PM ALBUMIN-3.1* ___ 04:30PM WBC-41.0# RBC-2.84 HGB-8.1* HCT-25.2* MCV-89 MCH-28.5 MCHC-32.1 RDW-15.8* RDWSD-48.2* ___ 04:30PM NEUTS-78* BANDS-8* LYMPHS-4* MONOS-7 EOS-3 BASOS-0 ___ MYELOS-0 AbsNeut-35.26* AbsLymp-1.64 AbsMono-2.87* AbsEos-1.23* AbsBaso-0.00* ___ 04:30PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-OCCASIONAL BURR-OCCASIONAL FRAGMENT-OCCASIONAL ___ 04:30PM PLT SMR-NORMAL PLT COUNT-386 PERTINENT IMAGING ================= -CT Abdomen/Pelvis w/ Contrast (___): 1. Worsening metastatic disease. 1.9 cm liver lesion is new. Necrotic metastatic lesions affecting the adrenal glands, mesenteric lymph nodes, the peritoneum, and within the left gluteal soft tissues have increased in size. 2. Short segment of intussuscepted small bowel within the left hemi abdomen, which may be incidental, but raises suspicion for an underlying metastatic lead point. No evidence of small-bowel obstruction. -CT Abdomen/Pelvis w/ Contrast (___): IMPRESSION: 1. Small bowel obstruction with transition point at a short segment intussusception within the mid to distal small bowel located in the right lower quadrant. In the presence of other intraluminal filling defects within the small bowel as described, suspect underlying metastatic lead point. 2. Diffuse metastatic disease involves a hypodense liver lesion, necrotic retroperitoneal and mesenteric adenopathy, adrenal glands, and peritoneum PERTINENT MICROBIOLOGY ====================== ___ 5:30 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S DISCHARGE LABS ============== ___ 06:55AM BLOOD WBC-59.5 RBC-2.58* Hgb-7.5* Hct-22.9* MCV-89 MCH-29.1 MCHC-32.8 RDW-16.7* RDWSD-50.9* Plt ___ ___ 06:55AM BLOOD Glucose-98 UreaN-26* Creat-1.2 Na-134 K-3.9 Cl-98 HCO3-25 AnGap-15 ___ 06:55AM BLOOD Calcium-10.4* Phos-4.4 Mg-1.___ with PMHx metastatic lung cancer (s/p C1 alimta/carboplatin) who presented with one week of diffuse crampy abdominal pain and constipation unrelieved with his home pain medications and stool softeners, as well as decreased appetite. CT A/P on admission notable for worsening metastasis of his lung cancer (including a new lesion in the liver), as well as intussusception with concern for a metastatic lead point. Evaluated by Colorectal Surgery and offered surgery. Given Pt goals of care, he declined the procedure and ultimately went home with hospice for symptom-focused care. ACTIVE ISSUES ============= # ABDOMINAL PAIN and # INTUSSUSCEPTION OF SMALL INTESTINE # CONSTIPATION: Pt with one week of diffuse cramping abdominal pain with constipation, unrelieved with home pain medications or stool softeners. His bowel regimen and pain meds were uptitrated in-house. CT A/P on admission demonstrated worsening metastasis of his lung cancer (including new liver lesion, worsening adrenal/LN/soft tissue masses), as well as an intussuscepted segment of small bowel with concern for an additional metastatic lead point. Pt evaluated by Colorectal Surgery, who offered surgical management. Ultimately Pt declined the procedure as it was not within his goals of care. He was discharged home with hospice care. # LEUKOCYTOSIS: Pt with chronic leukocytosis (baseline ___, increased to the 50's on admission. Pt without obvious infectious source or infections on admission. Likely reactive in setting of intussusception. Was stable at time of discharge. # BACK/RIB PAIN: Pt with history of multiple rib fractures, which were chronic in nature. Uptitrated Pt home pain regimen as above. # MALNUTRITION, SEVERE: Pt with very limited PO intake xfew months, which did not improve during hospitalization despite 1:1 nursing assistance. TPN considered, but not within Pt goals of care. He was provided with nutritional supplements. CHRONIC/STABLE ISSUES: ===================== # METASTATIC LUNG CANCER: C1D1 of alimta/carboplatin on ___. Given severity of progression of disease on in-hospital imaging, the decision was made to defer further treatment by the patient and his Oncologist. He will follow up with his Oncologist as an outpatient. # GENERALIZED WEAKNESS: Progressive, likely due to worsening metastatic lung cancer vs. severe malnutrition. Has previously refused appetite stimulants. # ANEMIA: Likely in setting of malignancy. No evidence of active bleeding, and H&H stable throughout. # CVA: Home dipyridamole-aspirin discontinued on discharge. TRANSITIONAL ISSUES: =================== # EMERGENCY CONTACT HCP: ___ (___/HCP) ___ # CODE: DNR/DNI [ ] MEDICATION CHANGES: - Added: Fentanyl patch 25mcg q72h, bisacodyl 10mg daily, docusate 100mg BID, polyethylene glycol 17g BID, senna 17.2mg BID - Increased: Diazepam (10mg q8h:PRN -> 20mg QHS:PRN anxiety), oxycodone ___ q6h:PRN -> 20mg q4h:PRN). - Stopped: Sildenafil, aspirin [ ] INTUSSUSCEPTION: - CT A/P with concern for obstruction at the start of his intussuscepted portion of small bowel, likely metastatic lead point. - Had 2 small filling defects in his small bowel on CT A/P. Pt opted for nonoperative management. [ ] LUNG CANCER: - Pt with worsening metastatic disease. Was scheduled to receive chemotherapy on ___, deferred in setting of acute illness. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 10 mg PO Q8H:PRN insomnia/anxiety 2. Dipyridamole-Aspirin 1 CAP PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Moderate 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. Sildenafil ___ mg PO PRN intercourse 8. Multivitamins 1 TAB PO DAILY 9. Dexamethasone 4 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY 2. Docusate Sodium 100 mg PO BID 3. Fentanyl Patch 25 mcg/h TD Q72H RX fentanyl 25 mcg/hour Apply to skin q72h Disp #1 Patch Refills:0 4. Polyethylene Glycol 17 g PO BID 5. Senna 17.2 mg PO BID 6. Diazepam 20 mg PO QHS:PRN insomnia/anxiety RX diazepam 10 mg ___ mg by mouth at bedtime Disp #6 Tablet Refills:0 7. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - Moderate RX oxycodone 10 mg ___ tablet(s) by mouth every four (4) hours Disp #36 Tablet Refills:0 8. Dexamethasone 4 mg PO DAILY 9. Dipyridamole-Aspirin 1 CAP PO BID 10. FoLIC Acid 1 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Ondansetron 8 mg PO Q8H:PRN nausea RX ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours Disp #10 Tablet Refills:0 13. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Intussusception of the small bowel Constipation Back/rib pain SECONDARY: Lung cancer, metastatic Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you at the ___ ___. WHY WAS I SEEN IN THE HOSPITAL? =============================== - You were having pain in your belly and severe constipation. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - We increased your home pain medications to try to control your pain. - We provided you with nutrition supplements because you had a low appetite. - We looked at your belly using a special camera ("CT scan"). This showed us two things: 1. Your lung cancer has spread more widely, including a new area that has spread to your liver. 2. Your pain may have been due to a condition called "intussusception" in your small bowel. - You decided not to undergo a surgery for your intussusception, due to the risks involved as well as the extent of your cancer. You requested that we focus on controlling your pain and symptoms. WHAT SHOULD I DO WHEN I AM HOME? ================================ - You will go home with Hospice services, who will be able to provide you the supplies and medicines you need to remain comfortable in your home. Thank you for letting us be involved in your care, Your ___ Care Team Followup Instructions: ___	[ "K561", "E43", "C772", "C787", "C784", "C7971", "D630", "C3412", "Q211", "C786", "C7972", "Z8673", "F17210", "G4700", "K5900", "D72829", "Z6821", "Z515", "M8448XD", "F419", "Z66" ]	Allergies: Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] male with history of history of metastatic lung cancer currently on alimta/carboplatin who presents with abdominal pain and constipation. Patient reports severe constipation, last bowel movement about one week ago. He has tried multiple stool softeners, including Colace, senna, milk of magnesia, suppository, and fleet enema without success. He also continues to have back and rib pain. He has been taking oxycodone and valium for pain. He feels very weak and tired. Has had difficulty walking at home recently due to abdominal pain. Not eating well. He was seen at [MASKED] Urgent Care where exam as notable for diffuse abdominal tenderness to palpation. KUB was unremarkable. He had manual disimpaction with removal of small amount of stool. He was referred to [MASKED] ED for further evaluation. On arrival to the ED, initial vitals were 98.4 89 98/59 22 98% RA. Labs were notable for WBC 41.0 (78% PMNs, 8% bands, 4% lymphs), H/H 8.1/25.2, Plt 386, Na 134, BUN/Cr [MASKED], LFTs wnl, UA negative. He had CT abdomen/pelvis which showed worsening metastatic disease and short segment of intussuscepted small bowel. Colorectal surgery was consulted and recommended no urgent surgical interventions. He was given dilaudid 1mg IV, valium 15mg PO, and 1L NS. Prior to transfer vitals were 98.9 78 100/49 16 100% RA. On arrival to the floor, patient reports abdominal pain has improved. Reports [MASKED] back and rib pain. He denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: - [MASKED] PET scan:There is a 2.7 x 1.6 cm left upper lobe irregular soft tissue mass with significant increased FDG uptake, concerning for malignancy, with a few associated mildly avid left axillary lymph nodes. There is a prominent 0.8 cm left cervical level IIA lymph node with increased FDG uptake, concerning for metastatic focus. There is a 1.4 cm FDG avid soft tissue lesion at the level of the kidneys, which may represent either an enlarged left para-aortic lymph node or a left adrenal gland nodule. Recommend further evaluation with additional diagnostic CT imaging. 1.0 cm right adrenal nodule with mildly increased FDG uptake, also incompletely evaluated on this low-dose exam. Sigmoid diverticulosis. Prostamegaly. Renal cysts - [MASKED]- cervical node biopsy (FNA)- non-diagnostic - [MASKED]- left axillary node biopsy (FNA)- negative - [MASKED]- EUS/Adrenal gland core biopsy: Poorly differentiated carcinoma with extensive necrosis. Note: Immunohistochemical stains are performed. The tumor cells are positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20, TTF-1, Napsin, P40 and Inhibin are negative. The findings are not specific for the origin of this tumor. - [MASKED] Head MRI showed no evidence of intracranial metastatic disease at this time. Chronic right thalamic lacunar and left cerebellar infarcts - [MASKED] Admitted to [MASKED] with generalized weakness - [MASKED] He received his first chemotherapy with carboplatin and pemetrexed--took decadron premedication and is on folate supplementation. - [MASKED] Admitted to [MASKED] with right flank and RUQ pain. Imaging with abdominal CT and RUQ US negative except for cholelithiasis. Resolved after 24 hours PAST MEDICAL HISTORY: - History of Alcohol Abuse - History of Substance Abuse - Atrial Septal Defect - Stroke, small vessel in [MASKED] without residual deficits, on aggrenox - Tobacco Dependence - Hypercholesteremia - Insomnia Social History: [MASKED] Family History: No family history of cancer. Physical Exam: ADMISSION EXAM ============== VS: Temp 97.7, BP 100/63, HR 81, RR 18, O2 sat 94% RA. GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, mild diffuse tenderness to palpation without rebound, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. DISCHARGE EXAM ============== VS: 97.8 97/62 91 18 95% RA I/O: x1 BM yesterday and x1 this morning. GENERAL: NAD, lying on his back in bed. Sleepy, but able to open his eyes and converse with me. HEENT: Anicteric sclerae, OP clear. CARDIAC: RRR, normal S1/S2, no M/R/G. LUNG: Clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: NABS. Abdomen is soft, nondistended, mild diffuse tenderness to palpation (worst in the LUQ today) without rebound or guarding. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, moves all four extremities spontaneously. SKIN: No significant rashes. Pertinent Results: ADMISSION LABS ============== [MASKED] 05:30PM URINE HOURS-RANDOM [MASKED] 05:30PM URINE UHOLD-HOLD [MASKED] 05:30PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [MASKED] 05:30PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 05:30PM URINE AMORPH-RARE [MASKED] 05:30PM URINE MUCOUS-RARE [MASKED] 04:30PM GLUCOSE-83 UREA N-12 CREAT-0.7 SODIUM-134 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-25 ANION GAP-15 [MASKED] 04:30PM estGFR-Using this [MASKED] 04:30PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-174* TOT BILI-0.2 [MASKED] 04:30PM LIPASE-49 [MASKED] 04:30PM ALBUMIN-3.1* [MASKED] 04:30PM WBC-41.0# RBC-2.84 HGB-8.1* HCT-25.2* MCV-89 MCH-28.5 MCHC-32.1 RDW-15.8* RDWSD-48.2* [MASKED] 04:30PM NEUTS-78* BANDS-8* LYMPHS-4* MONOS-7 EOS-3 BASOS-0 [MASKED] MYELOS-0 AbsNeut-35.26* AbsLymp-1.64 AbsMono-2.87* AbsEos-1.23* AbsBaso-0.00* [MASKED] 04:30PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-OCCASIONAL BURR-OCCASIONAL FRAGMENT-OCCASIONAL [MASKED] 04:30PM PLT SMR-NORMAL PLT COUNT-386 PERTINENT IMAGING ================= -CT Abdomen/Pelvis w/ Contrast ([MASKED]): 1. Worsening metastatic disease. 1.9 cm liver lesion is new. Necrotic metastatic lesions affecting the adrenal glands, mesenteric lymph nodes, the peritoneum, and within the left gluteal soft tissues have increased in size. 2. Short segment of intussuscepted small bowel within the left hemi abdomen, which may be incidental, but raises suspicion for an underlying metastatic lead point. No evidence of small-bowel obstruction. -CT Abdomen/Pelvis w/ Contrast ([MASKED]): IMPRESSION: 1. Small bowel obstruction with transition point at a short segment intussusception within the mid to distal small bowel located in the right lower quadrant. In the presence of other intraluminal filling defects within the small bowel as described, suspect underlying metastatic lead point. 2. Diffuse metastatic disease involves a hypodense liver lesion, necrotic retroperitoneal and mesenteric adenopathy, adrenal glands, and peritoneum PERTINENT MICROBIOLOGY ====================== [MASKED] 5:30 pm URINE *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S DISCHARGE LABS ============== [MASKED] 06:55AM BLOOD WBC-59.5 RBC-2.58* Hgb-7.5* Hct-22.9* MCV-89 MCH-29.1 MCHC-32.8 RDW-16.7* RDWSD-50.9* Plt [MASKED] [MASKED] 06:55AM BLOOD Glucose-98 UreaN-26* Creat-1.2 Na-134 K-3.9 Cl-98 HCO3-25 AnGap-15 [MASKED] 06:55AM BLOOD Calcium-10.4* Phos-4.4 Mg-1.[MASKED] with PMHx metastatic lung cancer (s/p C1 alimta/carboplatin) who presented with one week of diffuse crampy abdominal pain and constipation unrelieved with his home pain medications and stool softeners, as well as decreased appetite. CT A/P on admission notable for worsening metastasis of his lung cancer (including a new lesion in the liver), as well as intussusception with concern for a metastatic lead point. Evaluated by Colorectal Surgery and offered surgery. Given Pt goals of care, he declined the procedure and ultimately went home with hospice for symptom-focused care. ACTIVE ISSUES ============= # ABDOMINAL PAIN and # INTUSSUSCEPTION OF SMALL INTESTINE # CONSTIPATION: Pt with one week of diffuse cramping abdominal pain with constipation, unrelieved with home pain medications or stool softeners. His bowel regimen and pain meds were uptitrated in-house. CT A/P on admission demonstrated worsening metastasis of his lung cancer (including new liver lesion, worsening adrenal/LN/soft tissue masses), as well as an intussuscepted segment of small bowel with concern for an additional metastatic lead point. Pt evaluated by Colorectal Surgery, who offered surgical management. Ultimately Pt declined the procedure as it was not within his goals of care. He was discharged home with hospice care. # LEUKOCYTOSIS: Pt with chronic leukocytosis (baseline [MASKED], increased to the 50's on admission. Pt without obvious infectious source or infections on admission. Likely reactive in setting of intussusception. Was stable at time of discharge. # BACK/RIB PAIN: Pt with history of multiple rib fractures, which were chronic in nature. Uptitrated Pt home pain regimen as above. # MALNUTRITION, SEVERE: Pt with very limited PO intake xfew months, which did not improve during hospitalization despite 1:1 nursing assistance. TPN considered, but not within Pt goals of care. He was provided with nutritional supplements. CHRONIC/STABLE ISSUES: ===================== # METASTATIC LUNG CANCER: C1D1 of alimta/carboplatin on [MASKED]. Given severity of progression of disease on in-hospital imaging, the decision was made to defer further treatment by the patient and his Oncologist. He will follow up with his Oncologist as an outpatient. # GENERALIZED WEAKNESS: Progressive, likely due to worsening metastatic lung cancer vs. severe malnutrition. Has previously refused appetite stimulants. # ANEMIA: Likely in setting of malignancy. No evidence of active bleeding, and H&H stable throughout. # CVA: Home dipyridamole-aspirin discontinued on discharge. TRANSITIONAL ISSUES: =================== # EMERGENCY CONTACT HCP: [MASKED] ([MASKED]/HCP) [MASKED] # CODE: DNR/DNI [ ] MEDICATION CHANGES: - Added: Fentanyl patch 25mcg q72h, bisacodyl 10mg daily, docusate 100mg BID, polyethylene glycol 17g BID, senna 17.2mg BID - Increased: Diazepam (10mg q8h:PRN -> 20mg QHS:PRN anxiety), oxycodone [MASKED] q6h:PRN -> 20mg q4h:PRN). - Stopped: Sildenafil, aspirin [ ] INTUSSUSCEPTION: - CT A/P with concern for obstruction at the start of his intussuscepted portion of small bowel, likely metastatic lead point. - Had 2 small filling defects in his small bowel on CT A/P. Pt opted for nonoperative management. [ ] LUNG CANCER: - Pt with worsening metastatic disease. Was scheduled to receive chemotherapy on [MASKED], deferred in setting of acute illness. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 10 mg PO Q8H:PRN insomnia/anxiety 2. Dipyridamole-Aspirin 1 CAP PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q6H:PRN Pain - Moderate 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. Sildenafil [MASKED] mg PO PRN intercourse 8. Multivitamins 1 TAB PO DAILY 9. Dexamethasone 4 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY 2. Docusate Sodium 100 mg PO BID 3. Fentanyl Patch 25 mcg/h TD Q72H RX fentanyl 25 mcg/hour Apply to skin q72h Disp #1 Patch Refills:0 4. Polyethylene Glycol 17 g PO BID 5. Senna 17.2 mg PO BID 6. Diazepam 20 mg PO QHS:PRN insomnia/anxiety RX diazepam 10 mg [MASKED] mg by mouth at bedtime Disp #6 Tablet Refills:0 7. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - Moderate RX oxycodone 10 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #36 Tablet Refills:0 8. Dexamethasone 4 mg PO DAILY 9. Dipyridamole-Aspirin 1 CAP PO BID 10. FoLIC Acid 1 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Ondansetron 8 mg PO Q8H:PRN nausea RX ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours Disp #10 Tablet Refills:0 13. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY: Intussusception of the small bowel Constipation Back/rib pain SECONDARY: Lung cancer, metastatic Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure to care for you at the [MASKED] [MASKED]. WHY WAS I SEEN IN THE HOSPITAL? =============================== - You were having pain in your belly and severe constipation. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - We increased your home pain medications to try to control your pain. - We provided you with nutrition supplements because you had a low appetite. - We looked at your belly using a special camera ("CT scan"). This showed us two things: 1. Your lung cancer has spread more widely, including a new area that has spread to your liver. 2. Your pain may have been due to a condition called "intussusception" in your small bowel. - You decided not to undergo a surgery for your intussusception, due to the risks involved as well as the extent of your cancer. You requested that we focus on controlling your pain and symptoms. WHAT SHOULD I DO WHEN I AM HOME? ================================ - You will go home with Hospice services, who will be able to provide you the supplies and medicines you need to remain comfortable in your home. Thank you for letting us be involved in your care, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "Z8673", "F17210", "G4700", "K5900", "Z515", "F419", "Z66" ]	[ "K561: Intussusception", "E43: Unspecified severe protein-calorie malnutrition", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C784: Secondary malignant neoplasm of small intestine", "C7971: Secondary malignant neoplasm of right adrenal gland", "D630: Anemia in neoplastic disease", "C3412: Malignant neoplasm of upper lobe, left bronchus or lung", "Q211: Atrial septal defect", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C7972: Secondary malignant neoplasm of left adrenal gland", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F17210: Nicotine dependence, cigarettes, uncomplicated", "G4700: Insomnia, unspecified", "K5900: Constipation, unspecified", "D72829: Elevated white blood cell count, unspecified", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "Z515: Encounter for palliative care", "M8448XD: Pathological fracture, other site, subsequent encounter for fracture with routine healing", "F419: Anxiety disorder, unspecified", "Z66: Do not resuscitate" ]
10,045,326	25,966,591	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___ Chief Complaint: Shortness of breath, lethargy, weakness, poor appetite Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y/o man with pmhx of newly diagnosed lung ca, who presents from home with ___ days of progressive dyspnea. He states that he has been feeling badly for weeks now since diagnosis of lung cancer nearly a month ago. He endorses poor PO intake due to mild nausea but mostly no appetite. He has tried dronabinol (terrible side effects of diarrhea and cramping) as well as marijuana (now no drive to even use that). He endorses nearly 30 pounds of weight loss over past few months. More acutely, he for the past few days has had increasing shortness of breath without significant cough or sputum production. He denies any fevers or chills. Does have some substernal pressure that is worse with coughing. No diagnosed lung disease apart from lung cancer, but does have decades of tobacco use and used to work in ___ so feels like had lots of exposure to potential toxins. He feels that he should have presented to ED multiple days ago, but did not have the drive to. Finally pushed by mother and girlfriend to come in. Of note, patient most recently saw Dr. ___ Atrius oncology on ___, at which point he was planned to start chemotherapy (___) on ___. He did take dexamethasone as instructed ___. He has not had any chemotherapy yet. Detailed oncologic history as below. In the ED, initial vitals were: 95.8 85 122/80 24 100% RA - Exam notable for: diffuse expiratory wheezing bilaterally, increased work of breathing with subcostal and supraclavicular respiratory muscle involvement - Labs notable for: WBC 39.8, flu A/B negative - Imaging: CXR without acute process, known lung mass - Duonebs and diazepam was given. Upon arrival to the floor, patient endorses the above history. He feels weak, +anorexia, hasn't slept in many days. He would like a diazepam to help him sleep. Feels breathing is still not at baseline. Has some mild chest tightness, but no other symptoms. REVIEW OF SYSTEMS: As per HPI. Past Medical History: Newly diagnosed lung cancer as below History of alcohol abuse History of substance abuse Atrial septal defect Stroke, small vessel in ___ without residual deficits, on aggrenox Tobacco dependence Hypercholesteremia Insomnia, unspecified ONCOLOGIC HISTORY PER ATRIUS: PATHOLOGY RESULTS: ___- cervical node biopsy (FNA)- non-diagnostic ___- left axillary node biopsy (FNA)- negative ___- EUS/Adrenal gland core biopsy: - Poorly differentiated carcinoma with extensive necrosis. Note: Immunohistochemical stains are performed. The tumor cells are positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20, TTF-1, Napsin, P40 and Inhibin are negative. The findings are not specific for the origin of this tumor. Clinical/imaging correlation is recommended. Social History: ___ Family History: No family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM VITAL SIGNS: 98.2 116/76 87 18 96 RA GENERAL: Chronically ill appearing, tired, but in NAD HEENT: NC/AT, wearing glasses, dry mucous membranes, tongue midline on protrusion NECK: supple, symmetric CARDIAC: RRR, no m/r/g LUNGS: air movement with poor effort is present but poor in all fields; no crackles, rhonchi, or wheezes can be appreciated in this context; no increased work of breathing and speaking in full senteces ABDOMEN: Soft, mildly tender on palpation diffusely, non-rigid, no r/g, BS+ EXTREMITIES: thin, WWP, no pitting edema, distal pulses intact NEUROLOGIC: alert and oriented; moving all extremities; symmetric smile, sensation to light touch symmetric and intact in all divisions of CN5, UE, torso, ___ strength ___ in b/l UE, able to lift both legs up against gravity and downward pressure b/l SKIN: no bruises or petechiae DISCHARGE PHYSICAL EXAM Vital Signs: T 97.6 PO BP 100 / 60 HR 86 RR 18 O2 93 RA General: Sitting up on a chair, eating breakfast, no acute distress Head: Normocephalic/ atraumatic, teeth and gums normal Lungs: Poor air movement throughout all lung fields, decreased breath sounds, no increased work of breathing, speaks in full sentences Heart: regular rate and rhythm, S1, S2 normal Abdomen: soft, non tender, normal bowel sounds Extremities: warm, well perfused, no edema Neuro: Alert and oriented, UE strength grossly normal, ___ strength normal. Sensation grossly intact throughout all extremities Pertinent Results: ADMISSION LABS --------------- ___ 10:03PM BLOOD WBC-39.8* RBC-4.54* Hgb-12.7* Hct-38.9* MCV-86 MCH-28.0 MCHC-32.6 RDW-14.2 RDWSD-43.8 Plt ___ ___ 10:03PM BLOOD Neuts-86.0* Lymphs-5.8* Monos-4.7* Eos-1.0 Baso-0.7 Im ___ AbsNeut-34.23* AbsLymp-2.30 AbsMono-1.89* AbsEos-0.38 AbsBaso-0.27* ___ 07:50AM BLOOD ___ PTT-29.7 ___ ___ 10:03PM BLOOD Glucose-84 UreaN-15 Creat-0.9 Na-137 K-4.8 Cl-96 HCO3-23 AnGap-23* ___ 10:03PM BLOOD CK(CPK)-25* ___ 07:50AM BLOOD ALT-12 AST-13 LD(LDH)-320* AlkPhos-168* TotBili-0.3 ___ 10:03PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 07:50AM BLOOD Albumin-3.1* Calcium-9.4 Phos-4.0 Mg-1.8 ___ 07:50AM BLOOD Cortsol-15.4 ___ 10:12PM BLOOD ___ pO2-25* pCO2-46* pH-7.42 calTCO2-31* Base XS-3 ___ 10:12PM BLOOD Lactate-1.4 ___ 10:35AM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 10:35AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 10:35AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 MICROBIOLOGY ------------ Time Taken Not Noted Log-In Date/Time: ___ 7:26 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. *FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). IMAGING --------- CXR (___): No acute cardiopulmonary process. Re- demonstration of left apical mass, better assessed on previous CT. Upper lobe predominant emphysema. CT CHEST (___): Growing left upper lobe lung mass. At least 3 rib metastases responsible for pathologic fractures, one healed and 2 not healed, were present in ___. No new metastases. Coronary atherosclerosis. Findings below the diaphragm including large bilateral adrenal masses will be reported separately. CT ABDOMEN/PELVIS (___): 1. 10 x 8 mm rounded soft tissue nodule in the left buttock deep to the gluteus musculature is new from the recent prior exam of ___, worrisome for soft tissue metastasis. 2. Bilateral heterogeneously hypoenhancing adrenal metastases are significantly larger since ___, now measuring up to 6.5 cm on the right and 5.5 cm on the left (previously up to 2.4 and 2.5 cm, respectively). 3. Please see separate report for intrathoracic findings from same-day CT chest. DISCHARGE LABS --------------- ___ 08:10AM BLOOD WBC-37.9 RBC-4.36* Hgb-12.1* Hct-37.4* MCV-86 MCH-27.8 MCHC-32.4 RDW-14.1 RDWSD-43.7 Plt ___ ___ 08:10AM BLOOD Glucose-50* UreaN-12 Creat-0.9 Na-139 K-4.4 Cl-97 HCO3-25 AnGap-21* ___ 08:10AM BLOOD Calcium-10.0 Phos-4.7* Mg-2.7* Brief Hospital Course: Mr. ___ is a ___ male with a ___ smoking history and recent diagnosis of lung cancer in ___ with metastasis to adrenal glands, who presents for failure to thrive, leukemoid reaction, and progression of his metastatic disease. # Failure to thrive. In the setting of progression of his metastatic lung cancer, Mr. ___ has been experiencing a decline in his ability to care for himself. Notable weight loss of ~20lbs in the past few months, decreased appetite, exhaustion and decreased physical activity. He has taken Dronabinol in the past but experienced significant diarrhea and cramping. Initial concern for adrenal insufficiency due to adrenal metastases was reassured by AM cortisol of 15. Patient was seen by physical therapy, social work, palliative care, and nutrition. Palliative care recommended symptomatic treatment of his constipation with Milk of Magnesia and appetite stimulants were discussed (consideration for dronabinol versus medical marijuana). He should have a bowel movement at least once every three days. If he does not, we advised him to take milk of magnesia till he has a bowel movement. Patient declined any additional appetite stimulants at this time; he did not want to be "stoned" during the day. Nutrition advised nutritional supplementation with Ensure supplements at meals. Patient remained hemodynamically and clinically stable throughout his hospital stay. Ambulatory O2sat on discharge was 98%. # Leukemoid reaction. Patient presented with leukocytosis to 39.8 which was a significant rise from his last CBC (normal in ___, though prior to diagnosis of his lung cancer). Clinically the patient did not appear infected (no fever, cough, diarrhea). Infectious workup is negative to date (blood cultures, urine culture, C. diff, CXR). Blood smear did not reveal any concern for a primary hematologic disorder and was consistent with a significant leukemoid reaction, likely in the setting of his progressive, metastatic, lung cancer. # Lung cancer, metastatic. Presenting with fatigue, general malaise, poor appetite and worsening dyspnea in the setting of recent diagnosis of lung cancer (___). CT abdomen and pelvis on this admission is concerning for progression of his adrenal metastasis and a new 10 x 8 mm rounded soft tissue nodule in the left buttock deep to the gluteus musculature (concerning for soft tissue metastasis). CT chest revealed growing left upper lobe lung mass. After discussions with Atrius oncology, patient will be discharged to begin chemotherapy on ___, as an outpatient. He will start Dexamethasone 4 mg daily today for three days. # Hyperlipidemia. Consider stopping statin given his shortened life expectancy versus time required for benefit of statin. # Insomnia. Patient has longstanding insomnia and is prescribed diazepam 15mg qhs. He noted that he frequently takes anywhere between ___ per night. He has not tried good sleep hygiene practices. Additionally, his primary problem is maintenance of sleep (not initiation) so it would be helpful for him to try medicaitons for maintenance of sleep as he is slowly weaned off diazepam (given his longstanding use of benzodiazepines for sleep). TRANSITIONAL ISSUES ------------------- FAILURE TO THRIVE [ ]Nutrition: Tried Dronabinol in the past but experienced diarrhea and cramping. Medical marijuana was discussed as an appetite stimulant, which he refuses at this time. PO supplementation with Ensure shakes has been advised [ ]Constipation: Patient has been advised to take Milk of Magnesia as needed if he is not experiencing bowel movements at least once every three days LEUKEMOID REACTION -WBC on discharge was 37.9 [ ]F/up on pending blood and urine cultures LUNG CANCER, METASTATIC TO ADRENALS/RIBS/LEFT BUTTOCK [ ]Patient to begin chemotherapy on ___ [ ]Advised to take Dexamethasone 4 mg daily on the day prior, day of, day after chemotherapy. Start date ___. End date ___ INSOMNIA [ ]Advised slowly titrating off Diazepam. Promotion of maintenance of sleep medications (Ambien), not initiation of sleep -Continue to encourage good sleep hygiene #Discharge weight: 57.4kg #CODE: FULL CODE for now #CONTACT: ___ Mother ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 2. Dexamethasone 4 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. Multivitamins W/minerals 1 TAB PO DAILY 7. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 8. Simvastatin 20 mg PO QPM 9. Dipyridamole-Aspirin 1 CAP PO BID 10. Sildenafil ___ mg PO PRN intercourse Discharge Medications: 1. Milk of Magnesia 30 mL PO Q6H:PRN constipation RX magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by mouth every six (6) hours Refills:2 2. Dexamethasone 4 mg PO DAILY Duration: 3 Days 3. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 4. Dipyridamole-Aspirin 1 CAP PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Sildenafil ___ mg PO PRN intercourse 11. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Failure to thrive, Leukemoid reaction secondary to progressive metastatic lung cancer, Constipation Secondary diagnoses: Metastatic Stave IV lung cancer, hyperlipidemia, insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized at ___ for weakness, poor appetite, decreased activity, and exhaustion. These symptoms are most consistent with your underlying lung cancer and the progression of the disease. We have advised nutritional supplementation with Ensure, Milk of Magnesium for your constipation (to be taken if you are not having a bowel movement every three days), and physical therapy as tolerated. Imaging and labs are negative for an infection at this time. You have an elevated white blood cell count (a marker of inflammation or infection) and in this case, we think it is a reflection of the progression of your lung cancer (as confirmed on imaging). We have spoken with the Oncology team at ___. They would like you to start chemotherapy on ___. You will take three days of Dexamethasone to begin today and to end on ___. Please make sure to take your bowel regimen medication. You should have a bowel movement atleast once every three days. If you do not have a bowel movement by the third day please take Milk of Magnesia till you have a bowel movement. It is important that you attend the follow-up appointments listed below. It was a pleasure taking care of you! We wish you the best! Your ___ Team Followup Instructions: ___	[ "R627", "D72823", "K5900", "C3412", "C7972", "C7971", "C7951", "C7989", "E785", "G4700", "Z8673", "F17210", "R42" ]	Allergies: Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Chief Complaint: Shortness of breath, lethargy, weakness, poor appetite Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] y/o man with pmhx of newly diagnosed lung ca, who presents from home with [MASKED] days of progressive dyspnea. He states that he has been feeling badly for weeks now since diagnosis of lung cancer nearly a month ago. He endorses poor PO intake due to mild nausea but mostly no appetite. He has tried dronabinol (terrible side effects of diarrhea and cramping) as well as marijuana (now no drive to even use that). He endorses nearly 30 pounds of weight loss over past few months. More acutely, he for the past few days has had increasing shortness of breath without significant cough or sputum production. He denies any fevers or chills. Does have some substernal pressure that is worse with coughing. No diagnosed lung disease apart from lung cancer, but does have decades of tobacco use and used to work in [MASKED] so feels like had lots of exposure to potential toxins. He feels that he should have presented to ED multiple days ago, but did not have the drive to. Finally pushed by mother and girlfriend to come in. Of note, patient most recently saw Dr. [MASKED] Atrius oncology on [MASKED], at which point he was planned to start chemotherapy ([MASKED]) on [MASKED]. He did take dexamethasone as instructed [MASKED]. He has not had any chemotherapy yet. Detailed oncologic history as below. In the ED, initial vitals were: 95.8 85 122/80 24 100% RA - Exam notable for: diffuse expiratory wheezing bilaterally, increased work of breathing with subcostal and supraclavicular respiratory muscle involvement - Labs notable for: WBC 39.8, flu A/B negative - Imaging: CXR without acute process, known lung mass - Duonebs and diazepam was given. Upon arrival to the floor, patient endorses the above history. He feels weak, +anorexia, hasn't slept in many days. He would like a diazepam to help him sleep. Feels breathing is still not at baseline. Has some mild chest tightness, but no other symptoms. REVIEW OF SYSTEMS: As per HPI. Past Medical History: Newly diagnosed lung cancer as below History of alcohol abuse History of substance abuse Atrial septal defect Stroke, small vessel in [MASKED] without residual deficits, on aggrenox Tobacco dependence Hypercholesteremia Insomnia, unspecified ONCOLOGIC HISTORY PER ATRIUS: PATHOLOGY RESULTS: [MASKED]- cervical node biopsy (FNA)- non-diagnostic [MASKED]- left axillary node biopsy (FNA)- negative [MASKED]- EUS/Adrenal gland core biopsy: - Poorly differentiated carcinoma with extensive necrosis. Note: Immunohistochemical stains are performed. The tumor cells are positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20, TTF-1, Napsin, P40 and Inhibin are negative. The findings are not specific for the origin of this tumor. Clinical/imaging correlation is recommended. Social History: [MASKED] Family History: No family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM VITAL SIGNS: 98.2 116/76 87 18 96 RA GENERAL: Chronically ill appearing, tired, but in NAD HEENT: NC/AT, wearing glasses, dry mucous membranes, tongue midline on protrusion NECK: supple, symmetric CARDIAC: RRR, no m/r/g LUNGS: air movement with poor effort is present but poor in all fields; no crackles, rhonchi, or wheezes can be appreciated in this context; no increased work of breathing and speaking in full senteces ABDOMEN: Soft, mildly tender on palpation diffusely, non-rigid, no r/g, BS+ EXTREMITIES: thin, WWP, no pitting edema, distal pulses intact NEUROLOGIC: alert and oriented; moving all extremities; symmetric smile, sensation to light touch symmetric and intact in all divisions of CN5, UE, torso, [MASKED] strength [MASKED] in b/l UE, able to lift both legs up against gravity and downward pressure b/l SKIN: no bruises or petechiae DISCHARGE PHYSICAL EXAM Vital Signs: T 97.6 PO BP 100 / 60 HR 86 RR 18 O2 93 RA General: Sitting up on a chair, eating breakfast, no acute distress Head: Normocephalic/ atraumatic, teeth and gums normal Lungs: Poor air movement throughout all lung fields, decreased breath sounds, no increased work of breathing, speaks in full sentences Heart: regular rate and rhythm, S1, S2 normal Abdomen: soft, non tender, normal bowel sounds Extremities: warm, well perfused, no edema Neuro: Alert and oriented, UE strength grossly normal, [MASKED] strength normal. Sensation grossly intact throughout all extremities Pertinent Results: ADMISSION LABS --------------- [MASKED] 10:03PM BLOOD WBC-39.8* RBC-4.54* Hgb-12.7* Hct-38.9* MCV-86 MCH-28.0 MCHC-32.6 RDW-14.2 RDWSD-43.8 Plt [MASKED] [MASKED] 10:03PM BLOOD Neuts-86.0* Lymphs-5.8* Monos-4.7* Eos-1.0 Baso-0.7 Im [MASKED] AbsNeut-34.23* AbsLymp-2.30 AbsMono-1.89* AbsEos-0.38 AbsBaso-0.27* [MASKED] 07:50AM BLOOD [MASKED] PTT-29.7 [MASKED] [MASKED] 10:03PM BLOOD Glucose-84 UreaN-15 Creat-0.9 Na-137 K-4.8 Cl-96 HCO3-23 AnGap-23* [MASKED] 10:03PM BLOOD CK(CPK)-25* [MASKED] 07:50AM BLOOD ALT-12 AST-13 LD(LDH)-320* AlkPhos-168* TotBili-0.3 [MASKED] 10:03PM BLOOD CK-MB-<1 cTropnT-<0.01 [MASKED] 07:50AM BLOOD Albumin-3.1* Calcium-9.4 Phos-4.0 Mg-1.8 [MASKED] 07:50AM BLOOD Cortsol-15.4 [MASKED] 10:12PM BLOOD [MASKED] pO2-25* pCO2-46* pH-7.42 calTCO2-31* Base XS-3 [MASKED] 10:12PM BLOOD Lactate-1.4 [MASKED] 10:35AM URINE Color-Yellow Appear-Cloudy Sp [MASKED] [MASKED] 10:35AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 10:35AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 MICROBIOLOGY ------------ Time Taken Not Noted Log-In Date/Time: [MASKED] 7:26 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. *FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). IMAGING --------- CXR ([MASKED]): No acute cardiopulmonary process. Re- demonstration of left apical mass, better assessed on previous CT. Upper lobe predominant emphysema. CT CHEST ([MASKED]): Growing left upper lobe lung mass. At least 3 rib metastases responsible for pathologic fractures, one healed and 2 not healed, were present in [MASKED]. No new metastases. Coronary atherosclerosis. Findings below the diaphragm including large bilateral adrenal masses will be reported separately. CT ABDOMEN/PELVIS ([MASKED]): 1. 10 x 8 mm rounded soft tissue nodule in the left buttock deep to the gluteus musculature is new from the recent prior exam of [MASKED], worrisome for soft tissue metastasis. 2. Bilateral heterogeneously hypoenhancing adrenal metastases are significantly larger since [MASKED], now measuring up to 6.5 cm on the right and 5.5 cm on the left (previously up to 2.4 and 2.5 cm, respectively). 3. Please see separate report for intrathoracic findings from same-day CT chest. DISCHARGE LABS --------------- [MASKED] 08:10AM BLOOD WBC-37.9 RBC-4.36* Hgb-12.1* Hct-37.4* MCV-86 MCH-27.8 MCHC-32.4 RDW-14.1 RDWSD-43.7 Plt [MASKED] [MASKED] 08:10AM BLOOD Glucose-50* UreaN-12 Creat-0.9 Na-139 K-4.4 Cl-97 HCO3-25 AnGap-21* [MASKED] 08:10AM BLOOD Calcium-10.0 Phos-4.7* Mg-2.7* Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with a [MASKED] smoking history and recent diagnosis of lung cancer in [MASKED] with metastasis to adrenal glands, who presents for failure to thrive, leukemoid reaction, and progression of his metastatic disease. # Failure to thrive. In the setting of progression of his metastatic lung cancer, Mr. [MASKED] has been experiencing a decline in his ability to care for himself. Notable weight loss of ~20lbs in the past few months, decreased appetite, exhaustion and decreased physical activity. He has taken Dronabinol in the past but experienced significant diarrhea and cramping. Initial concern for adrenal insufficiency due to adrenal metastases was reassured by AM cortisol of 15. Patient was seen by physical therapy, social work, palliative care, and nutrition. Palliative care recommended symptomatic treatment of his constipation with Milk of Magnesia and appetite stimulants were discussed (consideration for dronabinol versus medical marijuana). He should have a bowel movement at least once every three days. If he does not, we advised him to take milk of magnesia till he has a bowel movement. Patient declined any additional appetite stimulants at this time; he did not want to be "stoned" during the day. Nutrition advised nutritional supplementation with Ensure supplements at meals. Patient remained hemodynamically and clinically stable throughout his hospital stay. Ambulatory O2sat on discharge was 98%. # Leukemoid reaction. Patient presented with leukocytosis to 39.8 which was a significant rise from his last CBC (normal in [MASKED], though prior to diagnosis of his lung cancer). Clinically the patient did not appear infected (no fever, cough, diarrhea). Infectious workup is negative to date (blood cultures, urine culture, C. diff, CXR). Blood smear did not reveal any concern for a primary hematologic disorder and was consistent with a significant leukemoid reaction, likely in the setting of his progressive, metastatic, lung cancer. # Lung cancer, metastatic. Presenting with fatigue, general malaise, poor appetite and worsening dyspnea in the setting of recent diagnosis of lung cancer ([MASKED]). CT abdomen and pelvis on this admission is concerning for progression of his adrenal metastasis and a new 10 x 8 mm rounded soft tissue nodule in the left buttock deep to the gluteus musculature (concerning for soft tissue metastasis). CT chest revealed growing left upper lobe lung mass. After discussions with Atrius oncology, patient will be discharged to begin chemotherapy on [MASKED], as an outpatient. He will start Dexamethasone 4 mg daily today for three days. # Hyperlipidemia. Consider stopping statin given his shortened life expectancy versus time required for benefit of statin. # Insomnia. Patient has longstanding insomnia and is prescribed diazepam 15mg qhs. He noted that he frequently takes anywhere between [MASKED] per night. He has not tried good sleep hygiene practices. Additionally, his primary problem is maintenance of sleep (not initiation) so it would be helpful for him to try medicaitons for maintenance of sleep as he is slowly weaned off diazepam (given his longstanding use of benzodiazepines for sleep). TRANSITIONAL ISSUES ------------------- FAILURE TO THRIVE [ ]Nutrition: Tried Dronabinol in the past but experienced diarrhea and cramping. Medical marijuana was discussed as an appetite stimulant, which he refuses at this time. PO supplementation with Ensure shakes has been advised [ ]Constipation: Patient has been advised to take Milk of Magnesia as needed if he is not experiencing bowel movements at least once every three days LEUKEMOID REACTION -WBC on discharge was 37.9 [ ]F/up on pending blood and urine cultures LUNG CANCER, METASTATIC TO ADRENALS/RIBS/LEFT BUTTOCK [ ]Patient to begin chemotherapy on [MASKED] [ ]Advised to take Dexamethasone 4 mg daily on the day prior, day of, day after chemotherapy. Start date [MASKED]. End date [MASKED] INSOMNIA [ ]Advised slowly titrating off Diazepam. Promotion of maintenance of sleep medications (Ambien), not initiation of sleep -Continue to encourage good sleep hygiene #Discharge weight: 57.4kg #CODE: FULL CODE for now #CONTACT: [MASKED] Mother [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 2. Dexamethasone 4 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. Multivitamins W/minerals 1 TAB PO DAILY 7. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 8. Simvastatin 20 mg PO QPM 9. Dipyridamole-Aspirin 1 CAP PO BID 10. Sildenafil [MASKED] mg PO PRN intercourse Discharge Medications: 1. Milk of Magnesia 30 mL PO Q6H:PRN constipation RX magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by mouth every six (6) hours Refills:2 2. Dexamethasone 4 mg PO DAILY Duration: 3 Days 3. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 4. Dipyridamole-Aspirin 1 CAP PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Sildenafil [MASKED] mg PO PRN intercourse 11. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Failure to thrive, Leukemoid reaction secondary to progressive metastatic lung cancer, Constipation Secondary diagnoses: Metastatic Stave IV lung cancer, hyperlipidemia, insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were hospitalized at [MASKED] for weakness, poor appetite, decreased activity, and exhaustion. These symptoms are most consistent with your underlying lung cancer and the progression of the disease. We have advised nutritional supplementation with Ensure, Milk of Magnesium for your constipation (to be taken if you are not having a bowel movement every three days), and physical therapy as tolerated. Imaging and labs are negative for an infection at this time. You have an elevated white blood cell count (a marker of inflammation or infection) and in this case, we think it is a reflection of the progression of your lung cancer (as confirmed on imaging). We have spoken with the Oncology team at [MASKED]. They would like you to start chemotherapy on [MASKED]. You will take three days of Dexamethasone to begin today and to end on [MASKED]. Please make sure to take your bowel regimen medication. You should have a bowel movement atleast once every three days. If you do not have a bowel movement by the third day please take Milk of Magnesia till you have a bowel movement. It is important that you attend the follow-up appointments listed below. It was a pleasure taking care of you! We wish you the best! Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "K5900", "E785", "G4700", "Z8673", "F17210" ]	[ "R627: Adult failure to thrive", "D72823: Leukemoid reaction", "K5900: Constipation, unspecified", "C3412: Malignant neoplasm of upper lobe, left bronchus or lung", "C7972: Secondary malignant neoplasm of left adrenal gland", "C7971: Secondary malignant neoplasm of right adrenal gland", "C7951: Secondary malignant neoplasm of bone", "C7989: Secondary malignant neoplasm of other specified sites", "E785: Hyperlipidemia, unspecified", "G4700: Insomnia, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R42: Dizziness and giddiness" ]
10,045,326	26,512,329	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___. Chief Complaint: flank pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ yo man wit newly diagnosed poorly differentiated metastatic lung cancer based upon a biopsy of an adrenal lesion followed by Dr ___ admitted with right flank and RUQ abdominal pain and transient left leg discomfort and tingling. Past Medical History: Newly diagnosed lung cancer as below History of alcohol abuse History of substance abuse Atrial septal defect Stroke, small vessel in ___ without residual deficits, on aggrenox Tobacco dependence Hypercholesteremia Insomnia, unspecified ONCOLOGIC HISTORY PER ATRIUS: PATHOLOGY RESULTS: ___- cervical node biopsy (FNA)- non-diagnostic ___- left axillary node biopsy (FNA)- negative ___- EUS/Adrenal gland core biopsy: - Poorly differentiated carcinoma with extensive necrosis. Note: Immunohistochemical stains are performed. The tumor cells are positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20, TTF-1, Napsin, P40 and Inhibin are negative. The findings are not specific for the origin of this tumor. Clinical/imaging correlation is recommended. Social History: ___ Family History: No family history of cancer. Physical Exam: VS: 98.2 PO 92 / 55 102 18 93 RA GEN: cachectic appearing in NAD HEENT/Neck: anicteric sclera, MMM, OP clear, neck supple HEART: RRR no m/r/g LUNGS: CTAB no wheezes, rales, or crackles. Symmetric expansion ABD: soft NT/ND +BS no rebound or guarding EXT: warm well perfused, no pitting edema NEURO: alert and oriented. Fluent speech. CN II-XII intact. No focal deficits on strength testing, ___ strength with gross sensation intact Pertinent Results: ___ 08:52PM LACTATE-1.0 ___ 01:10PM URINE HOURS-RANDOM ___ 01:10PM URINE UHOLD-HOLD ___ 01:10PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:10PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 ___ 10:07AM TYPE-ART COMMENTS-GREEN TOP ___ 10:07AM LACTATE-1.5 ___ 10:01AM GLUCOSE-79 UREA N-26* CREAT-0.8 SODIUM-135 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18 ___ 10:01AM ALT(SGPT)-72* AST(SGOT)-43* ALK PHOS-178* TOT BILI-0.5 ___ 10:01AM LIPASE-35 ___ 10:01AM ALBUMIN-3.6 ___ 10:01AM WBC-34.0* RBC-3.78* HGB-10.7* HCT-32.6* MCV-86 MCH-28.3 MCHC-32.8 RDW-14.2 RDWSD-44.5 ___ 10:01AM NEUTS-90.9* LYMPHS-5.3* MONOS-0.6* EOS-1.4 BASOS-0.3 IM ___ AbsNeut-30.93* AbsLymp-1.80 AbsMono-0.20 AbsEos-0.47 AbsBaso-0.11* ___ 10:01AM PLT COUNT-370 FINDINGS: The liver appears normal in grayscale appearance and size without focal lesion of concern. No biliary ductal dilation. Gallstones noted within the gallbladder though there is no evidence for acute cholecystitis. Sonographic ___ sign is negative. Common bile duct measures up to 3 mm. The known right adrenal metastasis is visualized though better characterized on same-day CT exam. A simple appearing cyst is seen in the right kidney interpolar region measuring 2 cm in diameter. Lymphadenopathy adjacent to the pancreas better assessed on same-day CT. No ascites. IMPRESSION: 1. Cholelithiasis without evidence of cholecystitis. 2. Right adrenal mass and enlarged peripancreatic nodes better assessed on same-day CT exam. IMPRESSION: 1. No evidence of acute pulmonary embolism or aortic abnormality. 2. Interval worsening and enlargement of retroperitoneal lymph nodes, specifically with development of at least 3 centrally necrotic lymph nodes along the posterior aspect of the pancreas. 3. Slight interval increase in size of left gluteal soft tissue nodule since ___. 4. Bilateral adrenal metastatic lesions are unchanged in size from ___ but significantly larger than ___. 5. Unchanged left upper lobe pulmonary mass. Brief Hospital Course: ___ yo M with poorly differentiated metastatic lung cancer with adrenal mets, lymphadenopathy, s/p recent pemetrexed/carboplatin ___, who presented with R flank pain and episode of L leg numbness now resolved. Acute R flank pain: Work up as above and essentially negative except for cholelithiasis. Resolved after 24 hrs. Cause unclear. ___ be side effect from chemotherapy. ___ be biliary colic as well. RUQ US without cholecystitis or evidence of obstruction. Imaging re-assuring and not consistent with renal colic, pancreatitis, or referred pain. Follow up with oncology scheduled for day after discharge. Metastatic poorly differentiated lung cancer: s/p chemo on ___. Reviewed case with Dr. ___ ___ oncology. Cont Folate LLE numbness: Resolved. Possibly due to sciatica though no back pain. Metastatic dz to spine is also to be considered, though PET imaging was negative and symptoms resolved on their own spontaneously. One would expect persistent symptoms if there were a mass lesion. - Outpatient follow up Hypotension: IVF given Anxiety: stable h/o CVA: Continued aggrenox Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 2. Dipyridamole-Aspirin 1 CAP PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 7. Prochlorperazine 10 mg PO Q6H:PRN nausea 8. Simvastatin 20 mg PO QPM 9. Sildenafil ___ mg PO PRN intercourse 10. Dexamethasone 4 mg PO DAILY 11. Milk of Magnesia 30 mL PO Q6H:PRN constipation Discharge Medications: 1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 2. Dipyridamole-Aspirin 1 CAP PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Milk of Magnesia 30 mL PO Q6H:PRN constipation 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea 7. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 8. Prochlorperazine 10 mg PO Q6H:PRN nausea 9. Sildenafil ___ mg PO PRN intercourse 10. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Metastatic lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation of right sided pain and left leg numbness. Evaluation was negative. Your symptoms improved. Please stay well hydrated, take your medications as prescribed, and follow up with your oncologist as scheduled tomorrow Followup Instructions: ___	[ "C3490", "C7970", "R1011", "R531", "R0600", "M79605", "R590", "K8020", "Q211", "Z8673", "Z7902", "F17200", "E7800", "G4700", "F419", "R110", "I959" ]	Allergies: Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Chief Complaint: flank pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] yo man wit newly diagnosed poorly differentiated metastatic lung cancer based upon a biopsy of an adrenal lesion followed by Dr [MASKED] admitted with right flank and RUQ abdominal pain and transient left leg discomfort and tingling. Past Medical History: Newly diagnosed lung cancer as below History of alcohol abuse History of substance abuse Atrial septal defect Stroke, small vessel in [MASKED] without residual deficits, on aggrenox Tobacco dependence Hypercholesteremia Insomnia, unspecified ONCOLOGIC HISTORY PER ATRIUS: PATHOLOGY RESULTS: [MASKED]- cervical node biopsy (FNA)- non-diagnostic [MASKED]- left axillary node biopsy (FNA)- negative [MASKED]- EUS/Adrenal gland core biopsy: - Poorly differentiated carcinoma with extensive necrosis. Note: Immunohistochemical stains are performed. The tumor cells are positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20, TTF-1, Napsin, P40 and Inhibin are negative. The findings are not specific for the origin of this tumor. Clinical/imaging correlation is recommended. Social History: [MASKED] Family History: No family history of cancer. Physical Exam: VS: 98.2 PO 92 / 55 102 18 93 RA GEN: cachectic appearing in NAD HEENT/Neck: anicteric sclera, MMM, OP clear, neck supple HEART: RRR no m/r/g LUNGS: CTAB no wheezes, rales, or crackles. Symmetric expansion ABD: soft NT/ND +BS no rebound or guarding EXT: warm well perfused, no pitting edema NEURO: alert and oriented. Fluent speech. CN II-XII intact. No focal deficits on strength testing, [MASKED] strength with gross sensation intact Pertinent Results: [MASKED] 08:52PM LACTATE-1.0 [MASKED] 01:10PM URINE HOURS-RANDOM [MASKED] 01:10PM URINE UHOLD-HOLD [MASKED] 01:10PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 01:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 01:10PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 [MASKED] 10:07AM TYPE-ART COMMENTS-GREEN TOP [MASKED] 10:07AM LACTATE-1.5 [MASKED] 10:01AM GLUCOSE-79 UREA N-26* CREAT-0.8 SODIUM-135 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18 [MASKED] 10:01AM ALT(SGPT)-72* AST(SGOT)-43* ALK PHOS-178* TOT BILI-0.5 [MASKED] 10:01AM LIPASE-35 [MASKED] 10:01AM ALBUMIN-3.6 [MASKED] 10:01AM WBC-34.0* RBC-3.78* HGB-10.7* HCT-32.6* MCV-86 MCH-28.3 MCHC-32.8 RDW-14.2 RDWSD-44.5 [MASKED] 10:01AM NEUTS-90.9* LYMPHS-5.3* MONOS-0.6* EOS-1.4 BASOS-0.3 IM [MASKED] AbsNeut-30.93* AbsLymp-1.80 AbsMono-0.20 AbsEos-0.47 AbsBaso-0.11* [MASKED] 10:01AM PLT COUNT-370 FINDINGS: The liver appears normal in grayscale appearance and size without focal lesion of concern. No biliary ductal dilation. Gallstones noted within the gallbladder though there is no evidence for acute cholecystitis. Sonographic [MASKED] sign is negative. Common bile duct measures up to 3 mm. The known right adrenal metastasis is visualized though better characterized on same-day CT exam. A simple appearing cyst is seen in the right kidney interpolar region measuring 2 cm in diameter. Lymphadenopathy adjacent to the pancreas better assessed on same-day CT. No ascites. IMPRESSION: 1. Cholelithiasis without evidence of cholecystitis. 2. Right adrenal mass and enlarged peripancreatic nodes better assessed on same-day CT exam. IMPRESSION: 1. No evidence of acute pulmonary embolism or aortic abnormality. 2. Interval worsening and enlargement of retroperitoneal lymph nodes, specifically with development of at least 3 centrally necrotic lymph nodes along the posterior aspect of the pancreas. 3. Slight interval increase in size of left gluteal soft tissue nodule since [MASKED]. 4. Bilateral adrenal metastatic lesions are unchanged in size from [MASKED] but significantly larger than [MASKED]. 5. Unchanged left upper lobe pulmonary mass. Brief Hospital Course: [MASKED] yo M with poorly differentiated metastatic lung cancer with adrenal mets, lymphadenopathy, s/p recent pemetrexed/carboplatin [MASKED], who presented with R flank pain and episode of L leg numbness now resolved. Acute R flank pain: Work up as above and essentially negative except for cholelithiasis. Resolved after 24 hrs. Cause unclear. [MASKED] be side effect from chemotherapy. [MASKED] be biliary colic as well. RUQ US without cholecystitis or evidence of obstruction. Imaging re-assuring and not consistent with renal colic, pancreatitis, or referred pain. Follow up with oncology scheduled for day after discharge. Metastatic poorly differentiated lung cancer: s/p chemo on [MASKED]. Reviewed case with Dr. [MASKED] [MASKED] oncology. Cont Folate LLE numbness: Resolved. Possibly due to sciatica though no back pain. Metastatic dz to spine is also to be considered, though PET imaging was negative and symptoms resolved on their own spontaneously. One would expect persistent symptoms if there were a mass lesion. - Outpatient follow up Hypotension: IVF given Anxiety: stable h/o CVA: Continued aggrenox Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 2. Dipyridamole-Aspirin 1 CAP PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea 6. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 7. Prochlorperazine 10 mg PO Q6H:PRN nausea 8. Simvastatin 20 mg PO QPM 9. Sildenafil [MASKED] mg PO PRN intercourse 10. Dexamethasone 4 mg PO DAILY 11. Milk of Magnesia 30 mL PO Q6H:PRN constipation Discharge Medications: 1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety 2. Dipyridamole-Aspirin 1 CAP PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Milk of Magnesia 30 mL PO Q6H:PRN constipation 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea 7. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 8. Prochlorperazine 10 mg PO Q6H:PRN nausea 9. Sildenafil [MASKED] mg PO PRN intercourse 10. Simvastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Metastatic lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation of right sided pain and left leg numbness. Evaluation was negative. Your symptoms improved. Please stay well hydrated, take your medications as prescribed, and follow up with your oncologist as scheduled tomorrow Followup Instructions: [MASKED]	[]	[ "Z8673", "Z7902", "G4700", "F419" ]	[ "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "C7970: Secondary malignant neoplasm of unspecified adrenal gland", "R1011: Right upper quadrant pain", "R531: Weakness", "R0600: Dyspnea, unspecified", "M79605: Pain in left leg", "R590: Localized enlarged lymph nodes", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "Q211: Atrial septal defect", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "F17200: Nicotine dependence, unspecified, uncomplicated", "E7800: Pure hypercholesterolemia, unspecified", "G4700: Insomnia, unspecified", "F419: Anxiety disorder, unspecified", "R110: Nausea", "I959: Hypotension, unspecified" ]
10,045,395	29,383,457	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: peanuts / Singulair Attending: ___ Chief Complaint: Bilateral popliteal artery entrapment Major Surgical or Invasive Procedure: Bilateral Leg Popliteal Artery Releases; popliteal neurolysis, bilateral; myomectomies medial and lateral gastroxnemius muscles bilateral History of Present Illness: ___ is a very active young lady in her ___ who is a high school and college athlete. She has been treated in the Sports Medicine Clinic for a number of years for compartment syndromes. She has a very short, stocky, muscular habitus and she has had multiple compartment fasciotomies for exertional compartment syndrome. These helped, but did not completely solve her stress-induced pain completely. She subsequently had MRIs done using the plantar flexion maneuver. These showed partial compression of the popliteal artery on both sides, worse on the right than the left. Interestingly, on the right side she had a large osteophyte on the posterior aspect of the lateral femoral condyle, which is in an area where this compression was seen. She was brought to the OR today for a popliteal artery decompression. This included complete fasciectomy of the posterior aspect of both knees as well as resection of a portion of the origins of the medial and lateral gastrocnemius muscles within the popliteal space. She did not have hypertrophied plantaris or popliteus muscles. She did not have an extra medial and gastroc on either side. Past Medical History: Bilateral popliteal entrapment syndrome Social History: ___ Family History: Noncontributory Physical Exam: At discharge: ___ 0332 Temp: 98.5 PO BP: 114/71 HR: 80 RR: 18 O2 sat: 95% O2 delivery: RA Gen: NAD, A&Ox3, lying on stretcher. HEENT: Normocephalic. CV: RRR R: Breathing comfortably on room air. No wheezing. Ext: WWP. Dressings in place and are c/d/i; JP drains w/ SS output bilaterally; some diminished sensation bilaterally which is to be expected after this operation; able to wiggle toes bilaterally Pertinent Results: N/a Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on ___ for Bilateral Leg Popliteal Artery Releases; popliteal neurolysis, bilateral; myomectomies medial and lateral gastroxnemius muscles bilateral, 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. She was also started on a daily 81mg Aspirin. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. She was given knee immobilizers and crutches to ambulate, per protocol. At the time of discharge the patient's pain was well controlled with oral medications, dressings were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is partial weight bearing in her bilateral lower extremities, and will be discharged on Aspirin 81mg for thrombosis prophylaxis. The patient will follow up with Dr. ___ in ___ weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line 3. cefaDROXil 500 mg oral BID RX cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp #14 Capsule Refills:1 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 300 mg PO TID RX gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #60 Capsule Refills:0 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth q4-6 hours Disp #40 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bilateral popliteal artery entrapment Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: -Please leave your dressings in place until your follow up appointment -Please do not get your dressings wet; sponge bath only -Please wear your knee immobilizers at all times; please use crutches to help you ambulate -Please record your drain outputs daily Followup Instructions: ___	[ "I771", "M79A22", "M79A21", "G43909", "J45909", "G8918" ]	Allergies: peanuts / Singulair Chief Complaint: Bilateral popliteal artery entrapment Major Surgical or Invasive Procedure: Bilateral Leg Popliteal Artery Releases; popliteal neurolysis, bilateral; myomectomies medial and lateral gastroxnemius muscles bilateral History of Present Illness: [MASKED] is a very active young lady in her [MASKED] who is a high school and college athlete. She has been treated in the Sports Medicine Clinic for a number of years for compartment syndromes. She has a very short, stocky, muscular habitus and she has had multiple compartment fasciotomies for exertional compartment syndrome. These helped, but did not completely solve her stress-induced pain completely. She subsequently had MRIs done using the plantar flexion maneuver. These showed partial compression of the popliteal artery on both sides, worse on the right than the left. Interestingly, on the right side she had a large osteophyte on the posterior aspect of the lateral femoral condyle, which is in an area where this compression was seen. She was brought to the OR today for a popliteal artery decompression. This included complete fasciectomy of the posterior aspect of both knees as well as resection of a portion of the origins of the medial and lateral gastrocnemius muscles within the popliteal space. She did not have hypertrophied plantaris or popliteus muscles. She did not have an extra medial and gastroc on either side. Past Medical History: Bilateral popliteal entrapment syndrome Social History: [MASKED] Family History: Noncontributory Physical Exam: At discharge: [MASKED] 0332 Temp: 98.5 PO BP: 114/71 HR: 80 RR: 18 O2 sat: 95% O2 delivery: RA Gen: NAD, A&Ox3, lying on stretcher. HEENT: Normocephalic. CV: RRR R: Breathing comfortably on room air. No wheezing. Ext: WWP. Dressings in place and are c/d/i; JP drains w/ SS output bilaterally; some diminished sensation bilaterally which is to be expected after this operation; able to wiggle toes bilaterally Pertinent Results: N/a Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on [MASKED] for Bilateral Leg Popliteal Artery Releases; popliteal neurolysis, bilateral; myomectomies medial and lateral gastroxnemius muscles bilateral, 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. She was also started on a daily 81mg Aspirin. The patient worked with [MASKED] who determined that discharge to home was appropriate. The [MASKED] hospital course was otherwise unremarkable. She was given knee immobilizers and crutches to ambulate, per protocol. At the time of discharge the patient's pain was well controlled with oral medications, dressings were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is partial weight bearing in her bilateral lower extremities, and will be discharged on Aspirin 81mg for thrombosis prophylaxis. The patient will follow up with Dr. [MASKED] in [MASKED] weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line 3. cefaDROXil 500 mg oral BID RX cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp #14 Capsule Refills:1 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 300 mg PO TID RX gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #60 Capsule Refills:0 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth q4-6 hours Disp #40 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bilateral popliteal artery entrapment Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: -Please leave your dressings in place until your follow up appointment -Please do not get your dressings wet; sponge bath only -Please wear your knee immobilizers at all times; please use crutches to help you ambulate -Please record your drain outputs daily Followup Instructions: [MASKED]	[]	[ "J45909" ]	[ "I771: Stricture of artery", "M79A22: Nontraumatic compartment syndrome of left lower extremity", "M79A21: Nontraumatic compartment syndrome of right lower extremity", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "J45909: Unspecified asthma, uncomplicated", "G8918: Other acute postprocedural pain" ]
10,045,518	21,269,540	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: facial fractures, pneumocephalus Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a ___ year old gentleman who was playing in a family softball game when he was struck in the face by a line drive of a softball. He was taken to an OSH where evaluation showed multiple facial fractures and a trace amount of pneumocephalus. He was given ancef and a tetanus shot and he was subsequently transferred to ___ for further monitoring and care. Past Medical History: afib Social History: ___ Family History: NC Physical Exam: Gen: WD/WN, comfortable, NAD. HEENT: Left sided facial swelling Pupils: EOMs intact wothout nystagmus Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1mm bilaterally. Visual fields are grossly full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: CT: no hemorrhage, trace pneumocephalus right frontal lobe Comminuted fracture of the left frontal bone/anterior wall of the left frontal sinus. Fractures extend in to the left ethmoid air cells. Fracture extends across the midline into the anterior wall of the right frontal sinus. There is depression of fragments. There are posterior frontal sinus wall fractures. There is a comminuted fracture of the left orbital roof. There is left orbital emphysema. There is a minimally displaced left lamina papyracea fracture. There is mild widening of the left zygomaticofrontal suture. There are air fluid levels in the frontal and maxillary sinuses and partial opacification of the ethmoid sinuses. Brief Hospital Course: Mr. ___ was admitted to the Neurosurgery service for observation for CSF leak. He was seen and evaluated by Plastic surgery for complex bilateral frontal sinus fractures with depressed components and left orbital roof fracture. They recommend sinus precautions, Augmentin x7 days and follow up within a week for possible delayed fixation of fractures. He was seen and evaluated by ophthalmology who did a dilated bedside exam. They recommend follow up with Ophthalmology, a retinal specialist, for retinal commotio within 1 week for a formal dilated fundoscopic exam. During his admission Mr. ___ remained neurologically intact without any signs of CSF rhinorrhea. At the time of discharge he was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. The patient will discharge to home and arrange for outpatient follow up with Ophthalmology and Plastic Surgery close to his home in ___. Medications on Admission: Aspirin 81 mg Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #12 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: - Complex depressed Bifrontal sinus fractures involving both the anterior and posterior tables - Left Orbital roof fracture - Retinal Commotio Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Activity SINUS PRECAUTIONS: - No straws - Do not blow your nose - Sneeze with open mouth - Do not smoke cigarettes, pipes or cigars - Avoid swimming and strenuous exercise for one week. - Ice to left eyelid x 48 hours - Seek Emergency eye evaluation for any change in vision sudden onset of shower of new floaters, persistent flashes of light or curtain over vision We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. No driving while taking any narcotic or sedating medication. You should avoid contact sports for 6 months. Medications You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience with Traumatic Brain Injury: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptoms after traumatic brain injury. Headaches can be long-lasting. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. More Information about Brain Injuries: You were given information about headaches after TBI and the impact that TBI can have on your family. If you would like to read more about other topics such as: sleeping, driving, cognitive problems, emotional problems, fatigue, seizures, return to school, depression, balance, or/and sexuality after TBI, please ask our staff for this information or visit ___ Followup Instructions: ___	[ "S0219XA", "W2103XA", "Y9239", "S058X9A", "G9389", "I4891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: facial fractures, pneumocephalus Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a [MASKED] year old gentleman who was playing in a family softball game when he was struck in the face by a line drive of a softball. He was taken to an OSH where evaluation showed multiple facial fractures and a trace amount of pneumocephalus. He was given ancef and a tetanus shot and he was subsequently transferred to [MASKED] for further monitoring and care. Past Medical History: afib Social History: [MASKED] Family History: NC Physical Exam: Gen: WD/WN, comfortable, NAD. HEENT: Left sided facial swelling Pupils: EOMs intact wothout nystagmus Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1mm bilaterally. Visual fields are grossly full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [MASKED] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: CT: no hemorrhage, trace pneumocephalus right frontal lobe Comminuted fracture of the left frontal bone/anterior wall of the left frontal sinus. Fractures extend in to the left ethmoid air cells. Fracture extends across the midline into the anterior wall of the right frontal sinus. There is depression of fragments. There are posterior frontal sinus wall fractures. There is a comminuted fracture of the left orbital roof. There is left orbital emphysema. There is a minimally displaced left lamina papyracea fracture. There is mild widening of the left zygomaticofrontal suture. There are air fluid levels in the frontal and maxillary sinuses and partial opacification of the ethmoid sinuses. Brief Hospital Course: Mr. [MASKED] was admitted to the Neurosurgery service for observation for CSF leak. He was seen and evaluated by Plastic surgery for complex bilateral frontal sinus fractures with depressed components and left orbital roof fracture. They recommend sinus precautions, Augmentin x7 days and follow up within a week for possible delayed fixation of fractures. He was seen and evaluated by ophthalmology who did a dilated bedside exam. They recommend follow up with Ophthalmology, a retinal specialist, for retinal commotio within 1 week for a formal dilated fundoscopic exam. During his admission Mr. [MASKED] remained neurologically intact without any signs of CSF rhinorrhea. At the time of discharge he was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. The patient will discharge to home and arrange for outpatient follow up with Ophthalmology and Plastic Surgery close to his home in [MASKED]. Medications on Admission: Aspirin 81 mg Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Duration: 7 Days RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #12 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours Disp #20 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: - Complex depressed Bifrontal sinus fractures involving both the anterior and posterior tables - Left Orbital roof fracture - Retinal Commotio Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Activity SINUS PRECAUTIONS: - No straws - Do not blow your nose - Sneeze with open mouth - Do not smoke cigarettes, pipes or cigars - Avoid swimming and strenuous exercise for one week. - Ice to left eyelid x 48 hours - Seek Emergency eye evaluation for any change in vision sudden onset of shower of new floaters, persistent flashes of light or curtain over vision We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. No driving while taking any narcotic or sedating medication. You should avoid contact sports for 6 months. Medications You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] Experience with Traumatic Brain Injury: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptoms after traumatic brain injury. Headaches can be long-lasting. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. More Information about Brain Injuries: You were given information about headaches after TBI and the impact that TBI can have on your family. If you would like to read more about other topics such as: sleeping, driving, cognitive problems, emotional problems, fatigue, seizures, return to school, depression, balance, or/and sexuality after TBI, please ask our staff for this information or visit [MASKED] Followup Instructions: [MASKED]	[]	[ "I4891" ]	[ "S0219XA: Other fracture of base of skull, initial encounter for closed fracture", "W2103XA: Struck by baseball, initial encounter", "Y9239: Other specified sports and athletic area as the place of occurrence of the external cause", "S058X9A: Other injuries of unspecified eye and orbit, initial encounter", "G9389: Other specified disorders of brain", "I4891: Unspecified atrial fibrillation" ]
10,045,670	23,104,678	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Pituitary macroadenoma Major Surgical or Invasive Procedure: ___: Endonasal transphenoidal resection of pituitary macroadenoma History of Present Illness: Enerx Derival is a ___ year-old-male who was found to have a pituitary abnormality on a head CT that was done after an MVC. A later MRI showed a 1.5cm pituitary lesion invading the left cavernous sinus. Prolactin levels do not indicate the lesion was a prolactinoma. Visual field testing was normal. Past Medical History: Non-contributory Social History: ___ Family History: Cancer, diabetes, kidney disease, neurological disease, gas intestinal problems Physical Exam: On discharge: ------------- Opens eyes: [x]Spontaneous [ ]To voice [ ]To noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 3-2mm EOM: [x]Full [ ]Restricted Face Symmetric: [X]Yes [ ]No Tongue Midline: [x]Yes [ ]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast [x]Sensation intact to light touch Wound: Nares Bilateral nares without drainage, denies salty/metallic taste. Pertinent Results: Please see OMR for pertinent results. Brief Hospital Course: #Pituitary Macroadenoma ___ who presented ___ for elective endonasal transphenoidal resection of pituitary macroadenoma. Please see separate operative report by Dr. ___ in OMR for further details. Patient was extubated and recovered in the PACU prior to being transferred to the ___. Postoperatively, the patient initially had nausea and vomiting that has since resolved. His course has been complicated by postoperative diabetes insipidus. #Diabetes Insipidus Endocrine was consulted for recommendations on ___ and he was given a course of vasopressin for DI. We continued to closely monitor urine output and serum sodium and osmolality for signs of DI requiring further treatment. The patient was ultimately managed on a regimen of PO desmopressin and discharged with close follow-up. #Multi-nodular Goiter Prior to admission, the patient underwent a Thyroid ultrasound on ___. This has been addressed with the Endocrinology team, and the patient will followup for further workup outpatient with established endocrinologist Dr. ___. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Bisacodyl 10 mg PO/PR DAILY 3. Desmopressin Acetate 0.2 mg PO BID RX desmopressin 0.2 mg 1 tablet(s) by mouth every 12 hours Disp #60 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe RX oxycodone 5 mg 1 tablet(s) by mouth every 8 hours as needed Disp #20 Tablet Refills:0 6. Senna 17.2 mg PO QHS 7. Sodium Chloride Nasal ___ SPRY NU QID Continue until your follow-up appointment with Dr. ___. RX sodium chloride [Nasal Spray (sodium chloride)] 0.65 % ___ spray in each nostril four times a day Disp #1 Bottle Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Pituitary macroadenoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Transphenoidal Excision of Tumor ¨Take your pain medicine as prescribed. ¨Exercise should be limited to walking; no lifting, straining, or excessive bending. ¨Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ¨Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ¨Clearance to drive and return to work will be addressed at your post-operative office visit. ¨Continue Sinus Precautions for an additional two weeks. This means, no use of straws, forceful blowing of your nose, or use of your incentive spirometer. ¨If you have been discharged on Prednisone, take it daily as prescribed. ¨If you are required to take Prednisone, an oral steroid, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as this medication can cause stomach irritation. Prednisone should also be taken with a glass of milk or with a meal. CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ¨New onset of tremors or seizures. ¨Any confusion or change in mental status. ¨Any numbness, tingling, weakness in your extremities. ¨Pain or headache that is continually increasing, or not relieved by pain medication. ¨Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ¨It is normal for feel nasal fullness for a few days after surgery, but if you begin to experience drainage or salty taste at the back of your throat, that resembles a dripping sensation, or persistent, clear fluid that drains from your nose that was not present when you were sent home, please call. ¨Fever greater than or equal to 101° F. ¨If you notice your urine output to be increasing, and/or excessive, and you are unable to quench your thirst, please call your endocrinologist. Followup Instructions: ___	[ "D352", "E232", "E8989", "E042", "K219", "Y838", "Y92230", "F17200" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Pituitary macroadenoma Major Surgical or Invasive Procedure: [MASKED]: Endonasal transphenoidal resection of pituitary macroadenoma History of Present Illness: Enerx Derival is a [MASKED] year-old-male who was found to have a pituitary abnormality on a head CT that was done after an MVC. A later MRI showed a 1.5cm pituitary lesion invading the left cavernous sinus. Prolactin levels do not indicate the lesion was a prolactinoma. Visual field testing was normal. Past Medical History: Non-contributory Social History: [MASKED] Family History: Cancer, diabetes, kidney disease, neurological disease, gas intestinal problems Physical Exam: On discharge: ------------- Opens eyes: [x]Spontaneous [ ]To voice [ ]To noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 3-2mm EOM: [x]Full [ ]Restricted Face Symmetric: [X]Yes [ ]No Tongue Midline: [x]Yes [ ]No Speech Fluent: [x]Yes [ ]No Comprehension intact: [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip IPQuadHamATEHLGast [x]Sensation intact to light touch Wound: Nares Bilateral nares without drainage, denies salty/metallic taste. Pertinent Results: Please see OMR for pertinent results. Brief Hospital Course: #Pituitary Macroadenoma [MASKED] who presented [MASKED] for elective endonasal transphenoidal resection of pituitary macroadenoma. Please see separate operative report by Dr. [MASKED] in OMR for further details. Patient was extubated and recovered in the PACU prior to being transferred to the [MASKED]. Postoperatively, the patient initially had nausea and vomiting that has since resolved. His course has been complicated by postoperative diabetes insipidus. #Diabetes Insipidus Endocrine was consulted for recommendations on [MASKED] and he was given a course of vasopressin for DI. We continued to closely monitor urine output and serum sodium and osmolality for signs of DI requiring further treatment. The patient was ultimately managed on a regimen of PO desmopressin and discharged with close follow-up. #Multi-nodular Goiter Prior to admission, the patient underwent a Thyroid ultrasound on [MASKED]. This has been addressed with the Endocrinology team, and the patient will followup for further workup outpatient with established endocrinologist Dr. [MASKED]. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Bisacodyl 10 mg PO/PR DAILY 3. Desmopressin Acetate 0.2 mg PO BID RX desmopressin 0.2 mg 1 tablet(s) by mouth every 12 hours Disp #60 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe RX oxycodone 5 mg 1 tablet(s) by mouth every 8 hours as needed Disp #20 Tablet Refills:0 6. Senna 17.2 mg PO QHS 7. Sodium Chloride Nasal [MASKED] SPRY NU QID Continue until your follow-up appointment with Dr. [MASKED]. RX sodium chloride [Nasal Spray (sodium chloride)] 0.65 % [MASKED] spray in each nostril four times a day Disp #1 Bottle Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Pituitary macroadenoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Transphenoidal Excision of Tumor ¨Take your pain medicine as prescribed. ¨Exercise should be limited to walking; no lifting, straining, or excessive bending. ¨Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ¨Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ¨Clearance to drive and return to work will be addressed at your post-operative office visit. ¨Continue Sinus Precautions for an additional two weeks. This means, no use of straws, forceful blowing of your nose, or use of your incentive spirometer. ¨If you have been discharged on Prednisone, take it daily as prescribed. ¨If you are required to take Prednisone, an oral steroid, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as this medication can cause stomach irritation. Prednisone should also be taken with a glass of milk or with a meal. CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ¨New onset of tremors or seizures. ¨Any confusion or change in mental status. ¨Any numbness, tingling, weakness in your extremities. ¨Pain or headache that is continually increasing, or not relieved by pain medication. ¨Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ¨It is normal for feel nasal fullness for a few days after surgery, but if you begin to experience drainage or salty taste at the back of your throat, that resembles a dripping sensation, or persistent, clear fluid that drains from your nose that was not present when you were sent home, please call. ¨Fever greater than or equal to 101° F. ¨If you notice your urine output to be increasing, and/or excessive, and you are unable to quench your thirst, please call your endocrinologist. Followup Instructions: [MASKED]	[]	[ "K219", "Y92230" ]	[ "D352: Benign neoplasm of pituitary gland", "E232: Diabetes insipidus", "E8989: Other postprocedural endocrine and metabolic complications and disorders", "E042: Nontoxic multinodular goiter", "K219: Gastro-esophageal reflux disease without esophagitis", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "F17200: Nicotine dependence, unspecified, uncomplicated" ]
10,045,785	20,513,306	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: amoxicillin Attending: ___. Chief Complaint: Right frontal brain mass Major Surgical or Invasive Procedure: ___ - Right craniotomy for resection of right frontal brain mass History of Present Illness: ___ is a ___ year old male with a known right frontal brain mass, initially discovered on work-up for headaches, who presented electively on ___ for a right craniotomy for mass resection. Past Medical History: - Fatty liver disease - IBS - Renal insufficiency - S/p colonoscopy - S/p wisdom teeth extraction Social History: ___ Family History: Father with hypertension. Mother with rheumatoid arthritis. No known family history of brain masses. Physical Exam: On Discharge: ------------- General: VS: T 98.1F, HR 57, BP 155/100, RR 20, O2Sat 95% on room air Exam: Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None Orientation: [x]Person [x]Place [x]Time Follows Commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL EOMs: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trap Deltoid Biceps Triceps Grip Right 5 5 5 5 5 Left 5 5 5 5 5 IP Quad Ham AT ___ ___ Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: Grossly intact to light touch. Surgical Site: - Incision clean, dry, intact - Closed with staples Pertinent Results: Please see OMR for relevant laboratory and imaging results. Brief Hospital Course: ___ year old male with a known right frontal brain mass, initially discovered on work-up for headaches. #Right frontal brain mass The patient presented electively on ___ for a right craniotomy for mass resection. The operation was uncomplicated. Please see OMR for further intraoperative details. He was extubated in the OR and recovered in the PACU. He was transferred to the step down unit postoperatively for close neurologic monitoring. Postoperatively, he was continued on Keppra for seizure prophylaxis and dexamethasone for cerebral edema. Postoperative CT of the head showed expected postoperative changes. Postoperative MRI of the head also showed expected postoperative changes and possible residual. Neuro Oncology and Radiation Oncology were consulted and followed along while the patient was admitted. He remained neurologically stable. On ___, the patient was afebrile with stable vital signs, mobilizing independently, tolerating a diet, voiding and stooling without difficulty, and his pain was well controlled with oral pain medications. He was discharged home on ___ in stable condition. Final pathology was still pending at the time of discharge. #Disposition The patient mobilized with the nurse postoperatively and was determined to be independent with mobilization. He was discharged home on ___ in stable condition. Medications on Admission: - cetirizine 10mg PO once daily - dexamethasone 4mg PO BID - famotidine 20mg PO BID - fluticasone propionate 50mcg/actuation nasal spray PRN - levetiracetam 500mg PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild Do not exceed 3000mg in 24 hours. 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 3. Famotidine 20 mg PO BID RX famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #17 Tablet Refills:0 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Do not drive while taking. RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours as needed for pain Disp #12 Tablet Refills:0 5. Dexamethasone 4 mg PO Q8H Duration: 6 Doses Step 2 of 5. This is dose # 2 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #6 Tablet Refills:0 6. Dexamethasone 3 mg PO Q8H Duration: 6 Doses Step 3 of 5. This is dose # 3 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 1.5 mg 2 tablet(s) by mouth every eight (8) hours Disp #12 Tablet Refills:0 7. Dexamethasone 2 mg PO Q8H Duration: 6 Doses Step 4 of 5. This is dose # 4 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 2 mg 1 tablet(s) by mouth every eight (8) hours Disp #6 Tablet Refills:0 8. Dexamethasone 1 mg PO Q8H Duration: 6 Doses Step 5 of 5. Then stop. This is dose # 5 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 1 mg 1 tablet(s) by mouth every eight (8) hours Disp #6 Tablet Refills:0 9. Dexamethasone 4 mg PO Q6H Duration: 6 Doses Step 1 of 5. This is dose # 1 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours Disp #6 Tablet Refills:0 10. LevETIRAcetam 1000 mg PO BID RX levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a day Disp #56 Tablet Refills:1 Discharge Disposition: Home Discharge Diagnosis: Right frontal brain mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory, independent. Discharge Instructions: Surgery: - You underwent surgery to remove a brain mass from your brain. - You may shower at this time, but please keep your surgical incision dry. - It is best to keep your surgical incision open to air, but it is okay to cover it when outside. - Please call your neurosurgeon if there are any signs of infection such as fever, pain, redness, swelling, or drainage from your surgical incision. Activity: - You may take leisurely walks and slowly increase your activity at your once pace once you are symptom free at rest. Don't try to do too much all at once. - We recommend that you avoid heavy lifting, running, climbing, and other strenuous exercise until your follow-up. - No contact sports until cleared by your neurosurgeon. You should avoid contact sports for at least 6 months. - No driving while taking narcotics or any other sedating medications. - If you experienced a seizure, you are not allowed to drive by law. Medications: - You may use acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. - You have been discharged on levetiracetam (Keppra). This medication helps to prevent seizures. Please continue this medication as prescribed. It is important that you take it consistently and on time. - Please do not take any blood thinning medications such as aspirin, clopidogrel (Plavix), ibuprofen, warfarin (Coumadin), etc. until cleared by your neurosurgeon. What You ___ Experience: - You may experience headaches and pain at the surgical incision. - You may also experience some postoperative swelling around your face and eyes. This is normal after surgery. You may apply ice or a cool or warm washcloth to help with this. It will be its worst in the morning after laying flat while sleeping but should decrease once up. - You may experience soreness with chewing. This is normal after surgery and will improve with time. Softer foods may be easier during this time. - Feeling more tired or restless is common. - Constipation is also common. Be sure to drink plenty of fluids and eat a high fiber diet. You may also try an over the counter stool softener if needed. Please Call Your Neurosurgeon At ___ For: - Fever greater than 101.4 degrees Fahrenheit. - Severe pain, redness, swelling, or drainage from the surgical incision. - Severe headaches not relieved by prescribed pain medications. - Extreme sleepiness or not being able to stay awake. - Any new problems with your vision or ability to speak. - Weakness or changes in sensation in your face, arms, or legs. - Nausea or vomiting. - Seizures. Call ___ And Go To The Nearest Emergency Department If You Experience Any Of The Following: - Sudden severe headaches with no known reason. - Sudden dizziness, trouble walking, or loss of balance or coordination. - Sudden confusion or trouble speaking or understanding. - Sudden weakness or numbness in the face, arms, or legs. Followup Instructions: ___	[ "C711", "I10" ]	Allergies: amoxicillin Chief Complaint: Right frontal brain mass Major Surgical or Invasive Procedure: [MASKED] - Right craniotomy for resection of right frontal brain mass History of Present Illness: [MASKED] is a [MASKED] year old male with a known right frontal brain mass, initially discovered on work-up for headaches, who presented electively on [MASKED] for a right craniotomy for mass resection. Past Medical History: - Fatty liver disease - IBS - Renal insufficiency - S/p colonoscopy - S/p wisdom teeth extraction Social History: [MASKED] Family History: Father with hypertension. Mother with rheumatoid arthritis. No known family history of brain masses. Physical Exam: On Discharge: ------------- General: VS: T 98.1F, HR 57, BP 155/100, RR 20, O2Sat 95% on room air Exam: Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None Orientation: [x]Person [x]Place [x]Time Follows Commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL EOMs: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trap Deltoid Biceps Triceps Grip Right 5 5 5 5 5 Left 5 5 5 5 5 IP Quad Ham AT [MASKED] [MASKED] Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: Grossly intact to light touch. Surgical Site: - Incision clean, dry, intact - Closed with staples Pertinent Results: Please see OMR for relevant laboratory and imaging results. Brief Hospital Course: [MASKED] year old male with a known right frontal brain mass, initially discovered on work-up for headaches. #Right frontal brain mass The patient presented electively on [MASKED] for a right craniotomy for mass resection. The operation was uncomplicated. Please see OMR for further intraoperative details. He was extubated in the OR and recovered in the PACU. He was transferred to the step down unit postoperatively for close neurologic monitoring. Postoperatively, he was continued on Keppra for seizure prophylaxis and dexamethasone for cerebral edema. Postoperative CT of the head showed expected postoperative changes. Postoperative MRI of the head also showed expected postoperative changes and possible residual. Neuro Oncology and Radiation Oncology were consulted and followed along while the patient was admitted. He remained neurologically stable. On [MASKED], the patient was afebrile with stable vital signs, mobilizing independently, tolerating a diet, voiding and stooling without difficulty, and his pain was well controlled with oral pain medications. He was discharged home on [MASKED] in stable condition. Final pathology was still pending at the time of discharge. #Disposition The patient mobilized with the nurse postoperatively and was determined to be independent with mobilization. He was discharged home on [MASKED] in stable condition. Medications on Admission: - cetirizine 10mg PO once daily - dexamethasone 4mg PO BID - famotidine 20mg PO BID - fluticasone propionate 50mcg/actuation nasal spray PRN - levetiracetam 500mg PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild Do not exceed 3000mg in 24 hours. 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 3. Famotidine 20 mg PO BID RX famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #17 Tablet Refills:0 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Do not drive while taking. RX oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours as needed for pain Disp #12 Tablet Refills:0 5. Dexamethasone 4 mg PO Q8H Duration: 6 Doses Step 2 of 5. This is dose # 2 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #6 Tablet Refills:0 6. Dexamethasone 3 mg PO Q8H Duration: 6 Doses Step 3 of 5. This is dose # 3 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 1.5 mg 2 tablet(s) by mouth every eight (8) hours Disp #12 Tablet Refills:0 7. Dexamethasone 2 mg PO Q8H Duration: 6 Doses Step 4 of 5. This is dose # 4 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 2 mg 1 tablet(s) by mouth every eight (8) hours Disp #6 Tablet Refills:0 8. Dexamethasone 1 mg PO Q8H Duration: 6 Doses Step 5 of 5. Then stop. This is dose # 5 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 1 mg 1 tablet(s) by mouth every eight (8) hours Disp #6 Tablet Refills:0 9. Dexamethasone 4 mg PO Q6H Duration: 6 Doses Step 1 of 5. This is dose # 1 of 5 tapered doses Tapered dose - DOWN RX dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours Disp #6 Tablet Refills:0 10. LevETIRAcetam 1000 mg PO BID RX levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a day Disp #56 Tablet Refills:1 Discharge Disposition: Home Discharge Diagnosis: Right frontal brain mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory, independent. Discharge Instructions: Surgery: - You underwent surgery to remove a brain mass from your brain. - You may shower at this time, but please keep your surgical incision dry. - It is best to keep your surgical incision open to air, but it is okay to cover it when outside. - Please call your neurosurgeon if there are any signs of infection such as fever, pain, redness, swelling, or drainage from your surgical incision. Activity: - You may take leisurely walks and slowly increase your activity at your once pace once you are symptom free at rest. Don't try to do too much all at once. - We recommend that you avoid heavy lifting, running, climbing, and other strenuous exercise until your follow-up. - No contact sports until cleared by your neurosurgeon. You should avoid contact sports for at least 6 months. - No driving while taking narcotics or any other sedating medications. - If you experienced a seizure, you are not allowed to drive by law. Medications: - You may use acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. - You have been discharged on levetiracetam (Keppra). This medication helps to prevent seizures. Please continue this medication as prescribed. It is important that you take it consistently and on time. - Please do not take any blood thinning medications such as aspirin, clopidogrel (Plavix), ibuprofen, warfarin (Coumadin), etc. until cleared by your neurosurgeon. What You [MASKED] Experience: - You may experience headaches and pain at the surgical incision. - You may also experience some postoperative swelling around your face and eyes. This is normal after surgery. You may apply ice or a cool or warm washcloth to help with this. It will be its worst in the morning after laying flat while sleeping but should decrease once up. - You may experience soreness with chewing. This is normal after surgery and will improve with time. Softer foods may be easier during this time. - Feeling more tired or restless is common. - Constipation is also common. Be sure to drink plenty of fluids and eat a high fiber diet. You may also try an over the counter stool softener if needed. Please Call Your Neurosurgeon At [MASKED] For: - Fever greater than 101.4 degrees Fahrenheit. - Severe pain, redness, swelling, or drainage from the surgical incision. - Severe headaches not relieved by prescribed pain medications. - Extreme sleepiness or not being able to stay awake. - Any new problems with your vision or ability to speak. - Weakness or changes in sensation in your face, arms, or legs. - Nausea or vomiting. - Seizures. Call [MASKED] And Go To The Nearest Emergency Department If You Experience Any Of The Following: - Sudden severe headaches with no known reason. - Sudden dizziness, trouble walking, or loss of balance or coordination. - Sudden confusion or trouble speaking or understanding. - Sudden weakness or numbness in the face, arms, or legs. Followup Instructions: [MASKED]	[]	[ "I10" ]	[ "C711: Malignant neoplasm of frontal lobe", "I10: Essential (primary) hypertension" ]
10,045,785	25,185,894	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: amoxicillin Attending: ___. Chief Complaint: Hypoxemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male history of recently diagnosed high grade glioma currently undergoing Radiation and chemotherapy, sent in from radiation ___ clinic due to tachycardia, tachypnea and decreased O2 sats for rule out PE. Patient also endorses new onset pain in the left tooth since last night, no purulent drainage or swelling. Found to have fever to 100.1 in triage. Denies chest pain, subjective fever/chills, dyspnea at rest or exertion, legs and calf swelling, dizziness/syncope. In the ED, - Initial vitals: 100.1 ___ 19 93% RA - Exam notable for: Constitutional: Well developed, NAD HEENT: Normocephalic, atraumatic, PERRL, patient has erythematous, tender prominence at the root of the left maxillary premolar inserting for possible abscess. Also endorsing some tenderness over the maxilla. Resp: Normal work of breathing, symmetric chest expansion, CTA bilaterally. CV: Regular rate and rhythm, no M/G/R Abd: Soft, nontender, nondistended, no masses or organomegaly, normoactive bs Skin: No rashes or lesions Extremities: No edema, erythema or tenderness Neurologic exam: Cranial nerves II through XII intact, 5+ strength in all extremities, sensation intact in all extremities, finger nose finger normal, gait normal, speech fluent Psych: Normal mood, normal mentation - Labs notable for: 5.5 > 12.4/37.8 < ___ 9 ----------------< 112 3.9 22 1.0 Lactate:2.6 ___: 13.8 PTT: 70.9 INR: 1.3 - Imaging notable for: CTA Chest: -Segmental and subsegmental pulmonary emboli within the left lower lobe. No evidence of right heart strain or pulmonary infarction. -Bibasilar opacities most likely represent atelectasis, although in the appropriate clinical setting, pneumonia cannot be excluded. -Mild diffuse bronchial wall inflammation is nonspecific. -Hepatic steatosis. - Pt given: IV dilaudid, started a heparin drip with NO bolus, Keppra, CTX/Azithro, 1L LR - Vitals prior to transfer: 98.3 ___ 22 96% 2L NC Upon arrival to the floor, the patient reports that he is currently having no symptoms. States that he might have had a cough the past couple of days, but only in retrospect. No fevers, though had the chills the other night. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative except for as noted in the HPI. Past Medical History: - Fatty liver disease - IBS - Renal insufficiency - S/p colonoscopy - S/p wisdom teeth extraction Social History: ___ Family History: Father with hypertension. Mother with rheumatoid arthritis. No known family history of brain masses. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: ___ 1441 Temp: 99.3 PO BP: 153/93 HR: 94 RR: 20 O2 sat: 95% O2 delivery: 2L NC GENERAL: NAD, lying comfortably in bed. HEENT: AT/NC, Sclerae anicteric, MMM. Well healed cranial scar. NECK: Supple, no LAD CV: Tachycardic RR. Normal S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABD: Abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXT: WWP, no cyanosis, clubbing, or edema, 2+ radial pulses bilaterally SKIN: Warm and well perfused, no excoriations or lesions, no rashes NEURO: CN II-XII intact. Strength and sensation intact in b/l upper and lower extremities. No deficits. DISCHARGE PHYSICAL EXAM: ======================== VS: ___ ___ Temp: 98.6 PO BP: 135/82 HR: 80 RR: 18 O2 sat: 93% O2 delivery: 1LNC GENERAL: NAD, lying comfortably in bed. Pleasant and conversant. HEENT: AT/NC, PERRLA, Sclerae anicteric, MMM. Well healed cranial scar. NECK: Supple, no LAD CV: RRR. Normal S1/S2, no murmurs, gallops, or rubs PULM: Non-labored work of breaths, CTAB, no wheezes, rales, rhonchi appreciated. On 2L O2 by N/C. ABD: Abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly, bowel sounds appreciated. EXT: WWP, no cyanosis, clubbing, or edema, peripheral pulses appreciated. SKIN: Warm and well perfused, no excoriations or lesions, no rashes NEURO: AOx3, CN II-XII intact. Strength and sensation intact in b/l upper and lower extremities. No deficits. Pertinent Results: ADMISSION LABS ============== ___ 03:25PM BLOOD WBC-5.5 RBC-4.36* Hgb-12.4* Hct-37.8* MCV-87 MCH-28.4 MCHC-32.8 RDW-14.0 RDWSD-44.2 Plt ___ ___ 03:25PM BLOOD Neuts-72.6* Lymphs-15.9* Monos-8.2 Eos-1.1 Baso-0.2 Im ___ AbsNeut-3.97 AbsLymp-0.87* AbsMono-0.45 AbsEos-0.06 AbsBaso-0.01 ___ 04:20AM BLOOD ___ PTT-65.6* ___ ___ 03:25PM BLOOD Glucose-112* UreaN-9 Creat-1.0 Na-137 K-3.9 Cl-100 HCO3-22 AnGap-15 DISCHARGE LABS =============== ___ 06:30AM BLOOD WBC-4.6 RBC-3.85* Hgb-10.8* Hct-33.9* MCV-88 MCH-28.1 MCHC-31.9* RDW-14.0 RDWSD-44.2 Plt ___ ___ 06:30AM BLOOD Glucose-98 UreaN-13 Creat-1.1 Na-142 K-4.5 Cl-104 HCO3-23 AnGap-15 ___ 06:30AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.2 ___ 11:30AM BLOOD Type-ART pO2-57* pCO2-34* pH-7.47* calTCO2-25 Base XS-1 IMAGING ======= ___ CTA CHEST 1. Segmental and subsegmental pulmonary emboli within the left lower lobe. No evidence of right heart strain or pulmonary infarction. 2. Hepatic steatosis. ___ CT HEAD W/O CONTRAST 1. Study is mildly degraded by motion. 2. Evolving postsurgical changes related to patient's known right frontal mass resection. 3. Curvilinear linear hyperdensities in region of surgical bed, at least partially demonstrated on ___ outside noncontrast head CT. Please note that superimposed small areas of acute blood products cannot be excluded on the basis of this examination. 4. Within limits of study, no definite evidence of acute intracranial hemorrhage. ___ CHEST CXR There are linear opacities in the bilateral lung bases (left greater than right), which most likely represent subsegmental atelectasis. There is no lobar consolidation, pleural effusion or pneumothorax. The cardiac silhouette is mildly enlarged. There is no pulmonary edema. No acute osseous abnormalities are identified. MICROBIOLOGY ============= Urine Culture ___, Final): No Growth Blood Culture ___, Final): No Growth Blood Culture ___, Final): No Growth Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [ ]Patient started on lovenox ___ BID, which he will continue as an outpatient. Can consider switching to oral agent in the future [ ]Patient should follow up with dentist after discharge for L lower molar pain. [ ]Discharged with home O2: Likely related to pulmonary embolism, however if continued oxygen requirement following anticoagulation would recommend continued workup with: - Pulmonology referral - Formal PFTs - Repeat CTA for evaluation of progression of PEs despite anticoagulation #Health care proxy: ___ (wife) ___ #CODE STATUS: Full confirmed SUMMARY: ======== ___ history of recently diagnosed high grade glioma currently undergoing radiation and chemotherapy, admitted for hypoxia and tachycardia at radiation appointment, found to have PE. HOSPITAL ISSUES: ================ #Low risk PE: CTA chest noted segmental and subsegmental PE in LLL, no evidence of right heart stain or pulmonary infarction. Etiology likely in setting of malignancy. EKG also negative for right heart strain. Trops and BNP were negative. He was started on a heparin drip for 48 hours before transitioning to lovenox ___ BID. He received a head CT, which did not show any bleeding or other intracranial process. He was persistently hypoxic, and as such alternative etiologies for hypoxia were considered. Repeat CT chest non-con did not reveal any explanatory etiology. TTE did not show any new depressed EF or valvular disease. His oxygen requirement was stable from ___ on the day of discharge, and ultimately his persistent hypoxia was thought to be related to continued V/Q mismatch secondary to his pulmonary emboli. He was discharged with home oxygen and his oxygen requirement should be followed up as an outpatient. If he continued to have an oxygen requirement as an outpatient despite treatment for his PE, he should be referred to pulmonology for formal PFTs as well as repeat imaging and further diagnostic workup for persistent hypoxia. #PNA: Possible pneumonia identified on CT chest. Given tachycardia (though more likely from PE as above) and T 100.1 in ED, he was treated for CAP. Abx course: CTX/azithro for ___, switched to cefpodoxime/azithro for ___ #Tooth pain: Some erythema surrounding L lower molar, concerning for possible abscess. He was covered with abx for PNA above (cefpodoxime/azithro). Patient should have dental follow-up after discharge. #High grade glioma: Planned for radiation and TMZ. ___ was his ___ of 30 planned radiation treatments, with TMZ one hour prior to radiation treatments. Held TMZ and radiation on ___, but regimen was continued on ___ and continued until his discharge on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 3. Famotidine 20 mg PO BID 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 5. LevETIRAcetam 1000 mg PO BID 6. temozolomide 160 mg oral DAILY Discharge Medications: 1. Enoxaparin Sodium 100 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time RX enoxaparin 100 mg/mL 100 mg SC every twelve (12) hours Disp #60 Syringe Refills:*0 2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 4. Famotidine 20 mg PO BID 5. LevETIRAcetam 1000 mg PO BID 6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 7. temozolomide 160 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: pulmonary emboli, glioblastoma status-post resection Secondary diagnoses: hypertension, fatty liver disease, irritable bowel syndrome, renal insufficiency, Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You came to the hospital because you had a fast heart rate and low oxygen saturation. WHAT HAPPENED IN THE HOSPITAL? ============================== - You received a CT can, which found blood clots in your lungs. - Your blood clots were treated with medications (lovenox). - You were found to have low oxygen levels so you are being discharged home with oxygen. 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. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___	[ "I2699", "J189", "C711", "R0902", "K760", "K047", "I129", "N189", "K589" ]	Allergies: amoxicillin Chief Complaint: Hypoxemia Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old male history of recently diagnosed high grade glioma currently undergoing Radiation and chemotherapy, sent in from radiation [MASKED] clinic due to tachycardia, tachypnea and decreased O2 sats for rule out PE. Patient also endorses new onset pain in the left tooth since last night, no purulent drainage or swelling. Found to have fever to 100.1 in triage. Denies chest pain, subjective fever/chills, dyspnea at rest or exertion, legs and calf swelling, dizziness/syncope. In the ED, - Initial vitals: 100.1 [MASKED] 19 93% RA - Exam notable for: Constitutional: Well developed, NAD HEENT: Normocephalic, atraumatic, PERRL, patient has erythematous, tender prominence at the root of the left maxillary premolar inserting for possible abscess. Also endorsing some tenderness over the maxilla. Resp: Normal work of breathing, symmetric chest expansion, CTA bilaterally. CV: Regular rate and rhythm, no M/G/R Abd: Soft, nontender, nondistended, no masses or organomegaly, normoactive bs Skin: No rashes or lesions Extremities: No edema, erythema or tenderness Neurologic exam: Cranial nerves II through XII intact, 5+ strength in all extremities, sensation intact in all extremities, finger nose finger normal, gait normal, speech fluent Psych: Normal mood, normal mentation - Labs notable for: 5.5 > 12.4/37.8 < [MASKED] 9 ----------------< 112 3.9 22 1.0 Lactate:2.6 [MASKED]: 13.8 PTT: 70.9 INR: 1.3 - Imaging notable for: CTA Chest: -Segmental and subsegmental pulmonary emboli within the left lower lobe. No evidence of right heart strain or pulmonary infarction. -Bibasilar opacities most likely represent atelectasis, although in the appropriate clinical setting, pneumonia cannot be excluded. -Mild diffuse bronchial wall inflammation is nonspecific. -Hepatic steatosis. - Pt given: IV dilaudid, started a heparin drip with NO bolus, Keppra, CTX/Azithro, 1L LR - Vitals prior to transfer: 98.3 [MASKED] 22 96% 2L NC Upon arrival to the floor, the patient reports that he is currently having no symptoms. States that he might have had a cough the past couple of days, but only in retrospect. No fevers, though had the chills the other night. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative except for as noted in the HPI. Past Medical History: - Fatty liver disease - IBS - Renal insufficiency - S/p colonoscopy - S/p wisdom teeth extraction Social History: [MASKED] Family History: Father with hypertension. Mother with rheumatoid arthritis. No known family history of brain masses. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: [MASKED] 1441 Temp: 99.3 PO BP: 153/93 HR: 94 RR: 20 O2 sat: 95% O2 delivery: 2L NC GENERAL: NAD, lying comfortably in bed. HEENT: AT/NC, Sclerae anicteric, MMM. Well healed cranial scar. NECK: Supple, no LAD CV: Tachycardic RR. Normal S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABD: Abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXT: WWP, no cyanosis, clubbing, or edema, 2+ radial pulses bilaterally SKIN: Warm and well perfused, no excoriations or lesions, no rashes NEURO: CN II-XII intact. Strength and sensation intact in b/l upper and lower extremities. No deficits. DISCHARGE PHYSICAL EXAM: ======================== VS: [MASKED] [MASKED] Temp: 98.6 PO BP: 135/82 HR: 80 RR: 18 O2 sat: 93% O2 delivery: 1LNC GENERAL: NAD, lying comfortably in bed. Pleasant and conversant. HEENT: AT/NC, PERRLA, Sclerae anicteric, MMM. Well healed cranial scar. NECK: Supple, no LAD CV: RRR. Normal S1/S2, no murmurs, gallops, or rubs PULM: Non-labored work of breaths, CTAB, no wheezes, rales, rhonchi appreciated. On 2L O2 by N/C. ABD: Abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly, bowel sounds appreciated. EXT: WWP, no cyanosis, clubbing, or edema, peripheral pulses appreciated. SKIN: Warm and well perfused, no excoriations or lesions, no rashes NEURO: AOx3, CN II-XII intact. Strength and sensation intact in b/l upper and lower extremities. No deficits. Pertinent Results: ADMISSION LABS ============== [MASKED] 03:25PM BLOOD WBC-5.5 RBC-4.36* Hgb-12.4* Hct-37.8* MCV-87 MCH-28.4 MCHC-32.8 RDW-14.0 RDWSD-44.2 Plt [MASKED] [MASKED] 03:25PM BLOOD Neuts-72.6* Lymphs-15.9* Monos-8.2 Eos-1.1 Baso-0.2 Im [MASKED] AbsNeut-3.97 AbsLymp-0.87* AbsMono-0.45 AbsEos-0.06 AbsBaso-0.01 [MASKED] 04:20AM BLOOD [MASKED] PTT-65.6* [MASKED] [MASKED] 03:25PM BLOOD Glucose-112* UreaN-9 Creat-1.0 Na-137 K-3.9 Cl-100 HCO3-22 AnGap-15 DISCHARGE LABS =============== [MASKED] 06:30AM BLOOD WBC-4.6 RBC-3.85* Hgb-10.8* Hct-33.9* MCV-88 MCH-28.1 MCHC-31.9* RDW-14.0 RDWSD-44.2 Plt [MASKED] [MASKED] 06:30AM BLOOD Glucose-98 UreaN-13 Creat-1.1 Na-142 K-4.5 Cl-104 HCO3-23 AnGap-15 [MASKED] 06:30AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.2 [MASKED] 11:30AM BLOOD Type-ART pO2-57* pCO2-34* pH-7.47* calTCO2-25 Base XS-1 IMAGING ======= [MASKED] CTA CHEST 1. Segmental and subsegmental pulmonary emboli within the left lower lobe. No evidence of right heart strain or pulmonary infarction. 2. Hepatic steatosis. [MASKED] CT HEAD W/O CONTRAST 1. Study is mildly degraded by motion. 2. Evolving postsurgical changes related to patient's known right frontal mass resection. 3. Curvilinear linear hyperdensities in region of surgical bed, at least partially demonstrated on [MASKED] outside noncontrast head CT. Please note that superimposed small areas of acute blood products cannot be excluded on the basis of this examination. 4. Within limits of study, no definite evidence of acute intracranial hemorrhage. [MASKED] CHEST CXR There are linear opacities in the bilateral lung bases (left greater than right), which most likely represent subsegmental atelectasis. There is no lobar consolidation, pleural effusion or pneumothorax. The cardiac silhouette is mildly enlarged. There is no pulmonary edema. No acute osseous abnormalities are identified. MICROBIOLOGY ============= Urine Culture [MASKED], Final): No Growth Blood Culture [MASKED], Final): No Growth Blood Culture [MASKED], Final): No Growth Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [ ]Patient started on lovenox [MASKED] BID, which he will continue as an outpatient. Can consider switching to oral agent in the future [ ]Patient should follow up with dentist after discharge for L lower molar pain. [ ]Discharged with home O2: Likely related to pulmonary embolism, however if continued oxygen requirement following anticoagulation would recommend continued workup with: - Pulmonology referral - Formal PFTs - Repeat CTA for evaluation of progression of PEs despite anticoagulation #Health care proxy: [MASKED] (wife) [MASKED] #CODE STATUS: Full confirmed SUMMARY: ======== [MASKED] history of recently diagnosed high grade glioma currently undergoing radiation and chemotherapy, admitted for hypoxia and tachycardia at radiation appointment, found to have PE. HOSPITAL ISSUES: ================ #Low risk PE: CTA chest noted segmental and subsegmental PE in LLL, no evidence of right heart stain or pulmonary infarction. Etiology likely in setting of malignancy. EKG also negative for right heart strain. Trops and BNP were negative. He was started on a heparin drip for 48 hours before transitioning to lovenox [MASKED] BID. He received a head CT, which did not show any bleeding or other intracranial process. He was persistently hypoxic, and as such alternative etiologies for hypoxia were considered. Repeat CT chest non-con did not reveal any explanatory etiology. TTE did not show any new depressed EF or valvular disease. His oxygen requirement was stable from [MASKED] on the day of discharge, and ultimately his persistent hypoxia was thought to be related to continued V/Q mismatch secondary to his pulmonary emboli. He was discharged with home oxygen and his oxygen requirement should be followed up as an outpatient. If he continued to have an oxygen requirement as an outpatient despite treatment for his PE, he should be referred to pulmonology for formal PFTs as well as repeat imaging and further diagnostic workup for persistent hypoxia. #PNA: Possible pneumonia identified on CT chest. Given tachycardia (though more likely from PE as above) and T 100.1 in ED, he was treated for CAP. Abx course: CTX/azithro for [MASKED], switched to cefpodoxime/azithro for [MASKED] #Tooth pain: Some erythema surrounding L lower molar, concerning for possible abscess. He was covered with abx for PNA above (cefpodoxime/azithro). Patient should have dental follow-up after discharge. #High grade glioma: Planned for radiation and TMZ. [MASKED] was his [MASKED] of 30 planned radiation treatments, with TMZ one hour prior to radiation treatments. Held TMZ and radiation on [MASKED], but regimen was continued on [MASKED] and continued until his discharge on [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 3. Famotidine 20 mg PO BID 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 5. LevETIRAcetam 1000 mg PO BID 6. temozolomide 160 mg oral DAILY Discharge Medications: 1. Enoxaparin Sodium 100 mg SC Q12H Start: [MASKED], First Dose: Next Routine Administration Time RX enoxaparin 100 mg/mL 100 mg SC every twelve (12) hours Disp #60 Syringe Refills:*0 2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 4. Famotidine 20 mg PO BID 5. LevETIRAcetam 1000 mg PO BID 6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 7. temozolomide 160 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: pulmonary emboli, glioblastoma status-post resection Secondary diagnoses: hypertension, fatty liver disease, irritable bowel syndrome, renal insufficiency, Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You came to the hospital because you had a fast heart rate and low oxygen saturation. WHAT HAPPENED IN THE HOSPITAL? ============================== - You received a CT can, which found blood clots in your lungs. - Your blood clots were treated with medications (lovenox). - You were found to have low oxygen levels so you are being discharged home with oxygen. 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. Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]	[]	[ "I129", "N189" ]	[ "I2699: Other pulmonary embolism without acute cor pulmonale", "J189: Pneumonia, unspecified organism", "C711: Malignant neoplasm of frontal lobe", "R0902: Hypoxemia", "K760: Fatty (change of) liver, not elsewhere classified", "K047: Periapical abscess without sinus", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "K589: Irritable bowel syndrome without diarrhea" ]
10,045,854	22,972,246	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Cipro Attending: ___ Chief Complaint: Consideration of cath Major Surgical or Invasive Procedure: None History of Present Illness: ___ with ___ CAD/CABG (DES x2, unclear anatomy), HTN, HLD, DM, who presented to BI-P with chest pain, found to have NSTEMI (tropI 10) and ST depressions in anterolateral leads, ST elevation in aVR, transferred to ___ for consideration of cath. Initially presented to BI-P on ___ with syncope (negative trauma evaluation) but with diffuse ST depressions on ECG and troponin I rise from 0.06 to 20 to peak of 70. He was asymptomatic at that time. TTE at that time showed EF50% but akinetic infero-lateral wall and basal to mid ___ wall. He received medical management with ASA, IV heparin, plavix, beta blocker and was discharged on discharged ___ from BI-P. However this AM he developed crushing R chest pain (his anginal equivalent) and thought he was "going to die." BIBEMS to BI-P, there trop-I 10 and ECG again showed diffuse ST depressions and ST elevation in aVR. CXR with pulmory edema edema. Received ASA324mg, NTG paste, started on heparin gtt. Labs there also noted mild stable anemia (Hb mid-high 9s) with negative FOBT, chem panel with Cr 1.6 (baseline appears 1.6-1.8). Cardiology evaluation there felt to have L main lesion requiring emergent transfer for stenting. Pre-transfer, VSS and 95%RA. At ___, pt reports currently is chest pain free. No abd pain, nausea, vomiting, diaphoresis, fever, chills, diarrhea, urinary c/o. In the ED: Initial VS: 98.0 84 154/79 16 96% RA EKG: NSR with RBBB, LAFB, ST depressions in anterolateral leads, and ST elevation in aVR Labs notable for: tropT 3.8, CKMB 50, Cr 1.5, BNP 18435, Mg 1.4 Studies notable for: CXR Overall improvement in central pulmonary edema, now mild-moderate. No focal consolidation. Consults: cardiology Patient was given: Iv heparin, IV Mg, clopidogrel 300 mg, Vitals on transfer: 98 81 143/70 18 95% RA On the cardiology service, he endorses the history above. He reports the chest pain has resolved and he is not experiencing any pain or pressure currently. REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies 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: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD/remote CABG (?in ___) at ___, reportedly with DES x2, unclear anatomy 3. OTHER PAST MEDICAL HISTORY - GERD Social History: ___ Family History: NC Physical Exam: Admission exam ============== VS: 98.0 143 / 70 ___ 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: No JVD CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric Discharge exam ============== 24 HR Data (last updated ___ @ 1706) Temp: 97.3 (Tm 99.2), BP: 103/57 (100-125/48-70), HR: 62 (61-82), RR: 16 (___), O2 sat: 96% (93-97), O2 delivery: RA 24 HR Data (last updated ___ @ 1706) 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: No JVD CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: Admision labs ============= ___ 01:00PM BLOOD WBC-9.5 RBC-3.01* Hgb-9.2* Hct-30.1* MCV-100* MCH-30.6 MCHC-30.6* RDW-13.6 RDWSD-49.7* Plt ___ ___ 01:00PM BLOOD Neuts-74.6* Lymphs-13.1* Monos-9.3 Eos-2.2 Baso-0.3 Im ___ AbsNeut-7.11* AbsLymp-1.25 AbsMono-0.89* AbsEos-0.21 AbsBaso-0.03 ___ 01:08PM BLOOD ___ PTT-102.5* ___ ___ 01:00PM BLOOD Glucose-114* UreaN-15 Creat-1.6* Na-135 K-4.4 Cl-100 HCO3-20* AnGap-15 ___ 08:39PM BLOOD ALT-13 AST-66* AlkPhos-92 TotBili-0.6 ___ 01:08PM BLOOD CK-MB-50* MB Indx-10.2* ___ ___ 01:00PM BLOOD Calcium-8.9 Phos-2.3* Mg-1.4* ___ 08:39PM BLOOD HDL-40* CHOL/HD-3.2 Discharge labs ============== ___ 06:40AM BLOOD WBC-11.3* RBC-2.53* Hgb-7.8* Hct-24.1* MCV-95 MCH-30.8 MCHC-32.4 RDW-13.7 RDWSD-47.6* Plt ___ ___ 06:40AM BLOOD Plt ___ ___ 06:40AM BLOOD Glucose-168* UreaN-21* Creat-1.7* Na-131* K-4.8 Cl-95* HCO3-24 AnGap-12 ___ 06:40AM BLOOD ALT-10 AST-18 AlkPhos-82 ___ 06:40AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.6 Imaging ======= TTE ___ CONCLUSION: The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. Overall left ventricular systolic function is moderately-to-severely depressed secondary to hypokinesis of the inferior free wall and akinesis (with focal dyskinesis) of the posterior and lateral walls. The visually estimated left ventricular ejection fraction is 30%. Left ventricular cardiac index is depressed (less than 2.0 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with depressed free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is depressed. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate [2+] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: inferoposterolateral myocardial infarct CXR ___ FINDINGS: In comparison to the prior radiograph, diffuse bilateral reticular opacities and septal thickening are improved compared to the prior study. There is mild-moderate persistent central pulmonary edema slightly worse on the left. There is bronchovascular cuffing. Likely trace left pleural effusion. No pneumothorax. No large focal consolidation. The heart is mildly enlarged. The mediastinum is stable in size. Postsurgical changes after median sternotomy and CABG are demonstrated. IMPRESSION: Overall improvement in central pulmonary edema, now mild-moderate. No focal consolidation. Brief Hospital Course: TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT: 66 kg(145.5 lb) DISCHARGE Cr: 1.7 DISCHARGE DIURETIC: None MEDICATION CHANGES: - NEW: Nitroglycerin SL 0.3 mg, Atorvastatin 80 mg daily - STOPPED: nifedipine 30mg daily, Simvastatin 80mg daily - CHANGED: Increased Metoprolol succinate XL from 12.5mg daily to 50 mg daily TRANSITIONAL ISSUES: [] Did not start ___ due to elevated Cr. and soft blood pressures, can be considered as outpatient. FOR PCP: [] A1c 7.2%, will require continued monitoring as outpatient [] please recheck sodium and creatinine within 1 week to ensure not hyponatremic and no ___ --likely due to decreased PO Intake from hospital food [] continue to assess goals of care and ___ and need for rehab # CODE STATUS: DNR/DNI # CONTACT: Name of health care proxy: ___ ___ number: ___ ========= SUMMARY ========= ___ with ___ CAD/CABG (DES x2, unclear anatomy), HTN, HLD, DM, who presented to BI-P with chest pain, found to have NSTEMI (tropI 10) and ST depressions in anterolateral leads, ST elevation in aVR, transferred to ___ for consideration of cath, now with plan for medical management. CORONARIES: prior CABG, 2xDES, unknown coronary anatomy PUMP: EF 50% ___ RHYTHM: NSR =============== ACTIVE ISSUES: =============== # Type I NSTEMI: History of CAD and remote CABG and 2xDES (he doesn't remember the details). Initial presentation on ___ to ___ for syncope with rising troponin diffuse ST depressions with ST elevation in aVR, concerning for diffuse ischemia such as L main disease. He was medically managed with ASA, heparin gtt, BB, plavix and discharged on ___. His peak troponin I was 70. He then represented on ___ for chest pain and had troponin I of 10 ___epressions as before. He was started on heparin gtt, ASA 325 mg and transferred to ___ for consideration of cath. At ___, he reported being chest pain free. TropT 3.8 with MB down-trending 50 to 47. TTE ___ showed EF 30% with inferoposterolateral myocardial infarct. Event was thought to be >72 hours out and given his age and prior CABG, risks/benefits were discussed with interventional attending and cardiology fellow who recommended medical management and reassessment if he were to develop chest pain. Discussed with patient and he would rather avoid cath if possible. We discussed that if he were to have worsening chest pain we may pursue this option and could reverse his DNR/DNI ___. He and his family agree with this noninvasive plan. Plan to optimize medical management. He was treated with ASA 81mg, Plavix 75mg, Atorvastatin 80mg, Metoprolol. Restarted his home isosorbide mononitrate 30mg daily. Initally treated with IV heparin gtt. ACEI was not started due to his Cr. Can be considered in outpatient if Cr. improves. Stopped nifedipine 30mg daily as he his metoprolol was increased. #DM A1c at BI-P 7.2% - Restarted on home glipizide on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 12.5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 4. NIFEdipine (Extended Release) 30 mg PO DAILY 5. Simvastatin 80 mg PO QPM 6. Pantoprazole 40 mg PO Q12H 7. GlipiZIDE XL 2.5 mg PO DAILY 8. Clopidogrel 75 mg PO DAILY 9. PARoxetine 10 mg PO 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. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Take 1 tab every 5 mins as needed for chest pain, if pain doesn't resolve after 3 tablets, call ___ RX nitroglycerin 0.3 mg 1 tablet(s) sublingually Every 5 mins Disp #30 Tablet Refills:0 3. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 6. GlipiZIDE XL 2.5 mg PO DAILY RX glipizide [Glucotrol XL] 2.5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 8. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 9. PARoxetine 10 mg PO DAILY RX paroxetine HCl 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis ================= Type I NSTEMI Secondary diagnosis =================== Type 2 Diabetes Mellitus Hypertension Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ================================================ DISCHARGE INSTRUCTIONS ================================================ Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had a heart attack. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were found to have some damage to your heart. Together with you, we decided to avoid looking inside the arteries of your heart (Cardiac catherization). We gave you medications to treat your heart instead. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. Followup Instructions: ___	[ "I214", "I2510", "I10", "Z951", "Z955", "E785", "E119", "K219", "Z7902", "I4510", "Z66" ]	Allergies: Cipro Chief Complaint: Consideration of cath Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with [MASKED] CAD/CABG (DES x2, unclear anatomy), HTN, HLD, DM, who presented to BI-P with chest pain, found to have NSTEMI (tropI 10) and ST depressions in anterolateral leads, ST elevation in aVR, transferred to [MASKED] for consideration of cath. Initially presented to BI-P on [MASKED] with syncope (negative trauma evaluation) but with diffuse ST depressions on ECG and troponin I rise from 0.06 to 20 to peak of 70. He was asymptomatic at that time. TTE at that time showed EF50% but akinetic infero-lateral wall and basal to mid [MASKED] wall. He received medical management with ASA, IV heparin, plavix, beta blocker and was discharged on discharged [MASKED] from BI-P. However this AM he developed crushing R chest pain (his anginal equivalent) and thought he was "going to die." BIBEMS to BI-P, there trop-I 10 and ECG again showed diffuse ST depressions and ST elevation in aVR. CXR with pulmory edema edema. Received ASA324mg, NTG paste, started on heparin gtt. Labs there also noted mild stable anemia (Hb mid-high 9s) with negative FOBT, chem panel with Cr 1.6 (baseline appears 1.6-1.8). Cardiology evaluation there felt to have L main lesion requiring emergent transfer for stenting. Pre-transfer, VSS and 95%RA. At [MASKED], pt reports currently is chest pain free. No abd pain, nausea, vomiting, diaphoresis, fever, chills, diarrhea, urinary c/o. In the ED: Initial VS: 98.0 84 154/79 16 96% RA EKG: NSR with RBBB, LAFB, ST depressions in anterolateral leads, and ST elevation in aVR Labs notable for: tropT 3.8, CKMB 50, Cr 1.5, BNP 18435, Mg 1.4 Studies notable for: CXR Overall improvement in central pulmonary edema, now mild-moderate. No focal consolidation. Consults: cardiology Patient was given: Iv heparin, IV Mg, clopidogrel 300 mg, Vitals on transfer: 98 81 143/70 18 95% RA On the cardiology service, he endorses the history above. He reports the chest pain has resolved and he is not experiencing any pain or pressure currently. REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies 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: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD/remote CABG (?in [MASKED]) at [MASKED], reportedly with DES x2, unclear anatomy 3. OTHER PAST MEDICAL HISTORY - GERD Social History: [MASKED] Family History: NC Physical Exam: Admission exam ============== VS: 98.0 143 / 70 [MASKED] 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: No JVD CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric Discharge exam ============== 24 HR Data (last updated [MASKED] @ 1706) Temp: 97.3 (Tm 99.2), BP: 103/57 (100-125/48-70), HR: 62 (61-82), RR: 16 ([MASKED]), O2 sat: 96% (93-97), O2 delivery: RA 24 HR Data (last updated [MASKED] @ 1706) 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: No JVD CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. no thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: Admision labs ============= [MASKED] 01:00PM BLOOD WBC-9.5 RBC-3.01* Hgb-9.2* Hct-30.1* MCV-100* MCH-30.6 MCHC-30.6* RDW-13.6 RDWSD-49.7* Plt [MASKED] [MASKED] 01:00PM BLOOD Neuts-74.6* Lymphs-13.1* Monos-9.3 Eos-2.2 Baso-0.3 Im [MASKED] AbsNeut-7.11* AbsLymp-1.25 AbsMono-0.89* AbsEos-0.21 AbsBaso-0.03 [MASKED] 01:08PM BLOOD [MASKED] PTT-102.5* [MASKED] [MASKED] 01:00PM BLOOD Glucose-114* UreaN-15 Creat-1.6* Na-135 K-4.4 Cl-100 HCO3-20* AnGap-15 [MASKED] 08:39PM BLOOD ALT-13 AST-66* AlkPhos-92 TotBili-0.6 [MASKED] 01:08PM BLOOD CK-MB-50* MB Indx-10.2* [MASKED] [MASKED] 01:00PM BLOOD Calcium-8.9 Phos-2.3* Mg-1.4* [MASKED] 08:39PM BLOOD HDL-40* CHOL/HD-3.2 Discharge labs ============== [MASKED] 06:40AM BLOOD WBC-11.3* RBC-2.53* Hgb-7.8* Hct-24.1* MCV-95 MCH-30.8 MCHC-32.4 RDW-13.7 RDWSD-47.6* Plt [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-168* UreaN-21* Creat-1.7* Na-131* K-4.8 Cl-95* HCO3-24 AnGap-12 [MASKED] 06:40AM BLOOD ALT-10 AST-18 AlkPhos-82 [MASKED] 06:40AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.6 Imaging ======= TTE [MASKED] CONCLUSION: The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. Overall left ventricular systolic function is moderately-to-severely depressed secondary to hypokinesis of the inferior free wall and akinesis (with focal dyskinesis) of the posterior and lateral walls. The visually estimated left ventricular ejection fraction is 30%. Left ventricular cardiac index is depressed (less than 2.0 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with depressed free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is depressed. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate [2+] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: inferoposterolateral myocardial infarct CXR [MASKED] FINDINGS: In comparison to the prior radiograph, diffuse bilateral reticular opacities and septal thickening are improved compared to the prior study. There is mild-moderate persistent central pulmonary edema slightly worse on the left. There is bronchovascular cuffing. Likely trace left pleural effusion. No pneumothorax. No large focal consolidation. The heart is mildly enlarged. The mediastinum is stable in size. Postsurgical changes after median sternotomy and CABG are demonstrated. IMPRESSION: Overall improvement in central pulmonary edema, now mild-moderate. No focal consolidation. Brief Hospital Course: TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT: 66 kg(145.5 lb) DISCHARGE Cr: 1.7 DISCHARGE DIURETIC: None MEDICATION CHANGES: - NEW: Nitroglycerin SL 0.3 mg, Atorvastatin 80 mg daily - STOPPED: nifedipine 30mg daily, Simvastatin 80mg daily - CHANGED: Increased Metoprolol succinate XL from 12.5mg daily to 50 mg daily TRANSITIONAL ISSUES: [] Did not start [MASKED] due to elevated Cr. and soft blood pressures, can be considered as outpatient. FOR PCP: [] A1c 7.2%, will require continued monitoring as outpatient [] please recheck sodium and creatinine within 1 week to ensure not hyponatremic and no [MASKED] --likely due to decreased PO Intake from hospital food [] continue to assess goals of care and [MASKED] and need for rehab # CODE STATUS: DNR/DNI # CONTACT: Name of health care proxy: [MASKED] [MASKED] number: [MASKED] ========= SUMMARY ========= [MASKED] with [MASKED] CAD/CABG (DES x2, unclear anatomy), HTN, HLD, DM, who presented to BI-P with chest pain, found to have NSTEMI (tropI 10) and ST depressions in anterolateral leads, ST elevation in aVR, transferred to [MASKED] for consideration of cath, now with plan for medical management. CORONARIES: prior CABG, 2xDES, unknown coronary anatomy PUMP: EF 50% [MASKED] RHYTHM: NSR =============== ACTIVE ISSUES: =============== # Type I NSTEMI: History of CAD and remote CABG and 2xDES (he doesn't remember the details). Initial presentation on [MASKED] to [MASKED] for syncope with rising troponin diffuse ST depressions with ST elevation in aVR, concerning for diffuse ischemia such as L main disease. He was medically managed with ASA, heparin gtt, BB, plavix and discharged on [MASKED]. His peak troponin I was 70. He then represented on [MASKED] for chest pain and had troponin I of 10 epressions as before. He was started on heparin gtt, ASA 325 mg and transferred to [MASKED] for consideration of cath. At [MASKED], he reported being chest pain free. TropT 3.8 with MB down-trending 50 to 47. TTE [MASKED] showed EF 30% with inferoposterolateral myocardial infarct. Event was thought to be >72 hours out and given his age and prior CABG, risks/benefits were discussed with interventional attending and cardiology fellow who recommended medical management and reassessment if he were to develop chest pain. Discussed with patient and he would rather avoid cath if possible. We discussed that if he were to have worsening chest pain we may pursue this option and could reverse his DNR/DNI [MASKED]. He and his family agree with this noninvasive plan. Plan to optimize medical management. He was treated with ASA 81mg, Plavix 75mg, Atorvastatin 80mg, Metoprolol. Restarted his home isosorbide mononitrate 30mg daily. Initally treated with IV heparin gtt. ACEI was not started due to his Cr. Can be considered in outpatient if Cr. improves. Stopped nifedipine 30mg daily as he his metoprolol was increased. #DM A1c at BI-P 7.2% - Restarted on home glipizide on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 12.5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 4. NIFEdipine (Extended Release) 30 mg PO DAILY 5. Simvastatin 80 mg PO QPM 6. Pantoprazole 40 mg PO Q12H 7. GlipiZIDE XL 2.5 mg PO DAILY 8. Clopidogrel 75 mg PO DAILY 9. PARoxetine 10 mg PO 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. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Take 1 tab every 5 mins as needed for chest pain, if pain doesn't resolve after 3 tablets, call [MASKED] RX nitroglycerin 0.3 mg 1 tablet(s) sublingually Every 5 mins Disp #30 Tablet Refills:0 3. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 6. GlipiZIDE XL 2.5 mg PO DAILY RX glipizide [Glucotrol XL] 2.5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 8. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 9. PARoxetine 10 mg PO DAILY RX paroxetine HCl 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis ================= Type I NSTEMI Secondary diagnosis =================== Type 2 Diabetes Mellitus Hypertension Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ================================================ DISCHARGE INSTRUCTIONS ================================================ Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had a heart attack. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were found to have some damage to your heart. Together with you, we decided to avoid looking inside the arteries of your heart (Cardiac catherization). We gave you medications to treat your heart instead. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. Followup Instructions: [MASKED]	[]	[ "I2510", "I10", "Z951", "Z955", "E785", "E119", "K219", "Z7902", "Z66" ]	[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I4510: Unspecified right bundle-branch block", "Z66: Do not resuscitate" ]
10,045,874	28,290,681	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Cipro / Flagyl / Dilaudid / morphine / Demerol / Darvocet-N Attending: ___. Chief Complaint: diverticulitis Major Surgical or Invasive Procedure: Robotic partial left colectomy with takedown of splenic flexure. Stapled #31 coloproctostomy and Firefly assessment of vascular inflow. History of Present Illness: ___ first episode divertiulitis requiring hospitalization ___ prior and again recently hospitalized at ___ ___ with complicated diverticulitis preceded by LLQ pain attacks and pressure culminating in hospitalization and IV antibiotics with CT scan demonstrating 2cm abscess in the sigmoid colon treated with IV antibiotics subsequently transitioned to BID Augmentin which she has been taking without interruption. Reportedly normal screening colonoscopy ___. Denies personal or family history of IBD, notes questionable history of colon cancer in maternal relative diagnosed at ___ of age. Currently denies fevers, chills, nausea or vomiting. Notes normal bowel function and flatus but on a restricted diet since ___. Last seen ___ with planned laparoscopic-assisted robotic sigmoid resection for ___, subsequently rescheduled to ___. At time of consultation, pt AFVSS with WBC 8.9, focal LLQ tenderness without peritoneal signs and uncomplicated diverticulitis in the descending colon. Past Medical History: Hypercholesterolemia Social History: ___ Family History: Negative for inflammatory bowel disease Physical Exam: Gen: Awake and alert CV: RRR Lungs: CTAB Abd: Soft, nontender, nondistended Laparoscopic sites clean, dry, and intact Pertinent Results: ___ 08:25AM BLOOD WBC-9.7# RBC-3.59* Hgb-11.3 Hct-33.0* MCV-92 MCH-31.5 MCHC-34.2 RDW-11.3 RDWSD-38.5 Plt ___ ___ 11:20AM BLOOD Neuts-76.2* Lymphs-15.8* Monos-7.1 Eos-0.5* Baso-0.2 Im ___ AbsNeut-6.77* AbsLymp-1.40 AbsMono-0.63 AbsEos-0.04 AbsBaso-0.02 ___ 08:25AM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-139 K-4.5 Cl-104 HCO3-29 AnGap-11 ___ 08:25AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.1 Brief Hospital Course: ___ presented to pre-op holding at ___ on ___ for a lap robotic sigmoid colectomy. She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Foley was taken out on ___ and she was able to void without difficulty, she was advanced to a regular diet as well. Her drain was removed on ___ without complication. Neuro: The patient received oxycodone with good effect and adequate pain control. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout the stay. Hematology: The patient's complete blood count was examined routinely for signs of bleeding and anemia Prophylaxis: The patient received subcutaneous heparin during this stay; was encouraged to get up and ambulate as early as possible. On ___, the patient was discharged to home. At discharge, she was tolerating a regular diet, passing flatus, voiding, and ambulating independently. She will follow-up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Include in Brief Hospital Course for Every Patient and check of boxes that apply: Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of ___ services [ ] Difficulty finding appropriate rehabilitation hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying discharge. [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. esomeprazole magnesium 20 mg oral DAILY 2. Simvastatin 20 mg PO QPM 3. Thyroid 30 mg PO DAILY Discharge Medications: 1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medication RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 2. esomeprazole magnesium 20 mg oral DAILY 3. Simvastatin 20 mg PO QPM 4. Thyroid 30 mg PO DAILY 5. home med it is ok to restart probiotics 6. Acetaminophen 650 mg PO Q6H:PRN pain 7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush RX nystatin 100,000 unit/mL 5 mL by mouth 4 times daily Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute on chronic diverticulitis involving the sigmoid colon and descending colon. Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to the hospital after a Laparoscopic Colectomy for surgical management of your Diverticulitis. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have ___ laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. These are healing well however it is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if you develop any of these symptoms or a fever. You may go to the emergency room if your symptoms are severe. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips) instead of Dermabond, these will fall off over time, please do not remove them. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. You will be prescribed narcotic pain medication Oxycodone. This medication should be taken when you have pain and as needed as written on the bottle. This is not a standing medication. You should continue to take Tylenol for pain around the clock and you can also take Advil. Please do not take more than 3000mg of Tylenol in 24 hours. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. ___ Dr. ___. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___	[ "K5732", "E039", "E780", "F40240", "K219", "K910", "Y836", "Y92239" ]	Allergies: Cipro / Flagyl / Dilaudid / morphine / Demerol / Darvocet-N Chief Complaint: diverticulitis Major Surgical or Invasive Procedure: Robotic partial left colectomy with takedown of splenic flexure. Stapled #31 coloproctostomy and Firefly assessment of vascular inflow. History of Present Illness: [MASKED] first episode divertiulitis requiring hospitalization [MASKED] prior and again recently hospitalized at [MASKED] [MASKED] with complicated diverticulitis preceded by LLQ pain attacks and pressure culminating in hospitalization and IV antibiotics with CT scan demonstrating 2cm abscess in the sigmoid colon treated with IV antibiotics subsequently transitioned to BID Augmentin which she has been taking without interruption. Reportedly normal screening colonoscopy [MASKED]. Denies personal or family history of IBD, notes questionable history of colon cancer in maternal relative diagnosed at [MASKED] of age. Currently denies fevers, chills, nausea or vomiting. Notes normal bowel function and flatus but on a restricted diet since [MASKED]. Last seen [MASKED] with planned laparoscopic-assisted robotic sigmoid resection for [MASKED], subsequently rescheduled to [MASKED]. At time of consultation, pt AFVSS with WBC 8.9, focal LLQ tenderness without peritoneal signs and uncomplicated diverticulitis in the descending colon. Past Medical History: Hypercholesterolemia Social History: [MASKED] Family History: Negative for inflammatory bowel disease Physical Exam: Gen: Awake and alert CV: RRR Lungs: CTAB Abd: Soft, nontender, nondistended Laparoscopic sites clean, dry, and intact Pertinent Results: [MASKED] 08:25AM BLOOD WBC-9.7# RBC-3.59* Hgb-11.3 Hct-33.0* MCV-92 MCH-31.5 MCHC-34.2 RDW-11.3 RDWSD-38.5 Plt [MASKED] [MASKED] 11:20AM BLOOD Neuts-76.2* Lymphs-15.8* Monos-7.1 Eos-0.5* Baso-0.2 Im [MASKED] AbsNeut-6.77* AbsLymp-1.40 AbsMono-0.63 AbsEos-0.04 AbsBaso-0.02 [MASKED] 08:25AM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-139 K-4.5 Cl-104 HCO3-29 AnGap-11 [MASKED] 08:25AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.1 Brief Hospital Course: [MASKED] presented to pre-op holding at [MASKED] on [MASKED] for a lap robotic sigmoid colectomy. She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Foley was taken out on [MASKED] and she was able to void without difficulty, she was advanced to a regular diet as well. Her drain was removed on [MASKED] without complication. Neuro: The patient received oxycodone with good effect and adequate pain control. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout the stay. Hematology: The patient's complete blood count was examined routinely for signs of bleeding and anemia Prophylaxis: The patient received subcutaneous heparin during this stay; was encouraged to get up and ambulate as early as possible. On [MASKED], the patient was discharged to home. At discharge, she was tolerating a regular diet, passing flatus, voiding, and ambulating independently. She will follow-up in the clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. Include in Brief Hospital Course for Every Patient and check of boxes that apply: Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of [MASKED] services [ ] Difficulty finding appropriate rehabilitation hospital disposition. [ ] Lack of insurance coverage for [MASKED] services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying discharge. [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. esomeprazole magnesium 20 mg oral DAILY 2. Simvastatin 20 mg PO QPM 3. Thyroid 30 mg PO DAILY Discharge Medications: 1. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medication RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 2. esomeprazole magnesium 20 mg oral DAILY 3. Simvastatin 20 mg PO QPM 4. Thyroid 30 mg PO DAILY 5. home med it is ok to restart probiotics 6. Acetaminophen 650 mg PO Q6H:PRN pain 7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush RX nystatin 100,000 unit/mL 5 mL by mouth 4 times daily Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute on chronic diverticulitis involving the sigmoid colon and descending colon. Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to the hospital after a Laparoscopic Colectomy for surgical management of your Diverticulitis. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have [MASKED] laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. These are healing well however it is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if you develop any of these symptoms or a fever. You may go to the emergency room if your symptoms are severe. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips) instead of Dermabond, these will fall off over time, please do not remove them. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. You will be prescribed narcotic pain medication Oxycodone. This medication should be taken when you have pain and as needed as written on the bottle. This is not a standing medication. You should continue to take Tylenol for pain around the clock and you can also take Advil. Please do not take more than 3000mg of Tylenol in 24 hours. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. [MASKED] Dr. [MASKED]. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED]	[]	[ "E039", "K219" ]	[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "E039: Hypothyroidism, unspecified", "E780: Pure hypercholesterolemia", "F40240: Claustrophobia", "K219: Gastro-esophageal reflux disease without esophagitis", "K910: Vomiting following gastrointestinal surgery", "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", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]
10,045,900	29,028,053	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: none History of Present Illness: ___ hx bicornuate uterus, PID, otherwise healthy who presents with nausea and vomiting. Her most recent symptoms started today, but she had similar symptoms earlier this month as below. Today, n/v awoke her from sleep. She has had multiple episodes of nbnb emesis. No abdominal pain, diarrhea, constipation. Has very mild generalized discomfort. Similar symptoms ___ weeks ago Recently moved here from ___ for her work. One month ago, was about to move out when she developed nausea, vomiting fatigue; other family members had this symptom. This resolved. Then, about two weeks ago, she developed a few episodes of severe, abrupt onset, nbnb emesis that felt better after vomiting. There has been minimal abdominal pain, no diarrhea. No fevers that she's aware of. A few days ago, she went to urgent care at ___ in ___, where she felt that "they were convinced I was pregnant." A urine pregnancy test was reportedly negative. She is sexually active with her boyfriend; they are monogamous to her knowledge. She takes OCPs and has not missed any doses recently. At ___, they felt her nausea/vomiting were due to anxiety symptoms, and prescribed PRN Zofran for this, which she has been taking with some relief. In the past ___ she redeveloped n/v, and was having chills and sweats at home. Of note, she denies dysuria and dyspareunia. She notes this is most similar to an episode of "pelvic infection" she had at a hospital in ___ about ___ ago. During that admission, she recalls having TTE ("they found a mild arrhythmia but nothing serious"), CTAP ("nothing abnormal"), and a pelvic ultrasound (showed "bicornuate uterus"). In the ED, initial vital signs were: 97.7 58 153/67 18 100% RA. - Exam notable for: "Benign. Observed sample of emesis, no gross blood." - Labs were notable for: WBC 13, otherwise unremarkable. - Imaging: none - The patient was given: IVF, lorazepam, ceftriaxone, - Consults: none Diagnosed with pyelonephritis and admitted to Medicine given inability to tolerate PO. Vitals prior to transfer were: 97.5 59 104/63 16 100% RA. On the floor, patient recounts the hx above. She denies symptoms other than mild n/v, lower abdominal discomfort worst just L of the umbilicus. Denies dysuria, dyspareunia, or purulent cervical discharge. Has had chills at home. No other symptoms - denies chest pain, dyspnea, unusual foreign travel, unusual food exposures. REVIEW OF SYSTEMS: Per HPI Past Medical History: -- bicornuate uterus -- hx "pelvic infection" at a ___ (___, ___ - hx "mild arrhythmia" Social History: ___ Family History: Mother, sister with UC Father d in ___ of gastric cancer Physical Exam: ============================ EXAM ON ADMISSION ============================ VITALS: 97.8 110/56 67 18 100/ra Genl: well appearing, pleasant, NAD HEENT: no icterus, PERRLA, MMM, no OP lesions Neck: no LAD Cor: RRR, ___ SEM throughout precordium Pulm: no incr WOB, CTAB Abd: soft, minimal ttp just L of the umbilicus at around ___ o'clock. Gyn: pelvic exam performed with RN chaperone. normal external female genitalia without any lesions. speculum - small amount of blood in vaginal vault, cervix could not be visualized; no obvious purulence. bimanual - cervix is R sided and posteriorly facing, no CMT. Neuro: AOx3 Skin: no obvious lesions or rashes of the torso, UEs, ___ ============================ EXAM ON DISCHARGE ============================ Vitals: 98.2, 97, 108/63, 18, 97%RA Genl: well appearing, pleasant, NAD Neck: no LAD Cor: RRR, no murmurs Pulm: no incr WOB, CTAB Abd: soft, minimal ttp just L of the umbilicus at around ___ o'clock. Neuro: AOx3 Skin: no obvious lesions or rashes of the torso, UEs, ___ ___ Results: =========================== LABS ON ADMISSION =========================== ___ 02:35PM BLOOD WBC-13.0* RBC-4.50 Hgb-12.4 Hct-38.4 MCV-85 MCH-27.6 MCHC-32.3 RDW-12.8 RDWSD-39.7 Plt ___ ___ 02:35PM BLOOD Neuts-85.9* Lymphs-9.8* Monos-3.1* Eos-0.2* Baso-0.5 Im ___ AbsNeut-11.19* AbsLymp-1.28 AbsMono-0.40 AbsEos-0.02* AbsBaso-0.07 ___ 02:35PM BLOOD Glucose-133* UreaN-10 Creat-0.7 Na-139 K-3.8 Cl-107 HCO3-21* AnGap-15 ___ 02:35PM BLOOD ALT-13 AST-19 AlkPhos-49 TotBili-0.2 ___ 02:35PM BLOOD Lipase-39 ___ 06:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0 ___ 02:35PM BLOOD Albumin-4.3 ___ 05:31PM BLOOD Lactate-1.5 =========================== LABS ON DISCHARGE =========================== ___ 06:40AM BLOOD WBC-8.9 RBC-3.96 Hgb-11.0* Hct-33.1* MCV-84 MCH-27.8 MCHC-33.2 RDW-13.0 RDWSD-39.3 Plt ___ ___ 06:40AM BLOOD Glucose-89 UreaN-9 Creat-0.5 Na-139 K-3.8 Cl-109* HCO3-21* AnGap-13 =========================== MICROBIOLOGY =========================== GC/CT - negative Urine culture - E. coli Blood cultures x2 - NGTD =========================== IMAGING =========================== none Brief Hospital Course: ___ no sign PMHx presenting with n/v, admitted for IV abx and observation given inability to tolerate PO. # Nausea, vomiting, abdominal discomfort: Patient presented with abdominal pain of unclear etiology. She was found to have leukocytosis, which resolved overnight, and was mostly likely related to the patient's vomiting. She had no fevers. She was found to have a UTI, and was started on ceftriaxone. Exam was negative for CVA tenderness, making pyelonephritis unlikely. A pelvic exam showed no cervical motion tenderness, and GC/CT testing was negative. She has a family history of gastric cancer, but this was felt to be very unlikely given patient's age, lack of risk factors, and that she had no other symptoms concerning for malignancy. She also has a family history of ulcerative colitis, but patient did not report any changes in bowel movements, and no diarrhea. Reported no heartburn. Given frequent use of marijuana, cyclic vomiting syndrome was considered as a possible diagnosis. Other possible causes are the oral contraceptive pill, which she started several weeks ago, and anxiety. After receiving IVF overnight, the patient was able to tolerate POs. She was discharged home with plan to establish with a PCP to further evaluate causes of her nausea. #Urinary tract infection: As above, patient had no urinary symptoms, but was found to have a positive u/a with a culture growing E. coli. She was covered on ceftriaxone and sent home with Bactrim to complete a 3 day course. TRANSITIONAL ISSUES: -consider changing OCP to IUD (for better compliance issues and possibility of symptoms being attributed to pseudomotor cerebri) -would like hip pain (chronic) to be worked up as an outpatient) -consider pelvic ultrasound to work up symptoms if persisting -complete UTI course of antibiotics with Bactrim (last day ___ -consider empiric PPI treatment if symptoms persist # CONTACT: mother ___, ___ # CODE STATUS: presumed full Medications on Admission: None Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID RX sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth every 12 hours Disp #2 Tablet Refills:0 2. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp #15 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Nausea/vomitting 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 having you here at the ___ ___. You were admitted here after you were found to have nausea and vomiting. Your pregnancy test was negative. You were found to have urine which showed signs of an infection. You will need to take one additional day of antibiotics to complete treatment for this (last day ___. We think your symptoms could be due to consumption of marijuana. We feel decreasing intake of this will help. Please follow up with your outpatient appointments below. We wish you the very best Your ___ medical team Followup Instructions: ___	[ "R112", "N390", "B9620", "F17210", "Q513" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] hx bicornuate uterus, PID, otherwise healthy who presents with nausea and vomiting. Her most recent symptoms started today, but she had similar symptoms earlier this month as below. Today, n/v awoke her from sleep. She has had multiple episodes of nbnb emesis. No abdominal pain, diarrhea, constipation. Has very mild generalized discomfort. Similar symptoms [MASKED] weeks ago Recently moved here from [MASKED] for her work. One month ago, was about to move out when she developed nausea, vomiting fatigue; other family members had this symptom. This resolved. Then, about two weeks ago, she developed a few episodes of severe, abrupt onset, nbnb emesis that felt better after vomiting. There has been minimal abdominal pain, no diarrhea. No fevers that she's aware of. A few days ago, she went to urgent care at [MASKED] in [MASKED], where she felt that "they were convinced I was pregnant." A urine pregnancy test was reportedly negative. She is sexually active with her boyfriend; they are monogamous to her knowledge. She takes OCPs and has not missed any doses recently. At [MASKED], they felt her nausea/vomiting were due to anxiety symptoms, and prescribed PRN Zofran for this, which she has been taking with some relief. In the past [MASKED] she redeveloped n/v, and was having chills and sweats at home. Of note, she denies dysuria and dyspareunia. She notes this is most similar to an episode of "pelvic infection" she had at a hospital in [MASKED] about [MASKED] ago. During that admission, she recalls having TTE ("they found a mild arrhythmia but nothing serious"), CTAP ("nothing abnormal"), and a pelvic ultrasound (showed "bicornuate uterus"). In the ED, initial vital signs were: 97.7 58 153/67 18 100% RA. - Exam notable for: "Benign. Observed sample of emesis, no gross blood." - Labs were notable for: WBC 13, otherwise unremarkable. - Imaging: none - The patient was given: IVF, lorazepam, ceftriaxone, - Consults: none Diagnosed with pyelonephritis and admitted to Medicine given inability to tolerate PO. Vitals prior to transfer were: 97.5 59 104/63 16 100% RA. On the floor, patient recounts the hx above. She denies symptoms other than mild n/v, lower abdominal discomfort worst just L of the umbilicus. Denies dysuria, dyspareunia, or purulent cervical discharge. Has had chills at home. No other symptoms - denies chest pain, dyspnea, unusual foreign travel, unusual food exposures. REVIEW OF SYSTEMS: Per HPI Past Medical History: -- bicornuate uterus -- hx "pelvic infection" at a [MASKED] ([MASKED], [MASKED] - hx "mild arrhythmia" Social History: [MASKED] Family History: Mother, sister with UC Father d in [MASKED] of gastric cancer Physical Exam: ============================ EXAM ON ADMISSION ============================ VITALS: 97.8 110/56 67 18 100/ra Genl: well appearing, pleasant, NAD HEENT: no icterus, PERRLA, MMM, no OP lesions Neck: no LAD Cor: RRR, [MASKED] SEM throughout precordium Pulm: no incr WOB, CTAB Abd: soft, minimal ttp just L of the umbilicus at around [MASKED] o'clock. Gyn: pelvic exam performed with RN chaperone. normal external female genitalia without any lesions. speculum - small amount of blood in vaginal vault, cervix could not be visualized; no obvious purulence. bimanual - cervix is R sided and posteriorly facing, no CMT. Neuro: AOx3 Skin: no obvious lesions or rashes of the torso, UEs, [MASKED] ============================ EXAM ON DISCHARGE ============================ Vitals: 98.2, 97, 108/63, 18, 97%RA Genl: well appearing, pleasant, NAD Neck: no LAD Cor: RRR, no murmurs Pulm: no incr WOB, CTAB Abd: soft, minimal ttp just L of the umbilicus at around [MASKED] o'clock. Neuro: AOx3 Skin: no obvious lesions or rashes of the torso, UEs, [MASKED] [MASKED] Results: =========================== LABS ON ADMISSION =========================== [MASKED] 02:35PM BLOOD WBC-13.0* RBC-4.50 Hgb-12.4 Hct-38.4 MCV-85 MCH-27.6 MCHC-32.3 RDW-12.8 RDWSD-39.7 Plt [MASKED] [MASKED] 02:35PM BLOOD Neuts-85.9* Lymphs-9.8* Monos-3.1* Eos-0.2* Baso-0.5 Im [MASKED] AbsNeut-11.19* AbsLymp-1.28 AbsMono-0.40 AbsEos-0.02* AbsBaso-0.07 [MASKED] 02:35PM BLOOD Glucose-133* UreaN-10 Creat-0.7 Na-139 K-3.8 Cl-107 HCO3-21* AnGap-15 [MASKED] 02:35PM BLOOD ALT-13 AST-19 AlkPhos-49 TotBili-0.2 [MASKED] 02:35PM BLOOD Lipase-39 [MASKED] 06:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0 [MASKED] 02:35PM BLOOD Albumin-4.3 [MASKED] 05:31PM BLOOD Lactate-1.5 =========================== LABS ON DISCHARGE =========================== [MASKED] 06:40AM BLOOD WBC-8.9 RBC-3.96 Hgb-11.0* Hct-33.1* MCV-84 MCH-27.8 MCHC-33.2 RDW-13.0 RDWSD-39.3 Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-89 UreaN-9 Creat-0.5 Na-139 K-3.8 Cl-109* HCO3-21* AnGap-13 =========================== MICROBIOLOGY =========================== GC/CT - negative Urine culture - E. coli Blood cultures x2 - NGTD =========================== IMAGING =========================== none Brief Hospital Course: [MASKED] no sign PMHx presenting with n/v, admitted for IV abx and observation given inability to tolerate PO. # Nausea, vomiting, abdominal discomfort: Patient presented with abdominal pain of unclear etiology. She was found to have leukocytosis, which resolved overnight, and was mostly likely related to the patient's vomiting. She had no fevers. She was found to have a UTI, and was started on ceftriaxone. Exam was negative for CVA tenderness, making pyelonephritis unlikely. A pelvic exam showed no cervical motion tenderness, and GC/CT testing was negative. She has a family history of gastric cancer, but this was felt to be very unlikely given patient's age, lack of risk factors, and that she had no other symptoms concerning for malignancy. She also has a family history of ulcerative colitis, but patient did not report any changes in bowel movements, and no diarrhea. Reported no heartburn. Given frequent use of marijuana, cyclic vomiting syndrome was considered as a possible diagnosis. Other possible causes are the oral contraceptive pill, which she started several weeks ago, and anxiety. After receiving IVF overnight, the patient was able to tolerate POs. She was discharged home with plan to establish with a PCP to further evaluate causes of her nausea. #Urinary tract infection: As above, patient had no urinary symptoms, but was found to have a positive u/a with a culture growing E. coli. She was covered on ceftriaxone and sent home with Bactrim to complete a 3 day course. TRANSITIONAL ISSUES: -consider changing OCP to IUD (for better compliance issues and possibility of symptoms being attributed to pseudomotor cerebri) -would like hip pain (chronic) to be worked up as an outpatient) -consider pelvic ultrasound to work up symptoms if persisting -complete UTI course of antibiotics with Bactrim (last day [MASKED] -consider empiric PPI treatment if symptoms persist # CONTACT: mother [MASKED], [MASKED] # CODE STATUS: presumed full Medications on Admission: None Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID RX sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth every 12 hours Disp #2 Tablet Refills:0 2. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp #15 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Nausea/vomitting 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 having you here at the [MASKED] [MASKED]. You were admitted here after you were found to have nausea and vomiting. Your pregnancy test was negative. You were found to have urine which showed signs of an infection. You will need to take one additional day of antibiotics to complete treatment for this (last day [MASKED]. We think your symptoms could be due to consumption of marijuana. We feel decreasing intake of this will help. Please follow up with your outpatient appointments below. We wish you the very best Your [MASKED] medical team Followup Instructions: [MASKED]	[]	[ "N390", "F17210" ]	[ "R112: Nausea with vomiting, unspecified", "N390: Urinary tract infection, site not specified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Q513: Bicornate uterus" ]
10,045,929	20,130,725	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right chest wall pain Major Surgical or Invasive Procedure: s/p bilateral chest tube placement due to bilateral pneumothorax. Right chest tube placed ___ taken out on ___, left chest tube placed ___, removed ___ ___ bilateral internal iliac gel foam embolization History of Present Illness: ___ year old male s/p pedestrian struck on right side at approximately 7pm on ___. Injury burden as listed below. Per report, the car was traveling at ___. +LOC, right chest wall crepitance, tension pnemothorax s/p needle decompression and chest tube placement in ED, pelvic bleed with active extravasation on CT. He received 1u PRBC in ED. Orthopaedic Surgery was consulted for right-sided sacral and pubic ramus fractures. He also have a right distal clavicle fracture noted on CXR. s/p bilateral chest tube placement due to bilateral pneumothorax. Right chest tube placed ___ taken out on ___, left chest tube placed ___, not yet removed ___ bilateral internal iliac gel foam embolization Patient has been ambulating with ___ here and will be d/c to a rehab hospital to continue management. The patients pain has improved and he is tolerating a regular diet. Past Medical History: No past medical history Social History: ___ Family History: No significant family medical history Physical Exam: PHYSICAL EXAMINATION: upon admission ___ Temp: 97.6 HR: 101 BP: 134/74 Resp: 24 O(2)Sat: 100% Normal Constitutional: No acute distress HEENT: left forehead abrasion, , Pupils equal, round and reactive to light Airway intact Chest: Equal breath sounds bilaterally Cardiovascular: Regular Rate and Rhythm Abdominal: Nontender, Soft Extr/Back: right lateral chest wall has crepitus to palpation, pelvis is stable, right lateral proximal femur ttp Skin: abrasions on left forehead, right knee, right lateral malleolus, left ulnar hand, left lateral ankle Neuro: Speech fluent, BLE strength intact Psych: Normal mentation ___: No petechiae Physical examination upon discharge: ___: General: NAD CV: ns1,s2, no murmurs LUNGS: clear ABDOMEN: soft, non-tender, hypoactive BS EXT: Scattered ecchymosis upper and lower ext., right groin site clean and dry MENTATION: alert and oriented x 3, speech clear Pertinent Results: ___ 05:39AM BLOOD WBC-11.5* RBC-2.65* Hgb-8.1* Hct-24.5* MCV-93 MCH-30.6 MCHC-33.1 RDW-15.4 RDWSD-50.6* Plt ___ ___ 10:02AM BLOOD WBC-13.8* RBC-2.65* Hgb-8.1* Hct-24.4* MCV-92 MCH-30.6 MCHC-33.2 RDW-15.9* RDWSD-53.2* Plt Ct-86* ___ 07:35PM BLOOD WBC-11.5* RBC-3.96* Hgb-12.7* Hct-37.6* MCV-95 MCH-32.1* MCHC-33.8 RDW-14.9 RDWSD-51.8* Plt ___ ___ 03:00AM BLOOD Neuts-84.6* Lymphs-3.4* Monos-11.1 Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.11* AbsLymp-0.52* AbsMono-1.72* AbsEos-0.00* AbsBaso-0.02 ___ 05:39AM BLOOD Plt ___ ___ 03:00AM BLOOD ___ PTT-25.6 ___ ___ 05:39AM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-136 K-3.5 Cl-101 HCO3-24 AnGap-15 ___ 12:45PM BLOOD LD(LDH)-319* ___ 05:39AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.0 ___ 05:31AM BLOOD Lactate-2.1* ___: DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. ___ has a new diagnosis of an anti-K antibody. The ___ is a member of the Kell blood group system. Anti-K is clinically significant and can cause hemolytic transfusion reactions. In the future, Mr. ___ should receive ___ negative products for all red blood cell transfusions. Approximately 91% of ABO compatible blood will be ___ negative. A wallet card and a letter stating the above will be sent to the patient. ___: cat scan of the head: No acute intracranial process. Right parietal subgaleal hematoma without underlying skull fracture. Moderate global cerebral atrophy. ___: cat scan of the c-spine: 1. No fracture or mal-alignment in the cervical spine. Multilevel degenerative disease. 2. Probable fracture involving the right transverse process of T1. 3. Subcutaneous emphysema in the neck, right greater than left. 4. Tiny apical pneumothorax, left greater than right, better assessed on concomitant CT torso examination. ___: cat scan of the chest: 1. Scattered right pulmonary contusion, small right and left pneumothorax, small bilateral hemothorax. Right chest tube in place. 2. Large pelvic hematoma with active bleeding. Right pelvic fractures involving right sacral ala, right pubic bone. Injury to the urinary bladder and urethra difficult to exclude. Consider CT cystogram and retrograde urethrogram. 3. Acute fractures involving ribs detailed above (R>L), left lumbar transverse processes, right distal clavicle. ___: abdomen: Single portable view of the pelvis provided. A contrast within the urinary bladder is noted. The urinary bladder has an abnormal configuration likely due to mass effect from adjacent hematoma better seen on CT. No definite signs of extravasation. Fractures of the right superior and inferior pubic ramus are again seen. Bilateral hip degenerative disease is of noted. ___: x-ray of the clavicle: . Minimally displaced distal clavicle fracture is again noted. 2. There are second and third rib fractures, more completely visualized and torso CT from 1 day earlier. 3. Subcutaneous emphysema is again noted. 4. Superior subluxation of the humeral head is compatible with a chronic rotator cuff tear. There is no gleno-humeral joint dislocation. 5. AC and gleno-humeral joint osteoarthritis. ___: chest x-ray: The previously small left apical pneumothorax is increased, small right apical pneumothorax is mildly improved, and previously mild left basal atelectasis increased since ___. ___: chest x-ray: There is a stable moderate left apical pneumothorax with a loculated basilar hydro-pneumothorax. The right apical pneumothorax is no longer appreciated. Linear opacity at the right base likely reflects subsegmental atelectasis. There is persistent but resolving subcutaneous emphysema within the right lateral chest wall soft tissues. No pulmonary edema. Overall cardiac and mediastinal contours are stable. Subacute fractures of at least the right third, fifth, and sixth posterolateral ribs better appreciated on the CT dated ___. Clips in the right upper quadrant consistent with prior cholecystectomy ___: chest x-ray: In comparison with the earlier study of this date, the left chest tube has been removed. The left apical pneumothorax has not increased. Brief Hospital Course: ___ year old gentleman admitted to the hospital after being struck by a car. He had no recollection of the accident. Upon admission, the patient was hypotensive and noted to have right chest wall crepitus and reported to have a tension pneumothorax. He underwent needle decompression and subsequent placement of a chest tube. Imaging studies showed multiple fractures including: bilateral rib fractures, bilateral lumbar transverse process fractures, right pulmonary contusion, bilateral pneumonthorax, right clavicle fracture, pelvic bleed with active extravasation and ?bladder perforation. Because of the patient's hypotension, he received 1 unit PRBC in the EW. After imaging studies were completed, the patient was admitted to the intensive care unit. The patient received an additional unit of blood in the Trauma Intensive care unit. His cervical spine was stabilized in the ___ collar. Because of the active bleeding in the pelvis, the patient was taken to ___ for Gel-Foam embolization of the left internal iliac artery anterior division and the right internal iliac artery. Orthopedic Surgery was consulted for right-sided sacral and pubic ramus fractures and a right distal clavicle fracture noted on CXR. The patient denied parethesia or weakness of the distal right upper extremity. The pelvic fracture was treated in a closed manner with no manipulation and the the patient was allowed to bear weight. After the patient's hematocrit stabilized, he was transferred to the surgical floor. Upon admission to the surgical floor, the patient resumed a regular diet. Imaging studies showed no spinal fractures and the cervical collar was removed after a non-tender physical examination of the neck. On HD #3, the right chest tube was placed to water seal and later removed. The patient's oxygen saturation was monitored and the patient was instructed in the use of the incentive spirometer. Despite these measures, the patient continued to have an oxygen requirement and on chest x-ray was reported to have a left basilar hydro-pneumothorax and a chest tube was placed with the removal of 300-400cc fluid. After imaging showed resolution of the fluid collection, the chest tube was removed. The patient's oxygenation saturation remained stable and he was weaned off the oxygen. In preparation for discharge, the patient was evaluated by Physical and occupational therapy and cleared for discharge home with the ___ services including physical therapy. The patient's vital signs remained stable and he was afebrile. His hematocrit stabilized at 24.5. His pain was controlled with oral analgesia and he was voiding without difficulty. The patient was discharged home on ___ in stable condition. An appointment for follow-up was made with the Acute care and Orthopedic service. Prior to discharge, the patient received instruction in lovenox injections, recommended by the Orthopedic service ( course to be determined by the Orthopedic service.) Medications on Admission: Baby aspirin Discharge Medications: 1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 2. Senna 8.6 mg PO BID:PRN constipation 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 4. Acetaminophen 650 mg PO Q6H:PRN pain 5. Aspirin 81 mg PO DAILY 6. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 mg once a day Disp #15 Syringe Refills:1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right pulmonary contusion, PTX Left PTX Right sacral ala, pubic bone fracture with hematoma Right clavicle fracture Bilateral rib fractures (Right 3,5,6,7)(Left 5) Left lumbar TP fracture (___) Right T1 TP fracture Right subgaleal hematoma 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: ___ year old male struck by car with positive loss of consciousness, bilateral rib fractures, right pneumothorax, pulmonary contusion s/p chest tube bilaterally. Your lungs have re-expanded and the chest tubes were removed. You also sustained a sacral/pelvic fractures with a pelvic hematoma. Because you had bleeding in your pelvis, you underwent ___ embolization. You are being discharged with the following instruction: Because you sustained rib fractures, please follow these instructions: Your injury caused bilateral rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). General care instructions: 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. Followup Instructions: ___	[ "S270XXA", "S32511A", "S2243XA", "S065X9A", "S32019A", "D62", "S32029A", "S32039A", "S27321A", "S37892A", "S32591A", "S3219XA", "V0390XA", "Y929", "S42001A", "S300XXA", "R768" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right chest wall pain Major Surgical or Invasive Procedure: s/p bilateral chest tube placement due to bilateral pneumothorax. Right chest tube placed [MASKED] taken out on [MASKED], left chest tube placed [MASKED], removed [MASKED] [MASKED] bilateral internal iliac gel foam embolization History of Present Illness: [MASKED] year old male s/p pedestrian struck on right side at approximately 7pm on [MASKED]. Injury burden as listed below. Per report, the car was traveling at [MASKED]. +LOC, right chest wall crepitance, tension pnemothorax s/p needle decompression and chest tube placement in ED, pelvic bleed with active extravasation on CT. He received 1u PRBC in ED. Orthopaedic Surgery was consulted for right-sided sacral and pubic ramus fractures. He also have a right distal clavicle fracture noted on CXR. s/p bilateral chest tube placement due to bilateral pneumothorax. Right chest tube placed [MASKED] taken out on [MASKED], left chest tube placed [MASKED], not yet removed [MASKED] bilateral internal iliac gel foam embolization Patient has been ambulating with [MASKED] here and will be d/c to a rehab hospital to continue management. The patients pain has improved and he is tolerating a regular diet. Past Medical History: No past medical history Social History: [MASKED] Family History: No significant family medical history Physical Exam: PHYSICAL EXAMINATION: upon admission [MASKED] Temp: 97.6 HR: 101 BP: 134/74 Resp: 24 O(2)Sat: 100% Normal Constitutional: No acute distress HEENT: left forehead abrasion, , Pupils equal, round and reactive to light Airway intact Chest: Equal breath sounds bilaterally Cardiovascular: Regular Rate and Rhythm Abdominal: Nontender, Soft Extr/Back: right lateral chest wall has crepitus to palpation, pelvis is stable, right lateral proximal femur ttp Skin: abrasions on left forehead, right knee, right lateral malleolus, left ulnar hand, left lateral ankle Neuro: Speech fluent, BLE strength intact Psych: Normal mentation [MASKED]: No petechiae Physical examination upon discharge: [MASKED]: General: NAD CV: ns1,s2, no murmurs LUNGS: clear ABDOMEN: soft, non-tender, hypoactive BS EXT: Scattered ecchymosis upper and lower ext., right groin site clean and dry MENTATION: alert and oriented x 3, speech clear Pertinent Results: [MASKED] 05:39AM BLOOD WBC-11.5* RBC-2.65* Hgb-8.1* Hct-24.5* MCV-93 MCH-30.6 MCHC-33.1 RDW-15.4 RDWSD-50.6* Plt [MASKED] [MASKED] 10:02AM BLOOD WBC-13.8* RBC-2.65* Hgb-8.1* Hct-24.4* MCV-92 MCH-30.6 MCHC-33.2 RDW-15.9* RDWSD-53.2* Plt Ct-86* [MASKED] 07:35PM BLOOD WBC-11.5* RBC-3.96* Hgb-12.7* Hct-37.6* MCV-95 MCH-32.1* MCHC-33.8 RDW-14.9 RDWSD-51.8* Plt [MASKED] [MASKED] 03:00AM BLOOD Neuts-84.6* Lymphs-3.4* Monos-11.1 Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-13.11* AbsLymp-0.52* AbsMono-1.72* AbsEos-0.00* AbsBaso-0.02 [MASKED] 05:39AM BLOOD Plt [MASKED] [MASKED] 03:00AM BLOOD [MASKED] PTT-25.6 [MASKED] [MASKED] 05:39AM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-136 K-3.5 Cl-101 HCO3-24 AnGap-15 [MASKED] 12:45PM BLOOD LD(LDH)-319* [MASKED] 05:39AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.0 [MASKED] 05:31AM BLOOD Lactate-2.1* [MASKED]: DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [MASKED] has a new diagnosis of an anti-K antibody. The [MASKED] is a member of the Kell blood group system. Anti-K is clinically significant and can cause hemolytic transfusion reactions. In the future, Mr. [MASKED] should receive [MASKED] negative products for all red blood cell transfusions. Approximately 91% of ABO compatible blood will be [MASKED] negative. A wallet card and a letter stating the above will be sent to the patient. [MASKED]: cat scan of the head: No acute intracranial process. Right parietal subgaleal hematoma without underlying skull fracture. Moderate global cerebral atrophy. [MASKED]: cat scan of the c-spine: 1. No fracture or mal-alignment in the cervical spine. Multilevel degenerative disease. 2. Probable fracture involving the right transverse process of T1. 3. Subcutaneous emphysema in the neck, right greater than left. 4. Tiny apical pneumothorax, left greater than right, better assessed on concomitant CT torso examination. [MASKED]: cat scan of the chest: 1. Scattered right pulmonary contusion, small right and left pneumothorax, small bilateral hemothorax. Right chest tube in place. 2. Large pelvic hematoma with active bleeding. Right pelvic fractures involving right sacral ala, right pubic bone. Injury to the urinary bladder and urethra difficult to exclude. Consider CT cystogram and retrograde urethrogram. 3. Acute fractures involving ribs detailed above (R>L), left lumbar transverse processes, right distal clavicle. [MASKED]: abdomen: Single portable view of the pelvis provided. A contrast within the urinary bladder is noted. The urinary bladder has an abnormal configuration likely due to mass effect from adjacent hematoma better seen on CT. No definite signs of extravasation. Fractures of the right superior and inferior pubic ramus are again seen. Bilateral hip degenerative disease is of noted. [MASKED]: x-ray of the clavicle: . Minimally displaced distal clavicle fracture is again noted. 2. There are second and third rib fractures, more completely visualized and torso CT from 1 day earlier. 3. Subcutaneous emphysema is again noted. 4. Superior subluxation of the humeral head is compatible with a chronic rotator cuff tear. There is no gleno-humeral joint dislocation. 5. AC and gleno-humeral joint osteoarthritis. [MASKED]: chest x-ray: The previously small left apical pneumothorax is increased, small right apical pneumothorax is mildly improved, and previously mild left basal atelectasis increased since [MASKED]. [MASKED]: chest x-ray: There is a stable moderate left apical pneumothorax with a loculated basilar hydro-pneumothorax. The right apical pneumothorax is no longer appreciated. Linear opacity at the right base likely reflects subsegmental atelectasis. There is persistent but resolving subcutaneous emphysema within the right lateral chest wall soft tissues. No pulmonary edema. Overall cardiac and mediastinal contours are stable. Subacute fractures of at least the right third, fifth, and sixth posterolateral ribs better appreciated on the CT dated [MASKED]. Clips in the right upper quadrant consistent with prior cholecystectomy [MASKED]: chest x-ray: In comparison with the earlier study of this date, the left chest tube has been removed. The left apical pneumothorax has not increased. Brief Hospital Course: [MASKED] year old gentleman admitted to the hospital after being struck by a car. He had no recollection of the accident. Upon admission, the patient was hypotensive and noted to have right chest wall crepitus and reported to have a tension pneumothorax. He underwent needle decompression and subsequent placement of a chest tube. Imaging studies showed multiple fractures including: bilateral rib fractures, bilateral lumbar transverse process fractures, right pulmonary contusion, bilateral pneumonthorax, right clavicle fracture, pelvic bleed with active extravasation and ?bladder perforation. Because of the patient's hypotension, he received 1 unit PRBC in the EW. After imaging studies were completed, the patient was admitted to the intensive care unit. The patient received an additional unit of blood in the Trauma Intensive care unit. His cervical spine was stabilized in the [MASKED] collar. Because of the active bleeding in the pelvis, the patient was taken to [MASKED] for Gel-Foam embolization of the left internal iliac artery anterior division and the right internal iliac artery. Orthopedic Surgery was consulted for right-sided sacral and pubic ramus fractures and a right distal clavicle fracture noted on CXR. The patient denied parethesia or weakness of the distal right upper extremity. The pelvic fracture was treated in a closed manner with no manipulation and the the patient was allowed to bear weight. After the patient's hematocrit stabilized, he was transferred to the surgical floor. Upon admission to the surgical floor, the patient resumed a regular diet. Imaging studies showed no spinal fractures and the cervical collar was removed after a non-tender physical examination of the neck. On HD #3, the right chest tube was placed to water seal and later removed. The patient's oxygen saturation was monitored and the patient was instructed in the use of the incentive spirometer. Despite these measures, the patient continued to have an oxygen requirement and on chest x-ray was reported to have a left basilar hydro-pneumothorax and a chest tube was placed with the removal of 300-400cc fluid. After imaging showed resolution of the fluid collection, the chest tube was removed. The patient's oxygenation saturation remained stable and he was weaned off the oxygen. In preparation for discharge, the patient was evaluated by Physical and occupational therapy and cleared for discharge home with the [MASKED] services including physical therapy. The patient's vital signs remained stable and he was afebrile. His hematocrit stabilized at 24.5. His pain was controlled with oral analgesia and he was voiding without difficulty. The patient was discharged home on [MASKED] in stable condition. An appointment for follow-up was made with the Acute care and Orthopedic service. Prior to discharge, the patient received instruction in lovenox injections, recommended by the Orthopedic service ( course to be determined by the Orthopedic service.) Medications on Admission: Baby aspirin Discharge Medications: 1. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 2. Senna 8.6 mg PO BID:PRN constipation 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 4. Acetaminophen 650 mg PO Q6H:PRN pain 5. Aspirin 81 mg PO DAILY 6. Enoxaparin Sodium 40 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 mg once a day Disp #15 Syringe Refills:1 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Right pulmonary contusion, PTX Left PTX Right sacral ala, pubic bone fracture with hematoma Right clavicle fracture Bilateral rib fractures (Right 3,5,6,7)(Left 5) Left lumbar TP fracture ([MASKED]) Right T1 TP fracture Right subgaleal hematoma 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] year old male struck by car with positive loss of consciousness, bilateral rib fractures, right pneumothorax, pulmonary contusion s/p chest tube bilaterally. Your lungs have re-expanded and the chest tubes were removed. You also sustained a sacral/pelvic fractures with a pelvic hematoma. Because you had bleeding in your pelvis, you underwent [MASKED] embolization. You are being discharged with the following instruction: Because you sustained rib fractures, please follow these instructions: Your injury caused bilateral rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). General care instructions: 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. Followup Instructions: [MASKED]	[]	[ "D62", "Y929" ]	[ "S270XXA: Traumatic pneumothorax, initial encounter", "S32511A: Fracture of superior rim of right pubis, initial encounter for closed fracture", "S2243XA: Multiple fractures of ribs, bilateral, initial encounter for closed fracture", "S065X9A: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter", "S32019A: Unspecified fracture of first lumbar vertebra, initial encounter for closed fracture", "D62: Acute posthemorrhagic anemia", "S32029A: Unspecified fracture of second lumbar vertebra, initial encounter for closed fracture", "S32039A: Unspecified fracture of third lumbar vertebra, initial encounter for closed fracture", "S27321A: Contusion of lung, unilateral, initial encounter", "S37892A: Contusion of other urinary and pelvic organ, initial encounter", "S32591A: Other specified fracture of right pubis, initial encounter for closed fracture", "S3219XA: Other fracture of sacrum, initial encounter for closed fracture", "V0390XA: Pedestrian on foot injured in collision with car, pick-up truck or van, unspecified whether traffic or nontraffic accident, initial encounter", "Y929: Unspecified place or not applicable", "S42001A: Fracture of unspecified part of right clavicle, initial encounter for closed fracture", "S300XXA: Contusion of lower back and pelvis, initial encounter", "R768: Other specified abnormal immunological findings in serum" ]
10,045,960	24,068,884	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with a history of HFpEF (EF 60%), COPD, AFib, CAD, OSA who presented with shortness of breath. He describes developing sudden shortness of breath at home yesterday evening which woke him from sleep. He describes orthopnea at that point although he generally sleeps with two pillows. He's had a dry cough for weeks, as well as insidious weight gain. He has been going to pulmonary rehab as recommended by his Pulmonologist, and underwent a session that morning. He thinks his diet has been the same, has not had sick contact. His only medication change was starting labetalol one week ago by his PCP. He denies fever/chills, chest pain, lightheadedness, palpitations. This morning he called EMS, who found him hypertensive to the 200s. He received oral nitro and was placed on CPAP on transfer. Of note, he had PEA arrest in ___ in the setting of hypoxia from a COPD exacerbation. He was diagnosed with AFib in that occasion and given an event monitor. He was also recently admitted on ___ with a CHF exacerbation which improved after diuresing. In the ED, Initial vital signs: T 97.7, HR 60, BP 230/130, RR 18, O2 sat 100% CPap Exam notable for: No exam documented. EKG: Sinus bradycardia w/ 1st degree AV block (PR 219), old anterioseptal MI (T wave inversions I, aVL, V4-6) Labs were notable for: CBC - WBC 7, Hgb 14.4, Plt 126; coags -INR 1.5; BMP - Cr 1; proBNP 1030; vBG 7.34/56/41 -> 7.42/45/55 ; lactate 1.6, trop negative. Studies performed include: CXR - Moderate pulmonary vascular congestion and edema. Bibasilar opacifications likely reflect a combination of atelectasis and edema, however a superimposed pneumonia would be difficult to exclude. New elevation of the left hemidiaphragm compared to ___. Probable small left pleural effusion. Patient was given: 4 SL nitro en route (1 additional in ED), Duonebs x 2, 40 mg IV Lasix, ceftriaxone, azithromycin, apixaban, aspirin, labetalol. His ED course was notable for starting BiPap on arrival and plan for ICU admission. However, his O2 requirement decreased to 5L NC so he was admitted to the floor. Vitals on transfer: HR 50, BP 163/85, RR 24, O2 sat 96% 5L NC Upon arrival to the floor, he is feeling well although still a little short of breath. Past Medical History: PEA arrest in the setting of hypoxia in ___ COPD HFpEF (EF 60% in ___ CAD (s/p DES to LCX ___ AFib Moderate AS L diaphragmatic paralysis OSA (ordered for outpatient BiPAP but declined this) Social History: ___ Family History: Father died from bone cancer at the age of ___. Mother died of dementia in her ___. Physical Exam: ADMISSION ========= VITALS: T 97.4, BP 185/84, HR 52, RR 18, O2 sat 97% 5L GEN: In NAD. HEENT: PERRL, moist mucous membranes, oropharynx clear without exudates. NECK: JVP to mandible, no cervical lymphadenopathy. CV: RRR, soft systolic ejection murmur at base. PULM: CTAB, no wheezing/crackles/rhonchi. ABD: Soft, non tender, non distended. EXTREM: Trace ___ edema. Pulses +2 ___P, ___ bilaterally. SKIN: No rashes. NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly intact. DISCHARGE ========= VITALS: Reviewed in OMR GENERAL: Alert and oriented, no acute distress ENT: NT/AC, MMM, EOMI CV: Bradycardic, regular. No murmurs, rubs, or gallops RESP: CTAB, normal work of breathing GI: NT/ND, BS+ EXT: Warm and well perfused, non-edematous NEURO: CNII-XII grossly intact, no focal neurologic deficits Pertinent Results: ADMISSION ========= ___ 04:47AM WBC-7.0 RBC-4.77 HGB-14.4 HCT-43.6 MCV-91 MCH-30.2 MCHC-33.0 RDW-14.5 RDWSD-48.9* ___ 04:47AM NEUTS-69.3 LYMPHS-18.0* MONOS-8.3 EOS-3.3 BASOS-0.7 IM ___ AbsNeut-4.82 AbsLymp-1.25 AbsMono-0.58 AbsEos-0.23 AbsBaso-0.05 ___ 04:47AM PLT COUNT-126* ___ 04:47AM ___ PTT-33.5 ___ ___ 04:47AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-1.9 ___ 04:47AM proBNP-1030* ___ 04:47AM cTropnT-<0.01 ___ 04:47AM GLUCOSE-156* UREA N-15 CREAT-1.0 SODIUM-142 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11 ___ 05:02AM LACTATE-1.6 ___ 05:02AM ___ PO2-41* PCO2-56* PH-7.34* TOTAL CO2-32* BASE XS-2 ___ 06:04AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 06:04AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06:04AM URINE UHOLD-HOLD ___ 06:04AM URINE HOURS-RANDOM ___ 06:16AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 03:21PM ___ PO2-55* PCO2-45 PH-7.42 TOTAL CO2-30 BASE XS-3 ___ 05:59PM GLUCOSE-85 UREA N-10 CREAT-0.7 SODIUM-147 POTASSIUM-3.1* CHLORIDE-114* TOTAL CO2-21* ANION GAP-12 DISCHARGE ========= ___ 06:15AM BLOOD WBC-6.0 RBC-5.15 Hgb-15.5 Hct-46.6 MCV-91 MCH-30.1 MCHC-33.3 RDW-14.5 RDWSD-47.8* Plt ___ ___ 06:15AM BLOOD Glucose-117* UreaN-20 Creat-1.2 Na-145 K-4.3 Cl-101 HCO3-27 AnGap-17 IMAGING ======= ___ CXR: 1. Moderate pulmonary vascular congestion and edema. 2. Bibasilar opacifications likely reflect a combination of atelectasis and edema, however a superimposed pneumonia would be difficult to exclude. 3. New elevation of the left hemidiaphragm compared to ___. 4. Probable small left pleural effusion. Brief Hospital Course: Mr. ___ is a ___ w/ PMH HFpEF (EF 60%), COPD, AFib, CAD, OSA presenting acute on chronic dyspnea presenting with acute on chronic hypoxemic respiratory failure initially requiring BiPAP but quickly transitioned to O2 via NC and then room air with diuresis. ACUTE ISSUES ============ #Dyspnea #HFpEF exacerbation Reported dry weight from last hospitalization 155 lb. Trigger for exacerbation is unclear, possibly flash pulmonary edema in the setting of labile BPs versus dietary indiscretion with recent weight gain. He was direused with IV furosemide and transitioned to oral torsemide. #HTN - Continued home ___ (losartan instead of non-formulary olmesartan) - Held home carvedilol, labetalol due to bradycardia, started on amlodipine 5MG daily for BP control in ___ of these agents. CHRONIC ISSUES ============== #COPD No wheezing, fevers, chills, productive cough, or other signs/symptoms of COPD exacerbation this admission. #CAD #AS Mild AS on TTE from ___. - Continued aspirin, atorvastatin #AFib #S/p cardiac arrest Patient with PEA cardiac arrest on ___, felt to be ___ acute hypoxic respiratory failure, with negative cath and required temporary pacer. Now with LINQ monitor. AFib developed during that hospitalization. - Held rate control with home carvedilol as above - Continued rhythm control with amiodarone - Continued AC with apixaban TRANSITIONAL ISSUES =================== Discharge Wt: 160 lb Discharge Cr: 1.2 [] Patient was discharged on Torsemide 10MG daily, please continue to monitor volume status closely and recheck CHEM7 at PCP follow up. [] Both carvedilol and labetalol were on the patient's preadmission medication list. Both of these were held on discharge due to bradycardia to the low ___ throughout this admission. [] Started on amlodipine 5MG for BP control in the setting of stopping carvedilol/labetalol as above, consider increasing if BP is still elevated or decreasing if beta blockers are restarted. [] Isolated thrombocytopenia this admission to 110-130s, no signs/symptoms of bleeding, consider further workup as outpatient if persistent. [] Patient should be on BiPAP at night as outpatient, but has been non-compliant. Would continue to reinforce using this as his OSA is probably contributing to HTN issues and heart failure exacerbations. #CONTACT: ___ (Son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. olmesartan 40 mg oral DAILY 2. CARVedilol 6.25 mg PO BID 3. Amiodarone 200 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Atorvastatin 80 mg PO QPM 6. Furosemide 20 mg PO DAILY 7. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 8. Aspirin 81 mg PO DAILY 9. Vitamin D ___ UNIT PO DAILY 10. dutasteride 0.5 mg oral QHS 11. Ranitidine 150 mg PO DAILY 12. Labetalol 300 mg PO BID Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Torsemide 10 mg PO DAILY RX torsemide 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. Amiodarone 200 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 8. dutasteride 0.5 mg oral QHS 9. olmesartan 40 mg oral DAILY 10. Ranitidine 150 mg PO DAILY 11. Vitamin D ___ UNIT PO DAILY 12. HELD- CARVedilol 6.25 mg PO BID This medication was held. Do not restart CARVedilol until Follow up with your PCP/Cardiologist 13. HELD- Labetalol 300 mg PO BID This medication was held. Do not restart Labetalol until follow up with your PCP/Cardiologist Discharge Disposition: Home Discharge Diagnosis: Primary: Acute on Chronic Diastolic Heart Failure Secondary: Hypertension Hyperlipidemia Chronic Obstructive Pulmonary Disease Atrial Fibrillation 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 having trouble breathing WHAT HAPPENED TO ME IN THE HOSPITAL? - Your trouble breathing what thought to be due to increased fluid in your body that backed up into your lungs. - You were treated with IV medications to help remove the fluid and were transitioned to a stronger medication called torsemide that you will continue to take on discharge. - Your home blood pressure medications were held due to your low heart rate and you were started on a new blood pressure medication. You should follow up with your PCP and your cardiologist about this. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Your weight at discharge is 160 lbs. Please weigh yourself today at home and use this as your new baseline. - Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs in one week. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "I110", "J9621", "I5033", "J449", "E785", "G4733", "I350", "R001", "I4891", "Z7901", "Z87891", "Z8674", "Z7951" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with a history of HFpEF (EF 60%), COPD, AFib, CAD, OSA who presented with shortness of breath. He describes developing sudden shortness of breath at home yesterday evening which woke him from sleep. He describes orthopnea at that point although he generally sleeps with two pillows. He's had a dry cough for weeks, as well as insidious weight gain. He has been going to pulmonary rehab as recommended by his Pulmonologist, and underwent a session that morning. He thinks his diet has been the same, has not had sick contact. His only medication change was starting labetalol one week ago by his PCP. He denies fever/chills, chest pain, lightheadedness, palpitations. This morning he called EMS, who found him hypertensive to the 200s. He received oral nitro and was placed on CPAP on transfer. Of note, he had PEA arrest in [MASKED] in the setting of hypoxia from a COPD exacerbation. He was diagnosed with AFib in that occasion and given an event monitor. He was also recently admitted on [MASKED] with a CHF exacerbation which improved after diuresing. In the ED, Initial vital signs: T 97.7, HR 60, BP 230/130, RR 18, O2 sat 100% CPap Exam notable for: No exam documented. EKG: Sinus bradycardia w/ 1st degree AV block (PR 219), old anterioseptal MI (T wave inversions I, aVL, V4-6) Labs were notable for: CBC - WBC 7, Hgb 14.4, Plt 126; coags -INR 1.5; BMP - Cr 1; proBNP 1030; vBG 7.34/56/41 -> 7.42/45/55 ; lactate 1.6, trop negative. Studies performed include: CXR - Moderate pulmonary vascular congestion and edema. Bibasilar opacifications likely reflect a combination of atelectasis and edema, however a superimposed pneumonia would be difficult to exclude. New elevation of the left hemidiaphragm compared to [MASKED]. Probable small left pleural effusion. Patient was given: 4 SL nitro en route (1 additional in ED), Duonebs x 2, 40 mg IV Lasix, ceftriaxone, azithromycin, apixaban, aspirin, labetalol. His ED course was notable for starting BiPap on arrival and plan for ICU admission. However, his O2 requirement decreased to 5L NC so he was admitted to the floor. Vitals on transfer: HR 50, BP 163/85, RR 24, O2 sat 96% 5L NC Upon arrival to the floor, he is feeling well although still a little short of breath. Past Medical History: PEA arrest in the setting of hypoxia in [MASKED] COPD HFpEF (EF 60% in [MASKED] CAD (s/p DES to LCX [MASKED] AFib Moderate AS L diaphragmatic paralysis OSA (ordered for outpatient BiPAP but declined this) Social History: [MASKED] Family History: Father died from bone cancer at the age of [MASKED]. Mother died of dementia in her [MASKED]. Physical Exam: ADMISSION ========= VITALS: T 97.4, BP 185/84, HR 52, RR 18, O2 sat 97% 5L GEN: In NAD. HEENT: PERRL, moist mucous membranes, oropharynx clear without exudates. NECK: JVP to mandible, no cervical lymphadenopathy. CV: RRR, soft systolic ejection murmur at base. PULM: CTAB, no wheezing/crackles/rhonchi. ABD: Soft, non tender, non distended. EXTREM: Trace [MASKED] edema. Pulses +2 P, [MASKED] bilaterally. SKIN: No rashes. NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly intact. DISCHARGE ========= VITALS: Reviewed in OMR GENERAL: Alert and oriented, no acute distress ENT: NT/AC, MMM, EOMI CV: Bradycardic, regular. No murmurs, rubs, or gallops RESP: CTAB, normal work of breathing GI: NT/ND, BS+ EXT: Warm and well perfused, non-edematous NEURO: CNII-XII grossly intact, no focal neurologic deficits Pertinent Results: ADMISSION ========= [MASKED] 04:47AM WBC-7.0 RBC-4.77 HGB-14.4 HCT-43.6 MCV-91 MCH-30.2 MCHC-33.0 RDW-14.5 RDWSD-48.9* [MASKED] 04:47AM NEUTS-69.3 LYMPHS-18.0* MONOS-8.3 EOS-3.3 BASOS-0.7 IM [MASKED] AbsNeut-4.82 AbsLymp-1.25 AbsMono-0.58 AbsEos-0.23 AbsBaso-0.05 [MASKED] 04:47AM PLT COUNT-126* [MASKED] 04:47AM [MASKED] PTT-33.5 [MASKED] [MASKED] 04:47AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-1.9 [MASKED] 04:47AM proBNP-1030* [MASKED] 04:47AM cTropnT-<0.01 [MASKED] 04:47AM GLUCOSE-156* UREA N-15 CREAT-1.0 SODIUM-142 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11 [MASKED] 05:02AM LACTATE-1.6 [MASKED] 05:02AM [MASKED] PO2-41* PCO2-56* PH-7.34* TOTAL CO2-32* BASE XS-2 [MASKED] 06:04AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 06:04AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 06:04AM URINE UHOLD-HOLD [MASKED] 06:04AM URINE HOURS-RANDOM [MASKED] 06:16AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 03:21PM [MASKED] PO2-55* PCO2-45 PH-7.42 TOTAL CO2-30 BASE XS-3 [MASKED] 05:59PM GLUCOSE-85 UREA N-10 CREAT-0.7 SODIUM-147 POTASSIUM-3.1* CHLORIDE-114* TOTAL CO2-21* ANION GAP-12 DISCHARGE ========= [MASKED] 06:15AM BLOOD WBC-6.0 RBC-5.15 Hgb-15.5 Hct-46.6 MCV-91 MCH-30.1 MCHC-33.3 RDW-14.5 RDWSD-47.8* Plt [MASKED] [MASKED] 06:15AM BLOOD Glucose-117* UreaN-20 Creat-1.2 Na-145 K-4.3 Cl-101 HCO3-27 AnGap-17 IMAGING ======= [MASKED] CXR: 1. Moderate pulmonary vascular congestion and edema. 2. Bibasilar opacifications likely reflect a combination of atelectasis and edema, however a superimposed pneumonia would be difficult to exclude. 3. New elevation of the left hemidiaphragm compared to [MASKED]. 4. Probable small left pleural effusion. Brief Hospital Course: Mr. [MASKED] is a [MASKED] w/ PMH HFpEF (EF 60%), COPD, AFib, CAD, OSA presenting acute on chronic dyspnea presenting with acute on chronic hypoxemic respiratory failure initially requiring BiPAP but quickly transitioned to O2 via NC and then room air with diuresis. ACUTE ISSUES ============ #Dyspnea #HFpEF exacerbation Reported dry weight from last hospitalization 155 lb. Trigger for exacerbation is unclear, possibly flash pulmonary edema in the setting of labile BPs versus dietary indiscretion with recent weight gain. He was direused with IV furosemide and transitioned to oral torsemide. #HTN - Continued home [MASKED] (losartan instead of non-formulary olmesartan) - Held home carvedilol, labetalol due to bradycardia, started on amlodipine 5MG daily for BP control in [MASKED] of these agents. CHRONIC ISSUES ============== #COPD No wheezing, fevers, chills, productive cough, or other signs/symptoms of COPD exacerbation this admission. #CAD #AS Mild AS on TTE from [MASKED]. - Continued aspirin, atorvastatin #AFib #S/p cardiac arrest Patient with PEA cardiac arrest on [MASKED], felt to be [MASKED] acute hypoxic respiratory failure, with negative cath and required temporary pacer. Now with LINQ monitor. AFib developed during that hospitalization. - Held rate control with home carvedilol as above - Continued rhythm control with amiodarone - Continued AC with apixaban TRANSITIONAL ISSUES =================== Discharge Wt: 160 lb Discharge Cr: 1.2 [] Patient was discharged on Torsemide 10MG daily, please continue to monitor volume status closely and recheck CHEM7 at PCP follow up. [] Both carvedilol and labetalol were on the patient's preadmission medication list. Both of these were held on discharge due to bradycardia to the low [MASKED] throughout this admission. [] Started on amlodipine 5MG for BP control in the setting of stopping carvedilol/labetalol as above, consider increasing if BP is still elevated or decreasing if beta blockers are restarted. [] Isolated thrombocytopenia this admission to 110-130s, no signs/symptoms of bleeding, consider further workup as outpatient if persistent. [] Patient should be on BiPAP at night as outpatient, but has been non-compliant. Would continue to reinforce using this as his OSA is probably contributing to HTN issues and heart failure exacerbations. #CONTACT: [MASKED] (Son) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. olmesartan 40 mg oral DAILY 2. CARVedilol 6.25 mg PO BID 3. Amiodarone 200 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Atorvastatin 80 mg PO QPM 6. Furosemide 20 mg PO DAILY 7. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 8. Aspirin 81 mg PO DAILY 9. Vitamin D [MASKED] UNIT PO DAILY 10. dutasteride 0.5 mg oral QHS 11. Ranitidine 150 mg PO DAILY 12. Labetalol 300 mg PO BID Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Torsemide 10 mg PO DAILY RX torsemide 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. Amiodarone 200 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 8. dutasteride 0.5 mg oral QHS 9. olmesartan 40 mg oral DAILY 10. Ranitidine 150 mg PO DAILY 11. Vitamin D [MASKED] UNIT PO DAILY 12. HELD- CARVedilol 6.25 mg PO BID This medication was held. Do not restart CARVedilol until Follow up with your PCP/Cardiologist 13. HELD- Labetalol 300 mg PO BID This medication was held. Do not restart Labetalol until follow up with your PCP/Cardiologist Discharge Disposition: Home Discharge Diagnosis: Primary: Acute on Chronic Diastolic Heart Failure Secondary: Hypertension Hyperlipidemia Chronic Obstructive Pulmonary Disease Atrial Fibrillation 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 having trouble breathing WHAT HAPPENED TO ME IN THE HOSPITAL? - Your trouble breathing what thought to be due to increased fluid in your body that backed up into your lungs. - You were treated with IV medications to help remove the fluid and were transitioned to a stronger medication called torsemide that you will continue to take on discharge. - Your home blood pressure medications were held due to your low heart rate and you were started on a new blood pressure medication. You should follow up with your PCP and your cardiologist about this. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Your weight at discharge is 160 lbs. Please weigh yourself today at home and use this as your new baseline. - Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs in one week. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "I110", "J449", "E785", "G4733", "I4891", "Z7901", "Z87891" ]	[ "I110: Hypertensive heart disease with heart failure", "J9621: Acute and chronic respiratory failure with hypoxia", "I5033: Acute on chronic diastolic (congestive) heart failure", "J449: Chronic obstructive pulmonary disease, unspecified", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I350: Nonrheumatic aortic (valve) stenosis", "R001: Bradycardia, unspecified", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "Z8674: Personal history of sudden cardiac arrest", "Z7951: Long term (current) use of inhaled steroids" ]
10,046,234	21,162,300	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: metformin Attending: ___. Chief Complaint: PEA arrest Major Surgical or Invasive Procedure: VT ablation ___ History of Present Illness: Mr ___ is a ___ year old man with CAD s/p remote 3 vessel CABG in ___, s/p PCI, VT and VF s/p ICD implant in ___ at ___, ___- Most recent LVEF 45% ___, IDDM, and CKD (baseline Cr. 1.8) who was transferred to the CCU post-VT ablation procedure where he suffered a cardiac arrest. He had recently been seen by EP on ___ in preparation for his VT ablation. An interrogation of his device had revealed multiple episodes of VT between ___ and ___. At the time, he reported feeling occasional dizziness and weakness due to SBP running periodically in the ___. He noted occasional palpitations and dyspnea on exertion but otherwise denied orthopnea, PND, ___ edema or chest pain. Of note, patient had previously had complicated admission to ___ ___ for VT storm (had been shocked > 40 times), requiring intubation, multiple antiarrythmics, pressors. Eventually loaded and discharged with amiodarone. Cath revealed a patent Cx stent and ischemia was not felt to be the cause of his arrest. During the admission he had acute metabolic encephalopathy, a retroperitoneal bleed post cath, acute worsening of his CR to 5.4, pneumonia and episodes of atrial fibrillation. He was discharged to rehab/home and has slowly been regaining strength. On arrival to the CCU, he is intubated and sedated on pressors. However, within an hour, he is awake and following commands. After recovering from sedation he is no longer requiring pressors. He was awake and following commands with cough and gag. Spontaneous breathing trial was successful and he was extubated shortly after arrival to the CCU. Upon extubation he is not in pain, asks for the time and knows where he is. Past Medical History: - Hypertension - Hyperlipidemia - T2DM on insulin - CAD s/p MI in his ___ and subsequent CABG (LIMA to LAD, SVG to RCA and OM) in ___, with subsequent LCX stent - HF, LVEF 45% in ___ - VT/VF s/p dual chamber ICD implant ___ - Stroke about ___ years ago- denies current deficits - hypothyroidism - ETOH use disorder, mild withdrawal symptoms on previous hospitalization Social History: ___ Family History: Father: HTN, DM, Early MI age ___ dies early ___ from CAD Brother: CAD first MI in his late ___ Mother's sisters with cancer unknown type. Physical Exam: Admission exam: VS: 98.8, 119/52, 80, 16, 96% face tent with humidifier s/p extubation 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. NECK: Supple. JVP of 8-9 cm. CARDIAC: Regular rate and rhythm. Normal S1, S2. no murmurs. LUNGS: Respiration is unlabored with no accessory muscle use. no crackles, mild expiratory wheeze. ABDOMEN: Soft, non-tender, non-distended. unable to appreciate organomegaly EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Discharge exam: VS: 98.4 PO \| 136 / 73 L Sitting \| HR 80 \| RR 18 \| O2 96 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. NECK: Supple. did not note JVP at 90 deg, +HJR CARDIAC: Regular rate and rhythm. Normal S1, S2. ___ systolic murmur at LUSB LUNGS: Respiration is unlabored with no accessory muscle use. Bibasilar crackles to mid lung, scattered expiratory wheezing ABDOMEN: Soft, obese, non-tender, non-distended. +BS 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: ---------------- ___ 05:37PM HGB-8.5* calcHCT-26 O2 SAT-26 CARBOXYHB-0 MET HGB-1 ___ 05:37PM GLUCOSE-247* LACTATE-1.8 NA+-146* K+-4.8 CL--101 ___ 05:37PM ___ PO2-21* PCO2-70* PH-7.38 TOTAL CO2-43* BASE XS-11 ___ 05:56PM TYPE-ART PO2-92 PCO2-52* PH-7.17* TOTAL CO2-20* BASE XS--9 ___ 05:56PM GLUCOSE-298* LACTATE-6.5* NA+-137 K+-4.1 CL--108 ___ 06:25PM HGB-8.1* calcHCT-24 O2 SAT-97 CARBOXYHB-0 ___ 06:25PM GLUCOSE-236* LACTATE-3.1* NA+-138 K+-3.9 CL--108 ___ 06:25PM TYPE-ART PO2-123* PCO2-39 PH-7.38 TOTAL CO2-24 BASE XS--1 Pertinent labs: --------------- Lytes: ___ 05:24AM BLOOD Glucose-183* UreaN-46* Creat-1.9* Na-144 K-4.5 Cl-107 HCO3-24 AnGap-13 ___ 04:46AM BLOOD Glucose-198* UreaN-38* Creat-1.8* Na-141 K-4.4 Cl-106 HCO3-24 AnGap-11 Liver enzymes: ___ 09:38PM BLOOD ALT-403* AST-401* LD(LDH)-568* AlkPhos-63 TotBili-0.3 ___ 05:24AM BLOOD ALT-317* AST-271* LD(LDH)-427* AlkPhos-56 TotBili-0.3 ___ 04:46AM BLOOD ALT-238* AST-136* LD(LDH)-348* AlkPhos-58 TotBili-0.3 Coagulation labs: ___ 05:24AM BLOOD ___ PTT-36.0 ___ ___ 05:24AM BLOOD Plt ___ ___ 04:46AM BLOOD ___ PTT-35.2 ___ ___ 04:46AM BLOOD Plt ___ Discharge labs: ___ 04:32AM BLOOD ___ PTT-34.1 ___ ___ 04:32AM BLOOD Plt ___ ___ 04:32AM BLOOD ALT-174* AST-69* AlkPhos-61 TotBili-0.4 ___ 04:32AM BLOOD Glucose-107* UreaN-31* Creat-1.8* Na-140 K-4.1 Cl-104 HCO3-23 AnGap-13 Pertinent Imaging/ Studies: ___ CXR: Postoperative changes. Left-sided pacemaker. No focal consolidation ___ Pathology: Mr. ___ has a new diagnosis of an Anti-C antibody. The ___ is a member of the Rh blood group system. Anti-C antibodies are clinically significant and capable of causing hemolytic transfusion reactions. In the future, Mr. ___ should receive ___ negative products for all red cell transfusions. Approximately 32% of ABO compatible blood will be ___ negative. Brief Hospital Course: Mr. ___ is a ___ M with a PMH of CAD s/p remote 3 vessel CABG in ___, s/p PCI, VT and VF s/p ICD implant in ___ at ___, CHF and CKD (baseline Cr. 1.8) who was transferred to the CCU from the EP lab, In the EP lab, during a VT ablation procedure, the patient had an episode of VT which was refractory to ATP and shock. This resulted in a PEA arrest with ROSC after 6 minutes of CPR and epi x2. A detailed list of all of the problems addressed during this hospitalization can be found below. Acute Issues: # Cardiac arrest # VT and hx of VF s/p ICD implant ___ Pt had a PEA arrest following triggered VT which was refractory to pacing termination and to DC shock. The pt had ROSC after 6 minutes of CPR and epinephrine x2. Post arrest, the patient was intubated and on pressors with a lactate elevated to 6.5. The pt was transferred to the CCU where he quickly no longer required pressors and was extubated. The pt was mentating well and without any signs of hypoperfusion to his brain, and with a lactate that normalized. The pt had three episodes of VT in the CCU, all of which were terminated by ATP. Per EP recommendations, his medications were changed from amiodarone 200 BID to mexilitine 150mg PO TID. The pt had no further episodes of VT, and once stable, was discharged home with close follow up. Chronic issues: # Transaminitis: The pt has a h/o elevated liver enzymes thought to be secondary to rouvastatin and amiodarone use. Apparent acute on chronic elevation of liver enzymes following arrest which was attributed to hypoperfusion during his PEA arrest. His statin was held in the setting of acute liver injury, however they were restarted when his transaminases quickly normalized. No further workup was pursued. # CAD s/p 3v CABG in ___, s/p PCI: Patient's home lisinopril, carvedilol and statin were all held in the setting of PEA arrest/hypotenstion and acute liver injury. He was restarted on home meds, but he was switched to metoprolol succinate 50mg PO BID per EP recs. # Heart failure (EF 45%): Not an active issue on this hospitalization. Pt continued on home regimen as above. # A-fib: Noted on previous pacer interrogation. On warfarin, previously on Xarelto that was stopped on last admission ___ RP bleed (from heparin). INR elevated post arrest, but therapeutic on discharge on home warfarin dose. # T2DM, on insulin: Home insulin regimen. # Leukocytosis and acute on chronic Anemia: Resolved. No infectious workup pursued. # CKD: Patient with elevated CR on last admission secondary to ATN, unknown previous baseline. Etiology likely secondary to DM/HTN/CHF. # Hypothyroidism: Continued on home levothyroxine # Stridor: Has had upper airway stridor since this ___, which can be worked up as a transitional issue. Transitional Issues: - Patient with down-trending liver enzymes after cardiac arrest. Discharge AST/ALT: 69/174. Please check transaminases at follow up appointment to assess for return to baseline following probable shock liver. - Patient with acute worsening of mild inspiratory stridor and no respiratory distress after intubation. He states that he has had these symptoms for a few months (since last extubation in ___. Please ensure that he follows up with ENT as an outpatient. - Patient with CKD, Cr at time of discharge 1.8, at baseline - Patient on warfarin for treatment of intermittent a-fib. INR therapeutic on discharge at 2.7. - Patient with mild anemia and thrombocytopenia at time of discharge. H&H 8.0* 24.8* and plt 136. Please repeat CBC at follow up appointment to ensure return to baseline. - During hospitalization patient had episodes of non-sustained VT on telemetry while on amiodarone. Therefore, amiodarone stopped and Mexiletine 150 Q8H was started to reduce ectopy. Patient initially with nausea that resolved after 24 hours. Metoprolol XL 50 BID was started and carvedilol was stopped to prevent hypotension. New meds: Mexiletine 150mg PO TID, Metoprolol succinate 50mg BID Stopped meds: Amiodarone 200 BID, Carvedilol 2mg BID # CODE: FULL CODE # CONTACT/HCP: ___ Relationship: WIFE Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Rosuvastatin Calcium 40 mg PO QPM 3. Amiodarone 200 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Carvedilol 25 mg PO BID 6. FoLIC Acid 1 mg PO DAILY 7. Lisinopril 5 mg PO DAILY 8. Thiamine 100 mg PO DAILY 9. Warfarin 2 mg PO DAILY16 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Lantus (insulin glargine) 100 unit/mL subcutaneous QHS 12. HumaLOG (insulin lispro) 100 unit/mL subcutaneous TID W/MEALS 13. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat;<br>multivitamin-iron-folic acid) ___ mg-mcg oral DAILY Discharge Medications: 1. Metoprolol Succinate XL 50 mg PO BID RX metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 2. Mexiletine 150 mg PO Q8H RX mexiletine 150 mg 1 capsule(s) by mouth every eight (8) hours Disp #90 Capsule Refills:0 3. Aspirin 81 mg PO DAILY 4. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat;<br>multivitamin-iron-folic acid) ___ mg-mcg oral DAILY 5. FoLIC Acid 1 mg PO DAILY 6. HumaLOG (insulin lispro) 100 unit/mL subcutaneous TID W/MEALS 7. Lantus (insulin glargine) 100 unit/mL subcutaneous QHS 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Lisinopril 5 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Rosuvastatin Calcium 40 mg PO QPM 12. Thiamine 100 mg PO DAILY 13. Warfarin 2 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia PEA arrest Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after there was a complication during your ablation procedure. You were monitored in the cardiac ICU and on the floor, and after your condition was stabilized you were discharged home. Below please find a detailed list of all that happened while you were in the hospital: WHILE YOU WERE IN THE HOSPITAL: =============================== - You had a ventricular ablation procedure for your history of ventricular tachycardia - During the procedure, you had ventricular tachycardia which was unable to be stopped - At this time, your heart stopped beating, and you were given chest compressions and medications to help your heart start beating again - You had a breathing tube inserted, and you were given medications to help support your blood pressure - You were brought to the cardiac ICU where your breathing tube was removed, and you no longer required medications to control your blood pressure - You had some more episodes of ventricular tachycardia which were all stopped by your pacemaker - The electrophysiology team saw you and made adjustments to your medications to try to stop these episodes - When you were no longer having episodes of ventricular tachycardia, you were discharged home with close follow up with the cardiology team WHEN YOU LEAVE: =============== - If you notice a weight gain of more than 3 pounds over a couple days, please see your cardiologist. - Please take all of your medications as prescribed for you - Please attend all of your follow up appointments - call to make a follow up appointment with ENT for your hoarseness and stridor while breathing. It was a pleasure to care for you during your hospitalization! - Your ___ Team Followup Instructions: ___	[ "I97120", "I472", "E1122", "I130", "D696", "Y838", "Y92530", "I255", "I2510", "I70203", "E039", "E785", "I482", "N189", "I509", "Z794", "Z7901", "Z951", "Z955", "Z87891", "Z8673", "D72829", "Z8249", "I462" ]	Allergies: metformin Chief Complaint: PEA arrest Major Surgical or Invasive Procedure: VT ablation [MASKED] History of Present Illness: Mr [MASKED] is a [MASKED] year old man with CAD s/p remote 3 vessel CABG in [MASKED], s/p PCI, VT and VF s/p ICD implant in [MASKED] at [MASKED], [MASKED]- Most recent LVEF 45% [MASKED], IDDM, and CKD (baseline Cr. 1.8) who was transferred to the CCU post-VT ablation procedure where he suffered a cardiac arrest. He had recently been seen by EP on [MASKED] in preparation for his VT ablation. An interrogation of his device had revealed multiple episodes of VT between [MASKED] and [MASKED]. At the time, he reported feeling occasional dizziness and weakness due to SBP running periodically in the [MASKED]. He noted occasional palpitations and dyspnea on exertion but otherwise denied orthopnea, PND, [MASKED] edema or chest pain. Of note, patient had previously had complicated admission to [MASKED] [MASKED] for VT storm (had been shocked > 40 times), requiring intubation, multiple antiarrythmics, pressors. Eventually loaded and discharged with amiodarone. Cath revealed a patent Cx stent and ischemia was not felt to be the cause of his arrest. During the admission he had acute metabolic encephalopathy, a retroperitoneal bleed post cath, acute worsening of his CR to 5.4, pneumonia and episodes of atrial fibrillation. He was discharged to rehab/home and has slowly been regaining strength. On arrival to the CCU, he is intubated and sedated on pressors. However, within an hour, he is awake and following commands. After recovering from sedation he is no longer requiring pressors. He was awake and following commands with cough and gag. Spontaneous breathing trial was successful and he was extubated shortly after arrival to the CCU. Upon extubation he is not in pain, asks for the time and knows where he is. Past Medical History: - Hypertension - Hyperlipidemia - T2DM on insulin - CAD s/p MI in his [MASKED] and subsequent CABG (LIMA to LAD, SVG to RCA and OM) in [MASKED], with subsequent LCX stent - HF, LVEF 45% in [MASKED] - VT/VF s/p dual chamber ICD implant [MASKED] - Stroke about [MASKED] years ago- denies current deficits - hypothyroidism - ETOH use disorder, mild withdrawal symptoms on previous hospitalization Social History: [MASKED] Family History: Father: HTN, DM, Early MI age [MASKED] dies early [MASKED] from CAD Brother: CAD first MI in his late [MASKED] Mother's sisters with cancer unknown type. Physical Exam: Admission exam: VS: 98.8, 119/52, 80, 16, 96% face tent with humidifier s/p extubation 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. NECK: Supple. JVP of 8-9 cm. CARDIAC: Regular rate and rhythm. Normal S1, S2. no murmurs. LUNGS: Respiration is unlabored with no accessory muscle use. no crackles, mild expiratory wheeze. ABDOMEN: Soft, non-tender, non-distended. unable to appreciate organomegaly EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Discharge exam: VS: 98.4 PO \| 136 / 73 L Sitting \| HR 80 \| RR 18 \| O2 96 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. NECK: Supple. did not note JVP at 90 deg, +HJR CARDIAC: Regular rate and rhythm. Normal S1, S2. [MASKED] systolic murmur at LUSB LUNGS: Respiration is unlabored with no accessory muscle use. Bibasilar crackles to mid lung, scattered expiratory wheezing ABDOMEN: Soft, obese, non-tender, non-distended. +BS EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: Admission labs: ---------------- [MASKED] 05:37PM HGB-8.5* calcHCT-26 O2 SAT-26 CARBOXYHB-0 MET HGB-1 [MASKED] 05:37PM GLUCOSE-247* LACTATE-1.8 NA+-146* K+-4.8 CL--101 [MASKED] 05:37PM [MASKED] PO2-21* PCO2-70* PH-7.38 TOTAL CO2-43* BASE XS-11 [MASKED] 05:56PM TYPE-ART PO2-92 PCO2-52* PH-7.17* TOTAL CO2-20* BASE XS--9 [MASKED] 05:56PM GLUCOSE-298* LACTATE-6.5* NA+-137 K+-4.1 CL--108 [MASKED] 06:25PM HGB-8.1* calcHCT-24 O2 SAT-97 CARBOXYHB-0 [MASKED] 06:25PM GLUCOSE-236* LACTATE-3.1* NA+-138 K+-3.9 CL--108 [MASKED] 06:25PM TYPE-ART PO2-123* PCO2-39 PH-7.38 TOTAL CO2-24 BASE XS--1 Pertinent labs: --------------- Lytes: [MASKED] 05:24AM BLOOD Glucose-183* UreaN-46* Creat-1.9* Na-144 K-4.5 Cl-107 HCO3-24 AnGap-13 [MASKED] 04:46AM BLOOD Glucose-198* UreaN-38* Creat-1.8* Na-141 K-4.4 Cl-106 HCO3-24 AnGap-11 Liver enzymes: [MASKED] 09:38PM BLOOD ALT-403* AST-401* LD(LDH)-568* AlkPhos-63 TotBili-0.3 [MASKED] 05:24AM BLOOD ALT-317* AST-271* LD(LDH)-427* AlkPhos-56 TotBili-0.3 [MASKED] 04:46AM BLOOD ALT-238* AST-136* LD(LDH)-348* AlkPhos-58 TotBili-0.3 Coagulation labs: [MASKED] 05:24AM BLOOD [MASKED] PTT-36.0 [MASKED] [MASKED] 05:24AM BLOOD Plt [MASKED] [MASKED] 04:46AM BLOOD [MASKED] PTT-35.2 [MASKED] [MASKED] 04:46AM BLOOD Plt [MASKED] Discharge labs: [MASKED] 04:32AM BLOOD [MASKED] PTT-34.1 [MASKED] [MASKED] 04:32AM BLOOD Plt [MASKED] [MASKED] 04:32AM BLOOD ALT-174* AST-69* AlkPhos-61 TotBili-0.4 [MASKED] 04:32AM BLOOD Glucose-107* UreaN-31* Creat-1.8* Na-140 K-4.1 Cl-104 HCO3-23 AnGap-13 Pertinent Imaging/ Studies: [MASKED] CXR: Postoperative changes. Left-sided pacemaker. No focal consolidation [MASKED] Pathology: Mr. [MASKED] has a new diagnosis of an Anti-C antibody. The [MASKED] is a member of the Rh blood group system. Anti-C antibodies are clinically significant and capable of causing hemolytic transfusion reactions. In the future, Mr. [MASKED] should receive [MASKED] negative products for all red cell transfusions. Approximately 32% of ABO compatible blood will be [MASKED] negative. Brief Hospital Course: Mr. [MASKED] is a [MASKED] M with a PMH of CAD s/p remote 3 vessel CABG in [MASKED], s/p PCI, VT and VF s/p ICD implant in [MASKED] at [MASKED], CHF and CKD (baseline Cr. 1.8) who was transferred to the CCU from the EP lab, In the EP lab, during a VT ablation procedure, the patient had an episode of VT which was refractory to ATP and shock. This resulted in a PEA arrest with ROSC after 6 minutes of CPR and epi x2. A detailed list of all of the problems addressed during this hospitalization can be found below. Acute Issues: # Cardiac arrest # VT and hx of VF s/p ICD implant [MASKED] Pt had a PEA arrest following triggered VT which was refractory to pacing termination and to DC shock. The pt had ROSC after 6 minutes of CPR and epinephrine x2. Post arrest, the patient was intubated and on pressors with a lactate elevated to 6.5. The pt was transferred to the CCU where he quickly no longer required pressors and was extubated. The pt was mentating well and without any signs of hypoperfusion to his brain, and with a lactate that normalized. The pt had three episodes of VT in the CCU, all of which were terminated by ATP. Per EP recommendations, his medications were changed from amiodarone 200 BID to mexilitine 150mg PO TID. The pt had no further episodes of VT, and once stable, was discharged home with close follow up. Chronic issues: # Transaminitis: The pt has a h/o elevated liver enzymes thought to be secondary to rouvastatin and amiodarone use. Apparent acute on chronic elevation of liver enzymes following arrest which was attributed to hypoperfusion during his PEA arrest. His statin was held in the setting of acute liver injury, however they were restarted when his transaminases quickly normalized. No further workup was pursued. # CAD s/p 3v CABG in [MASKED], s/p PCI: Patient's home lisinopril, carvedilol and statin were all held in the setting of PEA arrest/hypotenstion and acute liver injury. He was restarted on home meds, but he was switched to metoprolol succinate 50mg PO BID per EP recs. # Heart failure (EF 45%): Not an active issue on this hospitalization. Pt continued on home regimen as above. # A-fib: Noted on previous pacer interrogation. On warfarin, previously on Xarelto that was stopped on last admission [MASKED] RP bleed (from heparin). INR elevated post arrest, but therapeutic on discharge on home warfarin dose. # T2DM, on insulin: Home insulin regimen. # Leukocytosis and acute on chronic Anemia: Resolved. No infectious workup pursued. # CKD: Patient with elevated CR on last admission secondary to ATN, unknown previous baseline. Etiology likely secondary to DM/HTN/CHF. # Hypothyroidism: Continued on home levothyroxine # Stridor: Has had upper airway stridor since this [MASKED], which can be worked up as a transitional issue. Transitional Issues: - Patient with down-trending liver enzymes after cardiac arrest. Discharge AST/ALT: 69/174. Please check transaminases at follow up appointment to assess for return to baseline following probable shock liver. - Patient with acute worsening of mild inspiratory stridor and no respiratory distress after intubation. He states that he has had these symptoms for a few months (since last extubation in [MASKED]. Please ensure that he follows up with ENT as an outpatient. - Patient with CKD, Cr at time of discharge 1.8, at baseline - Patient on warfarin for treatment of intermittent a-fib. INR therapeutic on discharge at 2.7. - Patient with mild anemia and thrombocytopenia at time of discharge. H&H 8.0* 24.8* and plt 136. Please repeat CBC at follow up appointment to ensure return to baseline. - During hospitalization patient had episodes of non-sustained VT on telemetry while on amiodarone. Therefore, amiodarone stopped and Mexiletine 150 Q8H was started to reduce ectopy. Patient initially with nausea that resolved after 24 hours. Metoprolol XL 50 BID was started and carvedilol was stopped to prevent hypotension. New meds: Mexiletine 150mg PO TID, Metoprolol succinate 50mg BID Stopped meds: Amiodarone 200 BID, Carvedilol 2mg BID # CODE: FULL CODE # CONTACT/HCP: [MASKED] Relationship: WIFE Phone: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Rosuvastatin Calcium 40 mg PO QPM 3. Amiodarone 200 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Carvedilol 25 mg PO BID 6. FoLIC Acid 1 mg PO DAILY 7. Lisinopril 5 mg PO DAILY 8. Thiamine 100 mg PO DAILY 9. Warfarin 2 mg PO DAILY16 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Lantus (insulin glargine) 100 unit/mL subcutaneous QHS 12. HumaLOG (insulin lispro) 100 unit/mL subcutaneous TID W/MEALS 13. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat;<br>multivitamin-iron-folic acid) [MASKED] mg-mcg oral DAILY Discharge Medications: 1. Metoprolol Succinate XL 50 mg PO BID RX metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 2. Mexiletine 150 mg PO Q8H RX mexiletine 150 mg 1 capsule(s) by mouth every eight (8) hours Disp #90 Capsule Refills:0 3. Aspirin 81 mg PO DAILY 4. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat;<br>multivitamin-iron-folic acid) [MASKED] mg-mcg oral DAILY 5. FoLIC Acid 1 mg PO DAILY 6. HumaLOG (insulin lispro) 100 unit/mL subcutaneous TID W/MEALS 7. Lantus (insulin glargine) 100 unit/mL subcutaneous QHS 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Lisinopril 5 mg PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Rosuvastatin Calcium 40 mg PO QPM 12. Thiamine 100 mg PO DAILY 13. Warfarin 2 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia PEA arrest Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital after there was a complication during your ablation procedure. You were monitored in the cardiac ICU and on the floor, and after your condition was stabilized you were discharged home. Below please find a detailed list of all that happened while you were in the hospital: WHILE YOU WERE IN THE HOSPITAL: =============================== - You had a ventricular ablation procedure for your history of ventricular tachycardia - During the procedure, you had ventricular tachycardia which was unable to be stopped - At this time, your heart stopped beating, and you were given chest compressions and medications to help your heart start beating again - You had a breathing tube inserted, and you were given medications to help support your blood pressure - You were brought to the cardiac ICU where your breathing tube was removed, and you no longer required medications to control your blood pressure - You had some more episodes of ventricular tachycardia which were all stopped by your pacemaker - The electrophysiology team saw you and made adjustments to your medications to try to stop these episodes - When you were no longer having episodes of ventricular tachycardia, you were discharged home with close follow up with the cardiology team WHEN YOU LEAVE: =============== - If you notice a weight gain of more than 3 pounds over a couple days, please see your cardiologist. - Please take all of your medications as prescribed for you - Please attend all of your follow up appointments - call to make a follow up appointment with ENT for your hoarseness and stridor while breathing. It was a pleasure to care for you during your hospitalization! - Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "E1122", "I130", "D696", "I2510", "E039", "E785", "N189", "Z794", "Z7901", "Z951", "Z955", "Z87891", "Z8673" ]	[ "I97120: Postprocedural cardiac arrest following cardiac surgery", "I472: Ventricular tachycardia", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "D696: Thrombocytopenia, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92530: Ambulatory surgery center as the place of occurrence of the external cause", "I255: Ischemic cardiomyopathy", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I70203: Unspecified atherosclerosis of native arteries of extremities, bilateral legs", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "I482: Chronic atrial fibrillation", "N189: Chronic kidney disease, unspecified", "I509: Heart failure, unspecified", "Z794: Long term (current) use of insulin", "Z7901: Long term (current) use of anticoagulants", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z87891: Personal history of nicotine dependence", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "D72829: Elevated white blood cell count, unspecified", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "I462: Cardiac arrest due to underlying cardiac condition" ]
10,046,234	24,608,062	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: metformin Attending: ___. Chief Complaint: VT storm Major Surgical or Invasive Procedure: Endotracheal intubation at OSH prior to admission History of Present Illness: ___ w/CAD s/p remote 2v CABG ___ and PCI, VT and VF s/p AICD (Medtronix, bi-v), HFrEF (EF 45%), insulin-dependent diabetes, CKD (b/l Cr ___, hypothyroidism, and Etoh use disorder, who presents as a transfer from ___ for recurrent VT (shocked > 60 times) following an admission there on ___ for a syncopal episode in the setting of Vtach. The patient had a syncopal episode at home and was found to be in slow VT; apparently denied chest pain and AICD did not get triggered. CPR was started and the patient was defibrillated in the field. Upon arrival in the ED, he had recurrent episodes of VT and continued to be syncopal. In spite of multiple shocks, amiodarone 300mg, and IV lidocaine, he continued to have multiple episodes of VT. He was also found to be hypoglycemic w/FSBG 40-50. EMTs did report that he did smell of Etoh when they picked uim up, but the patient denied drinking any "significant" amounts of Etoh. In the ED, labs were notable for trop wnl, CBC and chem10 wnl except for hypokalemia and acidemia. K was repleted and pt received bicarb. Patient was cathed, reported to have no intervenable lesion/no ischemic etiology of VT was found (Lcx patent w/stent, LIMA to LAD patent, known ___ occluded LAD, RCA, SVG to RCA, SCG to OM patent unchanged from prior). He had his AICD interrogated and settings were changed to defibrillate at lower HR (154). Patient continued to have multiples episodes of MMVT (many w/HRs <150s-160s) accompanied by hypotension, and was intubated to control airway for sedation iso receiving multiple shocks. He was treated with amio bolus + gtt, lidocaine bolus + gtt, procainamide bolus + gtt. Also required levophed drip for hypotension, which was weaned. Also received IV metop bolus once normotensive. Repeat TTE was obtained, which showed EF 25% (worse from prior). Of note, during his hospitalization, he was noted to be tremulous and was diagnosed with mild Etoh withdrawal. Was treated with Librium/Ativan with improvement. At time of transfer, he has been shocked >60 times, he is still intubated on propofol, and continued on the procainamide 4 gtt, amio 1 gtt after load, metoprolol 50mg TID. He was also volume up, w/net ___ on ___ and received Lasix IV 40mg and spironolactone 12.5mg this AM. He is still receiving Ativan prn for Etoh withdrawal/tremulousness. Per EMS, his AICD is "not capturing" the VT. Last time he was shocked at 0759 on ___, at which time the procainamide/amio were started. REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies 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: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS - Insulin-dependent Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD w/CABG (___) w/subsequent stents - HFrEF (EF 45%) - Cardiac arrest w/VT and VF, s/p-AICD 3. OTHER PAST MEDICAL HISTORY Chronic kidney disease (b/l Cr ___ Hypothyroidism Social History: ___ Family History: Not obtained. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================ VS: BP 146/69 HR 85 RR 18 O2 SAT 99% on vent settings: TV 450, PEEP 5, R 15, FiO2 40% GENERAL: Well developed, well nourished in NAD. Intubated. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP not elevated. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. 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: DP pulses palpable bilaterally. DISCHARGE PHYSICAL EXAMINATION: ================================ VS 98.4 138/70 (67-138/35-70) 70 (69-71) 18 (___) 95-97% RA I/Os: 24hr: 24hr 1000\|1205, 8hr 100\|-- Weight: 72.4kg (NEW DRY WEIGHT) <-72.1<-72.4 GENERAL: Well developed, well-nourished in NAD. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP not elevated. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. 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: Ecchymosis noted on upper extremities PULSES: DP pulses palpable bilaterally. MENTAL STATUS: A&O x3 Pertinent Results: ADMISSION LABS: =============== ___ 09:34PM TYPE-ART TIDAL VOL-500 O2-50 PO2-85 PCO2-35 PH-7.46* TOTAL CO2-26 BASE XS-1 ___ 09:34PM LACTATE-1.2 ___ 07:50PM GLUCOSE-247* UREA N-25* CREAT-1.9* SODIUM-134 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-24 ANION GAP-15 ___ 07:50PM estGFR-Using this ___ 07:50PM ALT(SGPT)-53* AST(SGOT)-66* ALK PHOS-56 TOT BILI-0.5 ___ 07:50PM CK-MB-5 cTropnT-0.18* ___ 07:50PM CALCIUM-7.8* PHOSPHATE-4.1 MAGNESIUM-2.0 ___ 07:50PM WBC-7.2 RBC-3.19* HGB-10.9* HCT-32.0* MCV-100* MCH-34.2* MCHC-34.1 RDW-13.4 RDWSD-49.0* ___ 07:50PM PLT COUNT-122* ___ 07:50PM ___ PTT-28.6 ___ MICROBIOLOGY: ============= Urine cx (___): negative Urine cx (___): negative Urine cx (___): negative Blood cx x2 (___): negative Blood cx x2 (___): negative Blood cx x2 (___): negative C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay MRSA SCREEN (Final ___: No MRSA isolated. C. difficile DNA amplification assay (Pending): IMAGING: ======== CXR portable (___): Mild vascular congestion has improved. Mild to moderate cardiomegaly is stable. Pacer leads are in standard position. ET tube is in standard position. Right IJ catheter tip is in the mid to lower SVC. NG tube tip is out of view below the diaphragm. Right lower lobe opacities are a combination of small effusion and adjacent atelectasis. There is no evident pneumothorax. NCHCT (___): FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There are atherosclerotic calcifications in the bilateral cavernous carotids and vertebral arteries. There is no evidence of fracture. There is mucosal thickening in the ethmoid air cells. The visualized portion of the remainder of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Patient is status post bilateral lens replacement. The visualized portion of the orbits are otherwise unremarkable. IMPRESSION: No acute intracranial process. CT Abdomen & Pelvis (___): IMPRESSION: 1. Large retroperitoneal hematoma with a hematocrit level. 2. Bilateral duplicated renal collecting systems with ectopic right kidney. CXR Portable (___): FINDINGS: AP portable chest radiograph demonstrates a left chest cardiac pacing device, leads appear intact and in unchanged position. Median sternotomy wires appear intact. Several mediastinal clips project over the left cardiac border. An enteric tube descends the thorax in uncomplicated course, its tip which terminates below the left hemidiaphragm, not completely imaged. Lungs are clear without a focal consolidation. Heart size is enlarged without pulmonary edema. There is no pneumothorax or large pleural effusion. IMPRESSION: No focal opacity convincing for pneumonia. CARDIAC STUDIES: ================ TTE (___): The left atrial volume index is mildly increased. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40 %). The estimated cardiac index is normal (>=2.5L/min/m2). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Mild left ventricular cavity dilation with regional systolic dysfunction most c/w CAD (PDA distribution). No valvular pathology or pathologic flow identified. CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibitor or ___. DISCHARGE LABS: =============== ___ 05:57AM BLOOD WBC-9.0 RBC-3.02* Hgb-9.5* Hct-29.6* MCV-98 MCH-31.5 MCHC-32.1 RDW-16.3* RDWSD-55.5* Plt ___ ___ 05:57AM BLOOD Plt ___ ___ 05:57AM BLOOD Glucose-65* UreaN-46* Creat-1.8* Na-139 K-4.4 Cl-106 HCO3-22 AnGap-15 ___ 05:57AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.___ w/CAD s/p remote 2v CABG ___ and PCI, VT and VF s/p AICD, HFrEF (EF 45%), insulin-dependent diabetes, CKD (b/l Cr ___, hypothyroidism, and Etoh use disorder, who presents as a transfer from ___ (___) for recurrent VT (shocked > 60 times) following an admission there on ___ for a syncopal episode in the setting of Vtach. # CORONARIES: LHC on ___: LCx patent w/stent, LIMA to LAD patent, known ___ occluded LAD, RCA, SVG to RCA, SCG to OM patent # PUMP: EF 25% on TTE ___ # RHYTHM: Monomorphic VT on admission. Later intermittently A-V paced. # VT STORM: Pt w/CAD and hx VT/VF s/p bi-v AICD found to be in MMVT iso syncopal event at home w/o triggering his device. Required multiple shocks >60, but still had recurrent VT, ultimately requiring intubation for airway protection iso multiple shocks. Device was interrogated, revealing multiple episodes of AT/AF lasting minutes to hours; threshold was increased. No evidence of new ischemic changes on EKG, trop neg, and cath ___ without evidence of new/worsening CAD. Was medically managed w/amio gtt, lidocaine gtt, and ultimately w/ procainamide gtt, but continued to have intermittent VT. Was likely related to arrhythmogenic focus originating in extensive cardiac scarring secondary to lonstanding CAD. Repeat run of monormorphic VT on ___, which aborted with ATP. Patient was amiodarone loaded with 11g, and then continued on amiodarone PO 200mg daily and carvedilol 25mg BID. Per EP, no immediate plans to pursue ablation in inpatient setting given patient's complicated hospitalization and given no recurrent VT for over one week. #ACUTE METABOLIC ENCEPHALOPATHY: Pt was agitated, requiring precedex, and was delirious, only A&O to place on admission. Noncontrast head CT negative for intracranial pathology. Delirium likely exacerbated from hospitalization, and exacerbated by retroperitoneal bleed. Per S&S, pt had swallowing risk iso encephalopathy and Dobhoff placed ___ and patient was started on tube feeds. Pt's delirium improved with nonpharmacologic meausures, and he was weaned from precedex. He was on tube feeds until cleared by speech and swallow and advanced to regular diet upon discharge. # HFrEF (EF 25% on TTE ___: Known HFrEF thought to be ___ to extensive ischemic disease. EF 25% on TTE ___ at ___, reduced from prior EF 45%. TTE in house showed EF 40%, with mild LV cavity dilation with regional systolic dysfunction most c/w CAD (PDA distribution). Pt was noted to be volume overloaded at ___ and was treated with IV Lasix boluses until euvolemia was reached, and then transitioned to Lasix 20 mg po, with goal even. Patient's home metoprolol was switched to Coreg 25 BID upon discharge. For afterload reduction, patient was started on captopril, which was initially transitioned to lisinopril 30 mg daily. Patient had two episodes of orthostatic hypotension on ___ and ___ with SBPs dropping from 140s (supine) to ___ (standing). Patient was lightheaded during first episode, and SBPs increased to 110s and patient's symptoms resolved with 500cc bolus; he was asymptomatic during second episode, and encouraged PO intake. Most likely that patient was slightly hypovolemic secondary to diuresis, and we therefore opted to withhold further diuresis (discontinued Lasix 20mg daily) and reduce losartan from 30mg daily to 10mg daily. After discharge, patient should be reevaluated in terms of whether he needs addition of a diuretic as an outpatient and whether uptitration of losartan is warranted based on blood pressures. # ATN: reported b/l is 1.0-2.0. Initially exacerbated in the setting of hypervolemia from cardiorenal vs hypoperfusion i/s/o VT storm. Had significantly acute worsening of Cr to 5.4 in the setting of retroperitoneal bleed with concern for hypovolemia. Dense ATN on urine sediment on ___. Creatinine downtrending likely reflecting recovery from ATN, currently 1.8. Patient should have repeat chemistries within three days of discharge to ensure resolution of renal function. #RETROPERITONEAL HEMATOMA: Patient reported worst abdominal pain on ___ with H/H drop. CT abd/pelvis was obtained and showed large right retroperitoneal hematoma measuring up to 11.0 x 6.0 cm in the axial dimension and 18 cm in the coronal dimension with mass effect displacing the right psoas muscle and kidney anteriorly. Of note, patient had cath on ___ with right femoral access. Administered IVF and 2U pRBC and FFP x1 with appropriate bump in hematocrit, as well as vitamin K. Once hemodynamically stable and H&H stable, patient was started on GDMT for HFrEF was above and restarted on warfarin. #ATRIAL FIBRILLATION: Noted on pacer interrogation. Patient was started on amiodarone to be continued following discharge, as above. He is also on carvedilol as above. He was started on warfarin, which is at 2.5mg daily at time of discharge. INR at time of discharge is 3.0 with goal INR ___. Patient will need baseline LFTs and TFTs, as well as annual CXR given recent initiation of amiodarone. #TRANSAMINITIS: Had transaminitis with ALT/AST into the low 100s. Likely related to being on rosuvastatin, amiodarone. and ezetimibe. Ezetime was discontinued. LFTs currently downtrending. Patient will require repeat LFTs within three days to ensure resolution of transaminitis and for baseline given recent initiation of amiodarone. #LEUKOCYTOSIS: WBC increased to 26.6 on admission. Unclear etiology as patient has not been spiking fevers and has no infectious symptoms. C.diff negative. UTI ruled out with negative UCx and BCx. CXR wnl, however, he was treated for VAP as below due to recent pneumonia and recent intubation. Leukocytosis improved to WBC 9.0 at time of discharge. #VENTILATOR ASSOCIATED PNEUMONIA: Patient had been intubated iso VT storm as above. He developed a leukocytosis and was started on vancomycin/ceftazadime for VAP, which was transitioned to ceftazadime only on ___, and was treated for 8 day course which ended on ___. #CAD: s/p 2v CABG (___) and multiple PCIs. Hx of VT and VF w/Medtronix bi-v AICD in place. No new ischemic changes on EKG and trops flat. Cath on ___ showed Lcx patent w/stent, LIMA to LAD patent, known ___ occluded LAD, RCA, SVG to RCA, SCG to OM patent, unchanged from prior. Likely that VT is related to extensive cardiac scarring as above. Patiet was continued on home aspirin 81 mg daily and home rosuvastatin 40mg daily. Metoprolol was converted to carvedilolol 25mg BID for improved afterload control. #Insulin-dependent diabetes: Patient was taking glargine 10 units qhs at home. FSBGs were elevated into 400s during initial parts of admission. Endocrinology was consulted and pt's HISS was uptitrated and his glargine was increased to 30U qAM and 30U qhs. Upon removal of Dobhoff, pt had reduced PO intake in the setting of dysphagia diet and FSBGs dropped to 100s-200s. Reduced glargine to 10U qAM and 10U qHS and reduced mealtime Humalog from 4U to 2U with meals. In spite of the less aggressive regimen, pt continued to have AM sugars in the ___ (although FSBGs up to 190s-200s during the day), even with resumption of regular diet and improved PO intake. Opted to continue 10U AM lantus and discontinue ___ lantus, continue Humalog 2U qAC PLUS low-dose Humalog correction scale. Patient will need ongoing monitoring of sugars and modulation of insulin regimen following discharge. #Hyperlipidemia Patient was continued on home rosuvastatin 40mg daily. His home ezetimibe was discontinued in the setting of transaminitis. #Etoh withdrawal: Is a heavy scotch drinker w/Etoh use disorder. Had Etoh on his breath in field when found by EMS and found to be acidotic in ___ ED. Has been tremulous, requiring Ativan and Librium at ___. Ativan was initially continued in house, but was discontinued within 24hrs, when CIWAs trended to 0. Patient was counseled regarding the dangers of Etoh use, especially in the context of being on other hepatotoxic medications including rosuvastatin and amiodarone. #Hypothyroidism: Patient was continued on home levothyroxine 75mg daily. #CODE: Full (confirmed) #CONTACT/HCP: ___ (wife, home#: ___, cell#: ___ Discharge weight: 72.4kg (dry / euvolemic) Discharge creatinine: 1.8 TRANSITIONAL: - Patient's home hydrochlorothiazide 25mg daily and isosorbide mononitrate 30mg daily were discontinued. - Patient's ezetimibe was discontinued in the setting of transaminitis. - Patient's home apixaban was discontinued and he was started on warfarin for antiocoagulation in the setting of atrial fibrillation. At time of discharge, warfarin dose is 2.5mg daily and INR is 3.0. Patient will need INR rechecked on ___. - Patient's home metoprolol was discontinued and he was started on carvedilol 25mg BID for improved afterload control. - Patient was diuresed with plan to be discharged on Lasix PO 20mg daily. Have withheld diuresis in the setting of orthostatic hypotension as described. Please re-evaluate patient for ongoing diuresis needs. Has cardiology follow up scheduled for this. - Patient was started on lisinopril 30mg daily for afterload reduction. Dose was reduced to 10mg daily in context of orthostatic hypotension. Please evaluate for modulation of lisinopril dosing based on blood pressure trends. - Patient with AM FSBGs in the ___, and then ranging from 100s-200s during the day. Most recent insulin regimen is glargine 10U qAM, humalog 2U qAC, and HISS that is less aggressive qhs. Please continue to evaluate insulin regimen following discharge. - Patient will need baseline LFTs within three days, and TFTs and PFTs within ___ weeks, as well as annual CXR given recent initiation of amiodarone. - Patient should have repeat LFTs and chemistries within three days to ensure improvement in transaminitis and acute kidney injury. - If patient's hoarseness does not improve in two weeks, he will need to be evaluated by ENT. - Patient was counseled regarding his Etoh use disorder, and especially in the context of his medications, several of which are hepatotoxic (e.g., amiodarone, rosuvastatin). Please continue this dialogue following discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Glargine 10 Units Bedtime 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Rosuvastatin Calcium 40 mg PO QPM 4. Apixaban 5 mg PO BID 5. Hydrochlorothiazide 25 mg PO DAILY 6. Ezetimibe 10 mg PO DAILY 7. Metoprolol Tartrate 50 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Carvedilol 25 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Lidocaine 5% Patch 1 PTCH TD QPM back 6. Lisinopril 10 mg PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Thiamine 100 mg PO DAILY 9. Warfarin 2.5 mg PO DAILY16 10. Glargine 10 Units Breakfast Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Levothyroxine Sodium 75 mcg PO DAILY 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 13. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Ventricular Tachycardia / VT Storm 2. Atrial Fibrillation 3. Transaminitis 4. Acute on Chronic Heart Failure, with Reduced Ejection Fraction 5. Alcohol Withdrawal 6. Retroperitoneal Hematoma SECONDARY DIAGNOSIS 1. Hypothyroidism 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 during your hospital stay at ___. You were hospitalized here in our cardiac intensive care unit. You were admitted to our intensive care unit for having rapid irregular rhythms of your heart called ventricular tachycardia. We were able to change the settings on your defibrillator, and also were able to change your medications to hopefully prevent this from happening in the future. Please continue to take all of your home medications as prescribed. You will be going to a rehab center to build up your strength. You should also stop drinking when you leave as this can provoke this abnormal heart rhythm. Wishing you the best, Your ___ team Followup Instructions: ___	[ "I472", "I5023", "N170", "G9341", "J95851", "K661", "I429", "I130", "D62", "F10239", "E1122", "I4891", "R740", "N189", "F17210", "Z794", "E11649", "I2510", "E039", "E785", "E876", "I951", "E861", "T501X5A", "Y92230", "Z955", "Z951", "Z7901", "R0902", "R197" ]	Allergies: metformin Chief Complaint: VT storm Major Surgical or Invasive Procedure: Endotracheal intubation at OSH prior to admission History of Present Illness: [MASKED] w/CAD s/p remote 2v CABG [MASKED] and PCI, VT and VF s/p AICD (Medtronix, bi-v), HFrEF (EF 45%), insulin-dependent diabetes, CKD (b/l Cr [MASKED], hypothyroidism, and Etoh use disorder, who presents as a transfer from [MASKED] for recurrent VT (shocked > 60 times) following an admission there on [MASKED] for a syncopal episode in the setting of Vtach. The patient had a syncopal episode at home and was found to be in slow VT; apparently denied chest pain and AICD did not get triggered. CPR was started and the patient was defibrillated in the field. Upon arrival in the ED, he had recurrent episodes of VT and continued to be syncopal. In spite of multiple shocks, amiodarone 300mg, and IV lidocaine, he continued to have multiple episodes of VT. He was also found to be hypoglycemic w/FSBG 40-50. EMTs did report that he did smell of Etoh when they picked uim up, but the patient denied drinking any "significant" amounts of Etoh. In the ED, labs were notable for trop wnl, CBC and chem10 wnl except for hypokalemia and acidemia. K was repleted and pt received bicarb. Patient was cathed, reported to have no intervenable lesion/no ischemic etiology of VT was found (Lcx patent w/stent, LIMA to LAD patent, known [MASKED] occluded LAD, RCA, SVG to RCA, SCG to OM patent unchanged from prior). He had his AICD interrogated and settings were changed to defibrillate at lower HR (154). Patient continued to have multiples episodes of MMVT (many w/HRs <150s-160s) accompanied by hypotension, and was intubated to control airway for sedation iso receiving multiple shocks. He was treated with amio bolus + gtt, lidocaine bolus + gtt, procainamide bolus + gtt. Also required levophed drip for hypotension, which was weaned. Also received IV metop bolus once normotensive. Repeat TTE was obtained, which showed EF 25% (worse from prior). Of note, during his hospitalization, he was noted to be tremulous and was diagnosed with mild Etoh withdrawal. Was treated with Librium/Ativan with improvement. At time of transfer, he has been shocked >60 times, he is still intubated on propofol, and continued on the procainamide 4 gtt, amio 1 gtt after load, metoprolol 50mg TID. He was also volume up, w/net [MASKED] on [MASKED] and received Lasix IV 40mg and spironolactone 12.5mg this AM. He is still receiving Ativan prn for Etoh withdrawal/tremulousness. Per EMS, his AICD is "not capturing" the VT. Last time he was shocked at 0759 on [MASKED], at which time the procainamide/amio were started. REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. On further review of systems, denies 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: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS - Insulin-dependent Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD w/CABG ([MASKED]) w/subsequent stents - HFrEF (EF 45%) - Cardiac arrest w/VT and VF, s/p-AICD 3. OTHER PAST MEDICAL HISTORY Chronic kidney disease (b/l Cr [MASKED] Hypothyroidism Social History: [MASKED] Family History: Not obtained. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================ VS: BP 146/69 HR 85 RR 18 O2 SAT 99% on vent settings: TV 450, PEEP 5, R 15, FiO2 40% GENERAL: Well developed, well nourished in NAD. Intubated. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP not elevated. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. 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: DP pulses palpable bilaterally. DISCHARGE PHYSICAL EXAMINATION: ================================ VS 98.4 138/70 (67-138/35-70) 70 (69-71) 18 ([MASKED]) 95-97% RA I/Os: 24hr: 24hr 1000\|1205, 8hr 100\|-- Weight: 72.4kg (NEW DRY WEIGHT) <-72.1<-72.4 GENERAL: Well developed, well-nourished in NAD. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP not elevated. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. 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: Ecchymosis noted on upper extremities PULSES: DP pulses palpable bilaterally. MENTAL STATUS: A&O x3 Pertinent Results: ADMISSION LABS: =============== [MASKED] 09:34PM TYPE-ART TIDAL VOL-500 O2-50 PO2-85 PCO2-35 PH-7.46* TOTAL CO2-26 BASE XS-1 [MASKED] 09:34PM LACTATE-1.2 [MASKED] 07:50PM GLUCOSE-247* UREA N-25* CREAT-1.9* SODIUM-134 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-24 ANION GAP-15 [MASKED] 07:50PM estGFR-Using this [MASKED] 07:50PM ALT(SGPT)-53* AST(SGOT)-66* ALK PHOS-56 TOT BILI-0.5 [MASKED] 07:50PM CK-MB-5 cTropnT-0.18* [MASKED] 07:50PM CALCIUM-7.8* PHOSPHATE-4.1 MAGNESIUM-2.0 [MASKED] 07:50PM WBC-7.2 RBC-3.19* HGB-10.9* HCT-32.0* MCV-100* MCH-34.2* MCHC-34.1 RDW-13.4 RDWSD-49.0* [MASKED] 07:50PM PLT COUNT-122* [MASKED] 07:50PM [MASKED] PTT-28.6 [MASKED] MICROBIOLOGY: ============= Urine cx ([MASKED]): negative Urine cx ([MASKED]): negative Urine cx ([MASKED]): negative Blood cx x2 ([MASKED]): negative Blood cx x2 ([MASKED]): negative Blood cx x2 ([MASKED]): negative C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay MRSA SCREEN (Final [MASKED]: No MRSA isolated. C. difficile DNA amplification assay (Pending): IMAGING: ======== CXR portable ([MASKED]): Mild vascular congestion has improved. Mild to moderate cardiomegaly is stable. Pacer leads are in standard position. ET tube is in standard position. Right IJ catheter tip is in the mid to lower SVC. NG tube tip is out of view below the diaphragm. Right lower lobe opacities are a combination of small effusion and adjacent atelectasis. There is no evident pneumothorax. NCHCT ([MASKED]): FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. There are atherosclerotic calcifications in the bilateral cavernous carotids and vertebral arteries. There is no evidence of fracture. There is mucosal thickening in the ethmoid air cells. The visualized portion of the remainder of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Patient is status post bilateral lens replacement. The visualized portion of the orbits are otherwise unremarkable. IMPRESSION: No acute intracranial process. CT Abdomen & Pelvis ([MASKED]): IMPRESSION: 1. Large retroperitoneal hematoma with a hematocrit level. 2. Bilateral duplicated renal collecting systems with ectopic right kidney. CXR Portable ([MASKED]): FINDINGS: AP portable chest radiograph demonstrates a left chest cardiac pacing device, leads appear intact and in unchanged position. Median sternotomy wires appear intact. Several mediastinal clips project over the left cardiac border. An enteric tube descends the thorax in uncomplicated course, its tip which terminates below the left hemidiaphragm, not completely imaged. Lungs are clear without a focal consolidation. Heart size is enlarged without pulmonary edema. There is no pneumothorax or large pleural effusion. IMPRESSION: No focal opacity convincing for pneumonia. CARDIAC STUDIES: ================ TTE ([MASKED]): The left atrial volume index is mildly increased. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40 %). The estimated cardiac index is normal (>=2.5L/min/m2). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Mild left ventricular cavity dilation with regional systolic dysfunction most c/w CAD (PDA distribution). No valvular pathology or pathologic flow identified. CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibitor or [MASKED]. DISCHARGE LABS: =============== [MASKED] 05:57AM BLOOD WBC-9.0 RBC-3.02* Hgb-9.5* Hct-29.6* MCV-98 MCH-31.5 MCHC-32.1 RDW-16.3* RDWSD-55.5* Plt [MASKED] [MASKED] 05:57AM BLOOD Plt [MASKED] [MASKED] 05:57AM BLOOD Glucose-65* UreaN-46* Creat-1.8* Na-139 K-4.4 Cl-106 HCO3-22 AnGap-15 [MASKED] 05:57AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.[MASKED] w/CAD s/p remote 2v CABG [MASKED] and PCI, VT and VF s/p AICD, HFrEF (EF 45%), insulin-dependent diabetes, CKD (b/l Cr [MASKED], hypothyroidism, and Etoh use disorder, who presents as a transfer from [MASKED] ([MASKED]) for recurrent VT (shocked > 60 times) following an admission there on [MASKED] for a syncopal episode in the setting of Vtach. # CORONARIES: LHC on [MASKED]: LCx patent w/stent, LIMA to LAD patent, known [MASKED] occluded LAD, RCA, SVG to RCA, SCG to OM patent # PUMP: EF 25% on TTE [MASKED] # RHYTHM: Monomorphic VT on admission. Later intermittently A-V paced. # VT STORM: Pt w/CAD and hx VT/VF s/p bi-v AICD found to be in MMVT iso syncopal event at home w/o triggering his device. Required multiple shocks >60, but still had recurrent VT, ultimately requiring intubation for airway protection iso multiple shocks. Device was interrogated, revealing multiple episodes of AT/AF lasting minutes to hours; threshold was increased. No evidence of new ischemic changes on EKG, trop neg, and cath [MASKED] without evidence of new/worsening CAD. Was medically managed w/amio gtt, lidocaine gtt, and ultimately w/ procainamide gtt, but continued to have intermittent VT. Was likely related to arrhythmogenic focus originating in extensive cardiac scarring secondary to lonstanding CAD. Repeat run of monormorphic VT on [MASKED], which aborted with ATP. Patient was amiodarone loaded with 11g, and then continued on amiodarone PO 200mg daily and carvedilol 25mg BID. Per EP, no immediate plans to pursue ablation in inpatient setting given patient's complicated hospitalization and given no recurrent VT for over one week. #ACUTE METABOLIC ENCEPHALOPATHY: Pt was agitated, requiring precedex, and was delirious, only A&O to place on admission. Noncontrast head CT negative for intracranial pathology. Delirium likely exacerbated from hospitalization, and exacerbated by retroperitoneal bleed. Per S&S, pt had swallowing risk iso encephalopathy and Dobhoff placed [MASKED] and patient was started on tube feeds. Pt's delirium improved with nonpharmacologic meausures, and he was weaned from precedex. He was on tube feeds until cleared by speech and swallow and advanced to regular diet upon discharge. # HFrEF (EF 25% on TTE [MASKED]: Known HFrEF thought to be [MASKED] to extensive ischemic disease. EF 25% on TTE [MASKED] at [MASKED], reduced from prior EF 45%. TTE in house showed EF 40%, with mild LV cavity dilation with regional systolic dysfunction most c/w CAD (PDA distribution). Pt was noted to be volume overloaded at [MASKED] and was treated with IV Lasix boluses until euvolemia was reached, and then transitioned to Lasix 20 mg po, with goal even. Patient's home metoprolol was switched to Coreg 25 BID upon discharge. For afterload reduction, patient was started on captopril, which was initially transitioned to lisinopril 30 mg daily. Patient had two episodes of orthostatic hypotension on [MASKED] and [MASKED] with SBPs dropping from 140s (supine) to [MASKED] (standing). Patient was lightheaded during first episode, and SBPs increased to 110s and patient's symptoms resolved with 500cc bolus; he was asymptomatic during second episode, and encouraged PO intake. Most likely that patient was slightly hypovolemic secondary to diuresis, and we therefore opted to withhold further diuresis (discontinued Lasix 20mg daily) and reduce losartan from 30mg daily to 10mg daily. After discharge, patient should be reevaluated in terms of whether he needs addition of a diuretic as an outpatient and whether uptitration of losartan is warranted based on blood pressures. # ATN: reported b/l is 1.0-2.0. Initially exacerbated in the setting of hypervolemia from cardiorenal vs hypoperfusion i/s/o VT storm. Had significantly acute worsening of Cr to 5.4 in the setting of retroperitoneal bleed with concern for hypovolemia. Dense ATN on urine sediment on [MASKED]. Creatinine downtrending likely reflecting recovery from ATN, currently 1.8. Patient should have repeat chemistries within three days of discharge to ensure resolution of renal function. #RETROPERITONEAL HEMATOMA: Patient reported worst abdominal pain on [MASKED] with H/H drop. CT abd/pelvis was obtained and showed large right retroperitoneal hematoma measuring up to 11.0 x 6.0 cm in the axial dimension and 18 cm in the coronal dimension with mass effect displacing the right psoas muscle and kidney anteriorly. Of note, patient had cath on [MASKED] with right femoral access. Administered IVF and 2U pRBC and FFP x1 with appropriate bump in hematocrit, as well as vitamin K. Once hemodynamically stable and H&H stable, patient was started on GDMT for HFrEF was above and restarted on warfarin. #ATRIAL FIBRILLATION: Noted on pacer interrogation. Patient was started on amiodarone to be continued following discharge, as above. He is also on carvedilol as above. He was started on warfarin, which is at 2.5mg daily at time of discharge. INR at time of discharge is 3.0 with goal INR [MASKED]. Patient will need baseline LFTs and TFTs, as well as annual CXR given recent initiation of amiodarone. #TRANSAMINITIS: Had transaminitis with ALT/AST into the low 100s. Likely related to being on rosuvastatin, amiodarone. and ezetimibe. Ezetime was discontinued. LFTs currently downtrending. Patient will require repeat LFTs within three days to ensure resolution of transaminitis and for baseline given recent initiation of amiodarone. #LEUKOCYTOSIS: WBC increased to 26.6 on admission. Unclear etiology as patient has not been spiking fevers and has no infectious symptoms. C.diff negative. UTI ruled out with negative UCx and BCx. CXR wnl, however, he was treated for VAP as below due to recent pneumonia and recent intubation. Leukocytosis improved to WBC 9.0 at time of discharge. #VENTILATOR ASSOCIATED PNEUMONIA: Patient had been intubated iso VT storm as above. He developed a leukocytosis and was started on vancomycin/ceftazadime for VAP, which was transitioned to ceftazadime only on [MASKED], and was treated for 8 day course which ended on [MASKED]. #CAD: s/p 2v CABG ([MASKED]) and multiple PCIs. Hx of VT and VF w/Medtronix bi-v AICD in place. No new ischemic changes on EKG and trops flat. Cath on [MASKED] showed Lcx patent w/stent, LIMA to LAD patent, known [MASKED] occluded LAD, RCA, SVG to RCA, SCG to OM patent, unchanged from prior. Likely that VT is related to extensive cardiac scarring as above. Patiet was continued on home aspirin 81 mg daily and home rosuvastatin 40mg daily. Metoprolol was converted to carvedilolol 25mg BID for improved afterload control. #Insulin-dependent diabetes: Patient was taking glargine 10 units qhs at home. FSBGs were elevated into 400s during initial parts of admission. Endocrinology was consulted and pt's HISS was uptitrated and his glargine was increased to 30U qAM and 30U qhs. Upon removal of Dobhoff, pt had reduced PO intake in the setting of dysphagia diet and FSBGs dropped to 100s-200s. Reduced glargine to 10U qAM and 10U qHS and reduced mealtime Humalog from 4U to 2U with meals. In spite of the less aggressive regimen, pt continued to have AM sugars in the [MASKED] (although FSBGs up to 190s-200s during the day), even with resumption of regular diet and improved PO intake. Opted to continue 10U AM lantus and discontinue [MASKED] lantus, continue Humalog 2U qAC PLUS low-dose Humalog correction scale. Patient will need ongoing monitoring of sugars and modulation of insulin regimen following discharge. #Hyperlipidemia Patient was continued on home rosuvastatin 40mg daily. His home ezetimibe was discontinued in the setting of transaminitis. #Etoh withdrawal: Is a heavy scotch drinker w/Etoh use disorder. Had Etoh on his breath in field when found by EMS and found to be acidotic in [MASKED] ED. Has been tremulous, requiring Ativan and Librium at [MASKED]. Ativan was initially continued in house, but was discontinued within 24hrs, when CIWAs trended to 0. Patient was counseled regarding the dangers of Etoh use, especially in the context of being on other hepatotoxic medications including rosuvastatin and amiodarone. #Hypothyroidism: Patient was continued on home levothyroxine 75mg daily. #CODE: Full (confirmed) #CONTACT/HCP: [MASKED] (wife, home#: [MASKED], cell#: [MASKED] Discharge weight: 72.4kg (dry / euvolemic) Discharge creatinine: 1.8 TRANSITIONAL: - Patient's home hydrochlorothiazide 25mg daily and isosorbide mononitrate 30mg daily were discontinued. - Patient's ezetimibe was discontinued in the setting of transaminitis. - Patient's home apixaban was discontinued and he was started on warfarin for antiocoagulation in the setting of atrial fibrillation. At time of discharge, warfarin dose is 2.5mg daily and INR is 3.0. Patient will need INR rechecked on [MASKED]. - Patient's home metoprolol was discontinued and he was started on carvedilol 25mg BID for improved afterload control. - Patient was diuresed with plan to be discharged on Lasix PO 20mg daily. Have withheld diuresis in the setting of orthostatic hypotension as described. Please re-evaluate patient for ongoing diuresis needs. Has cardiology follow up scheduled for this. - Patient was started on lisinopril 30mg daily for afterload reduction. Dose was reduced to 10mg daily in context of orthostatic hypotension. Please evaluate for modulation of lisinopril dosing based on blood pressure trends. - Patient with AM FSBGs in the [MASKED], and then ranging from 100s-200s during the day. Most recent insulin regimen is glargine 10U qAM, humalog 2U qAC, and HISS that is less aggressive qhs. Please continue to evaluate insulin regimen following discharge. - Patient will need baseline LFTs within three days, and TFTs and PFTs within [MASKED] weeks, as well as annual CXR given recent initiation of amiodarone. - Patient should have repeat LFTs and chemistries within three days to ensure improvement in transaminitis and acute kidney injury. - If patient's hoarseness does not improve in two weeks, he will need to be evaluated by ENT. - Patient was counseled regarding his Etoh use disorder, and especially in the context of his medications, several of which are hepatotoxic (e.g., amiodarone, rosuvastatin). Please continue this dialogue following discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Glargine 10 Units Bedtime 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Rosuvastatin Calcium 40 mg PO QPM 4. Apixaban 5 mg PO BID 5. Hydrochlorothiazide 25 mg PO DAILY 6. Ezetimibe 10 mg PO DAILY 7. Metoprolol Tartrate 50 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Carvedilol 25 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Lidocaine 5% Patch 1 PTCH TD QPM back 6. Lisinopril 10 mg PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Thiamine 100 mg PO DAILY 9. Warfarin 2.5 mg PO DAILY16 10. Glargine 10 Units Breakfast Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Levothyroxine Sodium 75 mcg PO DAILY 12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 13. Rosuvastatin Calcium 40 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Ventricular Tachycardia / VT Storm 2. Atrial Fibrillation 3. Transaminitis 4. Acute on Chronic Heart Failure, with Reduced Ejection Fraction 5. Alcohol Withdrawal 6. Retroperitoneal Hematoma SECONDARY DIAGNOSIS 1. Hypothyroidism 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 during your hospital stay at [MASKED]. You were hospitalized here in our cardiac intensive care unit. You were admitted to our intensive care unit for having rapid irregular rhythms of your heart called ventricular tachycardia. We were able to change the settings on your defibrillator, and also were able to change your medications to hopefully prevent this from happening in the future. Please continue to take all of your home medications as prescribed. You will be going to a rehab center to build up your strength. You should also stop drinking when you leave as this can provoke this abnormal heart rhythm. Wishing you the best, Your [MASKED] team Followup Instructions: [MASKED]	[]	[ "I130", "D62", "E1122", "I4891", "N189", "F17210", "Z794", "I2510", "E039", "E785", "Y92230", "Z955", "Z951", "Z7901" ]	[ "I472: Ventricular tachycardia", "I5023: Acute on chronic systolic (congestive) heart failure", "N170: Acute kidney failure with tubular necrosis", "G9341: Metabolic encephalopathy", "J95851: Ventilator associated pneumonia", "K661: Hemoperitoneum", "I429: Cardiomyopathy, 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", "D62: Acute posthemorrhagic anemia", "F10239: Alcohol dependence with withdrawal, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I4891: Unspecified atrial fibrillation", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "N189: Chronic kidney disease, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z794: Long term (current) use of insulin", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "E876: Hypokalemia", "I951: Orthostatic hypotension", "E861: Hypovolemia", "T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z955: Presence of coronary angioplasty implant and graft", "Z951: Presence of aortocoronary bypass graft", "Z7901: Long term (current) use of anticoagulants", "R0902: Hypoxemia", "R197: Diarrhea, unspecified" ]
10,046,362	25,444,237	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left leg pain, difficulty walking Major Surgical or Invasive Procedure: None during this hospitalization History of Present Illness: ___ y/o female s/p laminectomy and foraminotomy back in ___. The patient presents today with 1 week of back pain. She saw Dr. ___ at clinic at that time and was placed on a Medrol dose pack with no effect. Over the last couple of days she has developed a band like pain across her abdomen along with worsening radiculopathy on the left leg. She presented to an OSH and a CT of the lumbar spine was obtained which showed a fluid collection. She was transferred here to ___ for further evaluation. The patient denies n/v/c/d, bowel or bladder incontinence. Past Medical History: arthritis, gout, diabetes, obesity Social History: ___ Family History: Non-contributory Physical Exam: On admission: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: IP Q H AT ___ G L 4+ 5 4 0 0 4+ Sensation: Intact to light touch, decreased sensation along the outside of the left leg. Reflexes: no clonus On discharge: Awake, alert, oriented. BUE full motor, RLE full, LLE ___ except ___ ___ at baseline. Baseline sensory. Pertinent Results: ___: MRI L spine with and without contrast: IMPRESSION: 1. Status post left L4-L5 hemilaminectomy with an irregular but well -defined fluid collection within the postoperative bed, most likely representing a seroma. Infection is felt to be less likely, but should be correlated clinically. 2. Stable multilevel degenerative changes in the remainder of the lumbar spine. ___ LEFT LOWER EXTREMITY ULTRASOUND IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Brief Hospital Course: On ___ this patient presented to the ___ ED from an outside hospital with complaints of worsening radiculopathy symptoms in the left leg. She is s/p a laminotomy and foraminotomy in ___ and has tried a Medrol dosepak as outpatient without improvement. A CT l-spine at the outside hospital showed a fluid collection at the surgical site. An MRI was done which also showed a fluid collection, likely a seroma per radiology report. She was examined again on morning rounds and is now reporting pain and decreased sensation on her RLE. Physical therapy ordered for further evaluation of functional mobility. On ___, the patient's neurological exam remained stable. A dose of 10mg IV dexamethasone was given once per Dr. ___ inflammation control. The patient was evaluated by Physical Therapy, who deemed that she would benefit from acute rehabilitation. The insurance screening process for acute rehab placement was initiated. On ___, patient remains neurologically and hemodynamically stable. Patient continues to complain of left leg pain, on exam leg/foot is swollen, LLE ultrasound ordered to rule out DVT. For pain medication, switched to percoset to ensure taking Tylenol. Blood sugars continue to be high, changed diet to carb controlled and will monitor closely however most likely related to steroid use. Patient is denying going to acute care rehab due to family concerns of distance away. It was discussed with the patient that it is in her best interest to go to acute rehab however continues to deny. On ___ she remained stable and was discharged to an extended care facility. Medications on Admission: Medications prior to admission: Acetaminophen 325-650 mg PO Q6H:PRN fever/pain Baclofen 20 mg PO TID Bisacodyl 10 mg PO DAILY:PRN constipation Diazepam 5 mg PO Q6H:PRN muscle spasm Docusate Sodium 100 mg PO BID Gabapentin 800 mg PO TID lantus 40 Units Bedtime OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN Pain Pregabalin 100 mg PO QHS TraZODone 100 mg PO QHS:PRN insomnia Discharge Medications: 1. Baclofen 20 mg PO TID 2. Glargine 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 800 mg PO TID 5. Pregabalin 100 mg PO DAILY 6. Tizanidine 4 mg PO TID 7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 8. TraZODone 100 mg PO QHS 9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 10. Methocarbamol 750 mg PO TID:PRN Muscle spasm 11. Heparin 5000 UNIT SC BID 12. Diclofenac Sodium ___ 75 mg PO TID 13. Bisacodyl 10 mg PO DAILY 14. Senna 8.6 mg PO QHS Discharge Disposition: Extended Care Facility: ___. Discharge Diagnosis: Post-operative Pain Seroma of the lumbar spine 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 You were admitted for concern of infection, imaging showed no signs of infection but of a fluid collection that should resolve in time. Your pain was evaluated and a pain regimen selected. 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 improved pain control. Otherwise You make take leisurely walks and slowly increase your activity at your own pace. 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: ___	[ "M96830", "Z6841", "E1165", "Y831", "Y92009", "M5416", "T380X5A", "Z794", "E669", "M1990", "M21379", "M7989" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left leg pain, difficulty walking Major Surgical or Invasive Procedure: None during this hospitalization History of Present Illness: [MASKED] y/o female s/p laminectomy and foraminotomy back in [MASKED]. The patient presents today with 1 week of back pain. She saw Dr. [MASKED] at clinic at that time and was placed on a Medrol dose pack with no effect. Over the last couple of days she has developed a band like pain across her abdomen along with worsening radiculopathy on the left leg. She presented to an OSH and a CT of the lumbar spine was obtained which showed a fluid collection. She was transferred here to [MASKED] for further evaluation. The patient denies n/v/c/d, bowel or bladder incontinence. Past Medical History: arthritis, gout, diabetes, obesity Social History: [MASKED] Family History: Non-contributory Physical Exam: On admission: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: IP Q H AT [MASKED] G L 4+ 5 4 0 0 4+ Sensation: Intact to light touch, decreased sensation along the outside of the left leg. Reflexes: no clonus On discharge: Awake, alert, oriented. BUE full motor, RLE full, LLE [MASKED] except [MASKED] [MASKED] at baseline. Baseline sensory. Pertinent Results: [MASKED]: MRI L spine with and without contrast: IMPRESSION: 1. Status post left L4-L5 hemilaminectomy with an irregular but well -defined fluid collection within the postoperative bed, most likely representing a seroma. Infection is felt to be less likely, but should be correlated clinically. 2. Stable multilevel degenerative changes in the remainder of the lumbar spine. [MASKED] LEFT LOWER EXTREMITY ULTRASOUND IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Brief Hospital Course: On [MASKED] this patient presented to the [MASKED] ED from an outside hospital with complaints of worsening radiculopathy symptoms in the left leg. She is s/p a laminotomy and foraminotomy in [MASKED] and has tried a Medrol dosepak as outpatient without improvement. A CT l-spine at the outside hospital showed a fluid collection at the surgical site. An MRI was done which also showed a fluid collection, likely a seroma per radiology report. She was examined again on morning rounds and is now reporting pain and decreased sensation on her RLE. Physical therapy ordered for further evaluation of functional mobility. On [MASKED], the patient's neurological exam remained stable. A dose of 10mg IV dexamethasone was given once per Dr. [MASKED] inflammation control. The patient was evaluated by Physical Therapy, who deemed that she would benefit from acute rehabilitation. The insurance screening process for acute rehab placement was initiated. On [MASKED], patient remains neurologically and hemodynamically stable. Patient continues to complain of left leg pain, on exam leg/foot is swollen, LLE ultrasound ordered to rule out DVT. For pain medication, switched to percoset to ensure taking Tylenol. Blood sugars continue to be high, changed diet to carb controlled and will monitor closely however most likely related to steroid use. Patient is denying going to acute care rehab due to family concerns of distance away. It was discussed with the patient that it is in her best interest to go to acute rehab however continues to deny. On [MASKED] she remained stable and was discharged to an extended care facility. Medications on Admission: Medications prior to admission: Acetaminophen 325-650 mg PO Q6H:PRN fever/pain Baclofen 20 mg PO TID Bisacodyl 10 mg PO DAILY:PRN constipation Diazepam 5 mg PO Q6H:PRN muscle spasm Docusate Sodium 100 mg PO BID Gabapentin 800 mg PO TID lantus 40 Units Bedtime OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN Pain Pregabalin 100 mg PO QHS TraZODone 100 mg PO QHS:PRN insomnia Discharge Medications: 1. Baclofen 20 mg PO TID 2. Glargine 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 800 mg PO TID 5. Pregabalin 100 mg PO DAILY 6. Tizanidine 4 mg PO TID 7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 8. TraZODone 100 mg PO QHS 9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 10. Methocarbamol 750 mg PO TID:PRN Muscle spasm 11. Heparin 5000 UNIT SC BID 12. Diclofenac Sodium [MASKED] 75 mg PO TID 13. Bisacodyl 10 mg PO DAILY 14. Senna 8.6 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED]. Discharge Diagnosis: Post-operative Pain Seroma of the lumbar spine 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 You were admitted for concern of infection, imaging showed no signs of infection but of a fluid collection that should resolve in time. Your pain was evaluated and a pain regimen selected. 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 improved pain control. Otherwise You make take leisurely walks and slowly increase your activity at your own pace. 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]	[]	[ "E1165", "Z794", "E669" ]	[ "M96830: Postprocedural hemorrhage of a musculoskeletal structure following a musculoskeletal system procedure", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "M5416: Radiculopathy, lumbar region", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "M21379: Foot drop, unspecified foot", "M7989: Other specified soft tissue disorders" ]
10,046,362	29,801,136	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L4-L5 herniated disc Major Surgical or Invasive Procedure: ___: L4-L5 LAMINOTOMY; FORAMINOTOMY History of Present Illness: ___ year old female with an L4-L5 herniated disc with developing and progressive very severe disabling radicular pain on the left side, in an L5 distribution. Patient has chronic left foot frop from prior back surgery in ___. Now presenting with L4-L5 disc bulging and POD # 2 of L4-L5 laminotomy and formainotomy. Past Medical History: arthritis, gout, diabetes, obesity Social History: ___ Family History: Non-contributory Physical Exam: UPON DISCHARGE: Patient is awake and alert. oriented x 3. Ambulating independently. Incision staples CDI without erythema. MAE ___ with the exception of a baseline left foot drop. Pertinent Results: ___ Lumbar Xray in OR Single intraoperative lateral film shows the 4 steps at the level of L4/5. Laminectomy at this level is noted Brief Hospital Course: On ___, the patient was admitted for an elective L4-L5 laminotomy/foraminotomy. She was transferred from the OR to the PACU for recovery and did well. On ___, the patient's pain regimen was increased. Valium was added for treatment of muscle spasm. She received Toradol and her home oxycodone dose was increased. On ___ the patient remained neurologically intact and was moving all of her extremities with full strength with the exception of her left ___ which was a ___ due to known baseline footdrop. The patients oxycodone was liberalized to every 3 hours as needed as the patient was having pain control issues. She was ambulating independently to the commode and was ordered for physical therapy. On ___ Given persistent pain chronic pain service was consulted. Neurologic examination was stable. Patient was started on Morphine PCA per recommendation of CPS. ___ The patient remained hemodynamically and neurologically intact. Her pain was well controlled on the morphine PCA. Chronic pain was consulted for recommendations of PO management and suggested oxycodone every 3 hours. On ___ the patient remained neurologically intact. Her pain has been well controlled on PO Oxycodone. She was discharged in stable condition. Medications on Admission: baclofen, gabapentin, vicoden, remeron, lyrica, insulin, lantus, novolog Discharge Medications: 1. Outpatient Physical Therapy Please eval and treat 2. Outpatient Physical Therapy S/p L4-L5 laminotomy and foraminotomy ___. No strenuous exercise or heavy lifting. Please focus on ambulation. 3. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain RX acetaminophen 325 mg ___ tablet(s) by mouth Q6 hours Disp #30 Tablet Refills:0 4. Baclofen 20 mg PO TID 5. Bisacodyl 10 mg PO DAILY:PRN constipation 6. Diazepam 5 mg PO Q6H:PRN muscle spasm RX diazepam 5 mg 1 tablet by mouth Q6 hours Disp #35 Tablet Refills:0 7. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 8. Gabapentin 800 mg PO TID 9. lantus 40 Units Bedtime 10. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN Pain Please do not drive while taking this medication RX oxycodone 10 mg 1 tablet(s) by mouth Q3 hours Disp #60 Tablet Refills:0 11. Pregabalin 100 mg PO QHS 12. TraZODone 100 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: L4-L5 herniated disc 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. You will need staple removal. Please keep your incision dry until staple removal. Do not apply any lotions or creams to the site. Please avoid swimming for two weeks after suture/staple removal. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. You are being discharged on Oxycodone - do not take this medication with Vicodin Please restart you insulin sliding scale as you were previously prescribed. 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: ___	[ "M5126", "Z6841", "E669", "E119", "Z794", "M21372", "M109" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: L4-L5 herniated disc Major Surgical or Invasive Procedure: [MASKED]: L4-L5 LAMINOTOMY; FORAMINOTOMY History of Present Illness: [MASKED] year old female with an L4-L5 herniated disc with developing and progressive very severe disabling radicular pain on the left side, in an L5 distribution. Patient has chronic left foot frop from prior back surgery in [MASKED]. Now presenting with L4-L5 disc bulging and POD # 2 of L4-L5 laminotomy and formainotomy. Past Medical History: arthritis, gout, diabetes, obesity Social History: [MASKED] Family History: Non-contributory Physical Exam: UPON DISCHARGE: Patient is awake and alert. oriented x 3. Ambulating independently. Incision staples CDI without erythema. MAE [MASKED] with the exception of a baseline left foot drop. Pertinent Results: [MASKED] Lumbar Xray in OR Single intraoperative lateral film shows the 4 steps at the level of L4/5. Laminectomy at this level is noted Brief Hospital Course: On [MASKED], the patient was admitted for an elective L4-L5 laminotomy/foraminotomy. She was transferred from the OR to the PACU for recovery and did well. On [MASKED], the patient's pain regimen was increased. Valium was added for treatment of muscle spasm. She received Toradol and her home oxycodone dose was increased. On [MASKED] the patient remained neurologically intact and was moving all of her extremities with full strength with the exception of her left [MASKED] which was a [MASKED] due to known baseline footdrop. The patients oxycodone was liberalized to every 3 hours as needed as the patient was having pain control issues. She was ambulating independently to the commode and was ordered for physical therapy. On [MASKED] Given persistent pain chronic pain service was consulted. Neurologic examination was stable. Patient was started on Morphine PCA per recommendation of CPS. [MASKED] The patient remained hemodynamically and neurologically intact. Her pain was well controlled on the morphine PCA. Chronic pain was consulted for recommendations of PO management and suggested oxycodone every 3 hours. On [MASKED] the patient remained neurologically intact. Her pain has been well controlled on PO Oxycodone. She was discharged in stable condition. Medications on Admission: baclofen, gabapentin, vicoden, remeron, lyrica, insulin, lantus, novolog Discharge Medications: 1. Outpatient Physical Therapy Please eval and treat 2. Outpatient Physical Therapy S/p L4-L5 laminotomy and foraminotomy [MASKED]. No strenuous exercise or heavy lifting. Please focus on ambulation. 3. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain RX acetaminophen 325 mg [MASKED] tablet(s) by mouth Q6 hours Disp #30 Tablet Refills:0 4. Baclofen 20 mg PO TID 5. Bisacodyl 10 mg PO DAILY:PRN constipation 6. Diazepam 5 mg PO Q6H:PRN muscle spasm RX diazepam 5 mg 1 tablet by mouth Q6 hours Disp #35 Tablet Refills:0 7. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 8. Gabapentin 800 mg PO TID 9. lantus 40 Units Bedtime 10. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN Pain Please do not drive while taking this medication RX oxycodone 10 mg 1 tablet(s) by mouth Q3 hours Disp #60 Tablet Refills:0 11. Pregabalin 100 mg PO QHS 12. TraZODone 100 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: L4-L5 herniated disc 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. You will need staple removal. Please keep your incision dry until staple removal. Do not apply any lotions or creams to the site. Please avoid swimming for two weeks after suture/staple removal. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. [MASKED] try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. You are being discharged on Oxycodone - do not take this medication with Vicodin Please restart you insulin sliding scale as you were previously prescribed. 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]	[]	[ "E669", "E119", "Z794", "M109" ]	[ "M5126: Other intervertebral disc displacement, lumbar region", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E669: Obesity, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "M21372: Foot drop, left foot", "M109: Gout, unspecified" ]
10,046,436	21,447,783	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: shellfish derived Attending: ___. Chief Complaint: glass ingestion Major Surgical or Invasive Procedure: EGD ___ Colonoscopy ___ History of Present Illness: ___ yo male with hx Prader-Willi Syndrome, NIDDM, GERD, and multiple prior foreign body ingestions requiring EGD and intubation presenting from ___ s/p glass ingestion after punching a window at his group home. He was reportedly agitated at OSH, was trying to hit police officers, didn't want to go to the hospital. He received 5 mg IM Haldol, 2 mg IM Ativan, D5NS at 110/hr, and tetanus vaccine. Labs were stable: WBC 10.2 Hb 14.9 Hct 44.2 Plt 200, Cr 1.1, Coags WNL. CT showed glass in the stomach and no free air. He was then transferred to ___. Upon arrival to ___ ED: - vitals: T 97.4, 86, 110/80, 16, 99% RA - Abdomen was soft, nontender - Labs showed: 143 102 13 ------------< 110 3.9 25 1.1 WBC 8.4 Hb 13.9 Plt 187 ___: 11.4 PTT: 23.7 INR: 1.1 He was admitted for EGD and went directly to the endoscopy suite. EGD was without abnormalities, but unfortunately the glass had passed on out of view of the scope. ACS was consulted, recommended repeat CT abdomen and serial abdominal exams. Admitted to medicine in stable condition. Past Medical History: Prader Willi Syndrome Bipolar Disorder Osteopenia GERD DM2 Hyperlipidemia Last hospitalization ___ for same presentation, reportedly shattered a picture frame and ingested several pieces of glass, which were not all able to be retrieved, had short course in MICU and no e/o bowel perforation, followed by ACS, and cleared by psychiatry to return to group home. Psychiatry felt his behavior might be in response to family stress and changes in staffing at the group home. OSH records indicate 9 prior EGDs for ingestions. Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.4 PO ___ 18 96 RA GENERAL: NAD HEENT: AT/NC, anicteric sclerae, pink conjunctiva, MMM NECK: supple, no LAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: 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, ecchymoses upper L chest mildly tender, R index finger bandaged, R upper forehead 2 cm linear cut DISCHARGE PHYSICAL EXAM: Vitals: 98 PO 118/78 Sitting 96 20 99% RA General: Reserved in conversation . in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Neck: supple CV: RRR, +S1/S2, no murmurs, rubs, gallops Lungs: good inspiratory effort. Clear to auscultation Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, 2+ DP pulses Neuro: Alert and oriented, no focal deficits appreciated Pertinent Results: ADMISSION LABS: ___ 05:30PM BLOOD WBC-8.4 RBC-4.72 Hgb-13.9 Hct-41.6 MCV-88 MCH-29.4 MCHC-33.4 RDW-12.1 RDWSD-39.0 Plt ___ ___ 07:30AM BLOOD WBC-7.2 RBC-4.83 Hgb-14.3 Hct-43.0 MCV-89 MCH-29.6 MCHC-33.3 RDW-12.1 RDWSD-39.6 Plt ___ ___ 07:35AM BLOOD WBC-6.4 RBC-4.97 Hgb-15.2 Hct-44.0 MCV-89 MCH-30.6 MCHC-34.5 RDW-12.2 RDWSD-39.5 Plt ___ ___ 05:30PM BLOOD Glucose-110* UreaN-13 Creat-1.1 Na-143 K-3.9 Cl-102 HCO3-25 AnGap-16 ___ 07:30AM BLOOD Glucose-126* UreaN-11 Creat-1.0 Na-140 K-4.4 Cl-100 HCO3-25 AnGap-15 IMAGING: CXR: ___ In comparison with study of ___, there again are low lung volumes. Cardiac silhouette is within normal limits without vascular congestion. Mild opacification at the left base most likely reflect combination of atelectasis and pleural fluid. However, in the appropriate clinical setting, it would be difficult to exclude superimposed aspiration/pneumonia. KUB ___: Surgical clips within the right upper quadrant are unchanged in configuration. The ingested foreign bodies originally seen on the ___ CT examination are no longer visualized radiographically. KUB ___: Larger glass fragment in the descending colon, smaller glass fragment at the hepatic flexure. KUB ___: 2.5 and 1.1 cm linear hyperdensities in the right lower quadrant correspond to previously described radiodense glass fragments on prior CT exam and appear located in the cecum and/or proximal ascending colon. CT AP ___: Unchanged position of the 2 radiodense objects with the 25 mm fragment within the cecal base and the 10 mm fragment within the appendiceal base. Given location, especially the fragment within the appendiceal base, these are felt unlikely to progress distally. No bowel rupture or adjacent colonic irritation. CT AP ___: Both of the radiopaque foreign objects are now within the cecum, measuring 2.6 cm and 0.9 cm. No evidence of perforation or bowel obstruction. CT AP ___: Ingested radiopaque foreign body has migrated distally and is seen within a loop of distal small bowel in the right lower quadrant. Another small radiopaque object is noted within the cecum which may represent a detached fragment. No evidence of bowel perforation or obstruction. PROCEDURES: EGD ___: 2 pills were found in the stomach. Both were mobile and not sharp. One was suctioned but the other was not able to be suctioned. No foreign body identified. No evidence of injury to the mucosa. No evidence of injury to the mucosa. No foreign body identified. No evidence of injury to the mucosa. Otherwise normal EGD to third part of the duodenum Colonoscopy ___: The prep was inadequate and several areas, including the cecum were unable to be completely visualized. Small pieces of glass could be missed in areas of poor prep. There was no glass seen near the appendiceal orifice. Otherwise normal colonoscopy to cecum DISCHARGE LABS: Patient declined laboratory draw on ___ day of discharge. ___ 09:25AM BLOOD WBC-9.8 RBC-4.27* Hgb-12.9* Hct-38.4* MCV-90 MCH-30.2 MCHC-33.6 RDW-13.2 RDWSD-43.3 Plt ___ ___ 09:25AM BLOOD Glucose-311* UreaN-24* Creat-0.8 Na-134 K-4.7 Cl-90* HCO3-25 AnGap-19* ___ 03:20PM BLOOD Glucose-267* UreaN-24* Creat-0.7 Na-136 K-4.7 Cl-94* HCO3-26 AnGap-16 ___ 09:25AM BLOOD Calcium-9.4 Phos-3.8 Mg-1.8 ___ 07:27AM BLOOD WBC-8.1 RBC-4.84 Hgb-14.1 Hct-42.6 MCV-88 MCH-29.1 MCHC-33.1 RDW-11.9 RDWSD-38.2 Plt ___ ___ 07:49AM BLOOD WBC-7.8 RBC-4.61 Hgb-14.2 Hct-39.6* MCV-86 MCH-30.8 MCHC-35.9 RDW-12.1 RDWSD-37.6 Plt ___ ___ 06:40AM BLOOD WBC-6.7 RBC-4.84 Hgb-14.8 Hct-42.4 MCV-88 MCH-30.6 MCHC-34.9 RDW-12.1 RDWSD-39.0 Plt ___ ___ 07:27AM BLOOD Glucose-168* UreaN-6 Creat-0.8 Na-136 K-4.6 Cl-93* HCO3-28 AnGap-15 ___ 07:49AM BLOOD Glucose-158* UreaN-7 Creat-0.8 Na-137 K-4.6 Cl-95* HCO3-29 AnGap-13 ___ 06:40AM BLOOD Glucose-174* UreaN-3* Creat-0.8 Na-139 K-4.7 Cl-96 HCO3-27 AnGap-16 Brief Hospital Course: Patient Summary for Admission: ============================== ___ yo male with h/o Prader-Willi Syndrome, NIDDM, and GERD, with multiple prior foreign body ingestions requiring EGD and intubation who presented from ___ s/p glass ingestion in the setting of being agitated at his home facility. Patient was transferred to ___ for endoscopic evaluation. Patient was evaluated by GI who attempted an EGD but were unsuccessful in retrieving the glass. He was also evaluated by ACS, but given the lack of evidence of perforation, he did not require surgery. The location of the glass was monitored with serial CT images of the abdomen, and a colonoscopy on ___ was performed but was unsuccessful in retrieving the glass. Given the patient's clinical stability, the patient was transitioned back to a regular diet and bowel regimen and subsequently passed the glass spontaneously. Hospital course was complicated by hyperglycemia following initiation of a regular diet. Patient initially required sliding scale insulin and long acting insulin to control blood sugars. Patient was not adhering with a carbohydrate controlled diet and with improved enforcement of the ordered dietary restrictions, blood sugars trended down. Subsequently glucose control was achieved through increased Glyburide, with plans to restart home Januvia at time of discharge. Patient was discharged once blood sugars were stabilized with plan for close primary care provider follow up. ___ Medical Issues Addressed: ================================ #Glass Ingestion: Patient ingested glass at his home facility and was subsequently transferred to ___ on ___ for endoscopic retrieval. EGD was performed and glass was unable to be retrieved. CT Abdomen and Pelvis completed ___ was notable for a 2.1cm piece of glass in the small bowel. Patient was evaluated by ACS who did not feel acute surgical intervention was needed given there was no evidence of perforation. Mr. ___ had serial abdominal exams, which remained benign. Given low concern for perforation, patient was monitored for passage of the glass. He had not spontaneously passed the glass as of ___P was completed on ___ and ___ which demonstrated the glass migrated to the cecum but remained in the cecum. Patient had a colonoscopy ___, but the glass was not able to be retrieved due to poor prep. Following a discussion with the ___ team and given the patient's hemodynamic stability, the patient was allowed to eat a regular diet and subsequently patient passed the glass spontaneously, which was confirmed with repeat KUB. Patient's abdomen remained without clinical change during admission. # Type 2 diabetes with hyperglycemia: Patient was initially transitioned to sliding scale insulin when admitted and home Glyburide and Januvia were held. Blood sugar was well controlled with HISS while patient was NPO and on a clear diet in anticipation of passing the ingested glass. With transition back to a carb controlled diet patient's blood sugars increased to 300-500. Initial concern was for infection driving the worsening hyperglycemia, however CXR and urine analysis were unrevealing for infection. On ___ patient's anion gap increased to 20 with trace ketones present in urine. With increased fluid and short acting insulin patient's gap subsequently closed. It later became obvious patient was ordering multiple trays at meals which was driving the hyperglycemia. ___ was consulted during admission due to new insulin initiation; however with improvement of sugars the patient was transitioned back to oral agents with an increase Glyburide dose of 10mg daily and plans to restart home Januvia (not on formulary inpatient) at time of discharge. Patient's blood sugars were approximately 120-250 at time of discharge, and he will require close follow up with his primary care provider for ongoing management. # Bipolar Disorder: Patient became agitated at group home resulting in foreign body ingestion. Patient was continued on home Lamotrigine and Ziprasidone and was evaluated by Psychiatry who did not recommend any acute medical changes. Patient had a 1:1 sitter while inpatient. CHRONIC ISSUES: =============== # Prader Willi Syndrome: Patient has a history of Prader Willi as well as impulsivity. Patient had a 1:1 sitter during hospitalization and was continued on home Naltrexone, ziprasidone and lamotrigine. Patient was evaluated by Psychiatry who did not recommend acute medication changes. # GERD: Patient continued home omeprazole, however Simethicone and Rulox were held while patient was waiting to pass the glass. Simethicone and Rulox were started again at time of discharge. # Insomnia: Patient continued home trazodone. Transitional Issues: ====================== Medications Stopped: -Rulox and Simethicone were held during admission but restarted at time of discharge -Januvia 100mg Daily held while inpatient, restarted at time of discharge Medications Added: -Glyburide increased from 1mg to 10mg daily []Patient's Glyburide dose increased significantly while inpatient with addition of Januvia 100mg at time of discharge. This medication change may need to be adjusted as patient returns to usual diet []Patient should check FSBG three times daily with a morning fasting glucose for the next few weeks until blood glucose stabilizes. []Patient will require close follow up by PCP for ongoing management of hyperglycemia []Patient will follow up with PCP ___ ___ at 1 pm Code Status: Full Code HCP: ___ (mother) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Gas Relief (simethicone) 125 mg oral TID W/MEALS 2. Calcium Carbonate 600 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. flaxseed oral unknown 5. ZIPRASidone Hydrochloride 80 mg PO BID 6. Loratadine 10 mg PO DAILY 7. Naltrexone 50 mg PO QHS 8. Fluticasone Propionate NASAL 2 SPRY NU BID 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Omeprazole 20 mg PO QAM 11. multivitamin with iron 1 tab oral DAILY 12. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID BEFORE MEALS 13. TraZODone 50 mg PO QHS 14. Vitamin D 400 UNIT PO BID 15. Januvia (SITagliptin) 100 mg oral QAM 16. Testosterone Cypionate unknown IM QMONTHLY 17. Phos-Flur (fluoride (sodium)) 0.02 % (0.044 % sod. fluoride) dental unknown 18. GlyBURIDE 1 mg PO DAILY Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 2. GlyBURIDE 10 mg PO DAILY RX glyburide 5 mg 2 tablet(s) by mouth daily Disp #60 Tablet Refills:0 3. Calcium Carbonate 600 mg PO BID 4. Docusate Sodium 100 mg PO BID 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. flaxseed oral Frequency is Unknown 7. Fluticasone Propionate NASAL 2 SPRY NU BID 8. Gas Relief (simethicone) 125 mg oral TID W/MEALS 9. Januvia (SITagliptin) 100 mg oral QAM 10. LamoTRIgine 125 mg PO BID 11. Loratadine 10 mg PO DAILY 12. multivitamin with iron 1 tab oral DAILY 13. Naltrexone 50 mg PO QHS 14. Omeprazole 20 mg PO QAM 15. Phos-Flur (fluoride (sodium)) 0.02 % (0.044 % sod. fluoride) dental unknown 16. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID BEFORE MEALS 17. Testosterone Cypionate unknown IM QMONTHLY 18. TraZODone 50 mg PO QHS 19. Vitamin D 400 UNIT PO BID 20. ZIPRASidone Hydrochloride 80 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: =================== Intentional Ingestion (glass) Hyperglycemia Diabetes Mellitus Type 2 Secondary Diagnosis: =================== Prader-___ Syndrome Bipolar Disorder GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for allowing us to be a part of your care at ___ ___! Why was I in the hospital? -You were admitted to the hospital after you swallowed a piece of glass. What was done while I was in the hospital? -While you were in the hospital you were evaluated by the GI team and the Surgical team. -The GI team place a camera in your stomach but were unable to remove the glass. -We continued to watch you and you did not have belly pain or pain in your bottom. -We watched the glass as it made its way through your gut with repeat images of your belly. -You had a colonoscopy on ___, but we were not able to remove the glass. -You were given back a regular diet and you were able to pass the glass on your own. -Your blood sugars were very high and we had to use insulin initially to decrease your blood sugar -We started you on new medications to decrease your blood sugars What should I do when I go home? -You should continue taking your medications as prescribed. -You should check your blood sugar first thing in the morning and two more times during the day. -You should also follow up with your primary care provider early next week to discuss your blood sugar. We wish you the best! Sincerely, Your ___ Medicine Team Followup Instructions: ___	[ "T183XXA", "Q871", "T182XXA", "E1165", "Y9289", "X838XXA", "F319", "R4587", "E785", "G4700", "K219", "F88", "E875", "Z7984" ]	Allergies: shellfish derived Chief Complaint: glass ingestion Major Surgical or Invasive Procedure: EGD [MASKED] Colonoscopy [MASKED] History of Present Illness: [MASKED] yo male with hx Prader-Willi Syndrome, NIDDM, GERD, and multiple prior foreign body ingestions requiring EGD and intubation presenting from [MASKED] s/p glass ingestion after punching a window at his group home. He was reportedly agitated at OSH, was trying to hit police officers, didn't want to go to the hospital. He received 5 mg IM Haldol, 2 mg IM Ativan, D5NS at 110/hr, and tetanus vaccine. Labs were stable: WBC 10.2 Hb 14.9 Hct 44.2 Plt 200, Cr 1.1, Coags WNL. CT showed glass in the stomach and no free air. He was then transferred to [MASKED]. Upon arrival to [MASKED] ED: - vitals: T 97.4, 86, 110/80, 16, 99% RA - Abdomen was soft, nontender - Labs showed: 143 102 13 ------------< 110 3.9 25 1.1 WBC 8.4 Hb 13.9 Plt 187 [MASKED]: 11.4 PTT: 23.7 INR: 1.1 He was admitted for EGD and went directly to the endoscopy suite. EGD was without abnormalities, but unfortunately the glass had passed on out of view of the scope. ACS was consulted, recommended repeat CT abdomen and serial abdominal exams. Admitted to medicine in stable condition. Past Medical History: Prader Willi Syndrome Bipolar Disorder Osteopenia GERD DM2 Hyperlipidemia Last hospitalization [MASKED] for same presentation, reportedly shattered a picture frame and ingested several pieces of glass, which were not all able to be retrieved, had short course in MICU and no e/o bowel perforation, followed by ACS, and cleared by psychiatry to return to group home. Psychiatry felt his behavior might be in response to family stress and changes in staffing at the group home. OSH records indicate 9 prior EGDs for ingestions. Social History: [MASKED] Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.4 PO [MASKED] 18 96 RA GENERAL: NAD HEENT: AT/NC, anicteric sclerae, pink conjunctiva, MMM NECK: supple, no LAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: 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, ecchymoses upper L chest mildly tender, R index finger bandaged, R upper forehead 2 cm linear cut DISCHARGE PHYSICAL EXAM: Vitals: 98 PO 118/78 Sitting 96 20 99% RA General: Reserved in conversation . in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear. Neck: supple CV: RRR, +S1/S2, no murmurs, rubs, gallops Lungs: good inspiratory effort. Clear to auscultation Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, 2+ DP pulses Neuro: Alert and oriented, no focal deficits appreciated Pertinent Results: ADMISSION LABS: [MASKED] 05:30PM BLOOD WBC-8.4 RBC-4.72 Hgb-13.9 Hct-41.6 MCV-88 MCH-29.4 MCHC-33.4 RDW-12.1 RDWSD-39.0 Plt [MASKED] [MASKED] 07:30AM BLOOD WBC-7.2 RBC-4.83 Hgb-14.3 Hct-43.0 MCV-89 MCH-29.6 MCHC-33.3 RDW-12.1 RDWSD-39.6 Plt [MASKED] [MASKED] 07:35AM BLOOD WBC-6.4 RBC-4.97 Hgb-15.2 Hct-44.0 MCV-89 MCH-30.6 MCHC-34.5 RDW-12.2 RDWSD-39.5 Plt [MASKED] [MASKED] 05:30PM BLOOD Glucose-110* UreaN-13 Creat-1.1 Na-143 K-3.9 Cl-102 HCO3-25 AnGap-16 [MASKED] 07:30AM BLOOD Glucose-126* UreaN-11 Creat-1.0 Na-140 K-4.4 Cl-100 HCO3-25 AnGap-15 IMAGING: CXR: [MASKED] In comparison with study of [MASKED], there again are low lung volumes. Cardiac silhouette is within normal limits without vascular congestion. Mild opacification at the left base most likely reflect combination of atelectasis and pleural fluid. However, in the appropriate clinical setting, it would be difficult to exclude superimposed aspiration/pneumonia. KUB [MASKED]: Surgical clips within the right upper quadrant are unchanged in configuration. The ingested foreign bodies originally seen on the [MASKED] CT examination are no longer visualized radiographically. KUB [MASKED]: Larger glass fragment in the descending colon, smaller glass fragment at the hepatic flexure. KUB [MASKED]: 2.5 and 1.1 cm linear hyperdensities in the right lower quadrant correspond to previously described radiodense glass fragments on prior CT exam and appear located in the cecum and/or proximal ascending colon. CT AP [MASKED]: Unchanged position of the 2 radiodense objects with the 25 mm fragment within the cecal base and the 10 mm fragment within the appendiceal base. Given location, especially the fragment within the appendiceal base, these are felt unlikely to progress distally. No bowel rupture or adjacent colonic irritation. CT AP [MASKED]: Both of the radiopaque foreign objects are now within the cecum, measuring 2.6 cm and 0.9 cm. No evidence of perforation or bowel obstruction. CT AP [MASKED]: Ingested radiopaque foreign body has migrated distally and is seen within a loop of distal small bowel in the right lower quadrant. Another small radiopaque object is noted within the cecum which may represent a detached fragment. No evidence of bowel perforation or obstruction. PROCEDURES: EGD [MASKED]: 2 pills were found in the stomach. Both were mobile and not sharp. One was suctioned but the other was not able to be suctioned. No foreign body identified. No evidence of injury to the mucosa. No evidence of injury to the mucosa. No foreign body identified. No evidence of injury to the mucosa. Otherwise normal EGD to third part of the duodenum Colonoscopy [MASKED]: The prep was inadequate and several areas, including the cecum were unable to be completely visualized. Small pieces of glass could be missed in areas of poor prep. There was no glass seen near the appendiceal orifice. Otherwise normal colonoscopy to cecum DISCHARGE LABS: Patient declined laboratory draw on [MASKED] day of discharge. [MASKED] 09:25AM BLOOD WBC-9.8 RBC-4.27* Hgb-12.9* Hct-38.4* MCV-90 MCH-30.2 MCHC-33.6 RDW-13.2 RDWSD-43.3 Plt [MASKED] [MASKED] 09:25AM BLOOD Glucose-311* UreaN-24* Creat-0.8 Na-134 K-4.7 Cl-90* HCO3-25 AnGap-19* [MASKED] 03:20PM BLOOD Glucose-267* UreaN-24* Creat-0.7 Na-136 K-4.7 Cl-94* HCO3-26 AnGap-16 [MASKED] 09:25AM BLOOD Calcium-9.4 Phos-3.8 Mg-1.8 [MASKED] 07:27AM BLOOD WBC-8.1 RBC-4.84 Hgb-14.1 Hct-42.6 MCV-88 MCH-29.1 MCHC-33.1 RDW-11.9 RDWSD-38.2 Plt [MASKED] [MASKED] 07:49AM BLOOD WBC-7.8 RBC-4.61 Hgb-14.2 Hct-39.6* MCV-86 MCH-30.8 MCHC-35.9 RDW-12.1 RDWSD-37.6 Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-6.7 RBC-4.84 Hgb-14.8 Hct-42.4 MCV-88 MCH-30.6 MCHC-34.9 RDW-12.1 RDWSD-39.0 Plt [MASKED] [MASKED] 07:27AM BLOOD Glucose-168* UreaN-6 Creat-0.8 Na-136 K-4.6 Cl-93* HCO3-28 AnGap-15 [MASKED] 07:49AM BLOOD Glucose-158* UreaN-7 Creat-0.8 Na-137 K-4.6 Cl-95* HCO3-29 AnGap-13 [MASKED] 06:40AM BLOOD Glucose-174* UreaN-3* Creat-0.8 Na-139 K-4.7 Cl-96 HCO3-27 AnGap-16 Brief Hospital Course: Patient Summary for Admission: ============================== [MASKED] yo male with h/o Prader-Willi Syndrome, NIDDM, and GERD, with multiple prior foreign body ingestions requiring EGD and intubation who presented from [MASKED] s/p glass ingestion in the setting of being agitated at his home facility. Patient was transferred to [MASKED] for endoscopic evaluation. Patient was evaluated by GI who attempted an EGD but were unsuccessful in retrieving the glass. He was also evaluated by ACS, but given the lack of evidence of perforation, he did not require surgery. The location of the glass was monitored with serial CT images of the abdomen, and a colonoscopy on [MASKED] was performed but was unsuccessful in retrieving the glass. Given the patient's clinical stability, the patient was transitioned back to a regular diet and bowel regimen and subsequently passed the glass spontaneously. Hospital course was complicated by hyperglycemia following initiation of a regular diet. Patient initially required sliding scale insulin and long acting insulin to control blood sugars. Patient was not adhering with a carbohydrate controlled diet and with improved enforcement of the ordered dietary restrictions, blood sugars trended down. Subsequently glucose control was achieved through increased Glyburide, with plans to restart home Januvia at time of discharge. Patient was discharged once blood sugars were stabilized with plan for close primary care provider follow up. [MASKED] Medical Issues Addressed: ================================ #Glass Ingestion: Patient ingested glass at his home facility and was subsequently transferred to [MASKED] on [MASKED] for endoscopic retrieval. EGD was performed and glass was unable to be retrieved. CT Abdomen and Pelvis completed [MASKED] was notable for a 2.1cm piece of glass in the small bowel. Patient was evaluated by ACS who did not feel acute surgical intervention was needed given there was no evidence of perforation. Mr. [MASKED] had serial abdominal exams, which remained benign. Given low concern for perforation, patient was monitored for passage of the glass. He had not spontaneously passed the glass as of P was completed on [MASKED] and [MASKED] which demonstrated the glass migrated to the cecum but remained in the cecum. Patient had a colonoscopy [MASKED], but the glass was not able to be retrieved due to poor prep. Following a discussion with the [MASKED] team and given the patient's hemodynamic stability, the patient was allowed to eat a regular diet and subsequently patient passed the glass spontaneously, which was confirmed with repeat KUB. Patient's abdomen remained without clinical change during admission. # Type 2 diabetes with hyperglycemia: Patient was initially transitioned to sliding scale insulin when admitted and home Glyburide and Januvia were held. Blood sugar was well controlled with HISS while patient was NPO and on a clear diet in anticipation of passing the ingested glass. With transition back to a carb controlled diet patient's blood sugars increased to 300-500. Initial concern was for infection driving the worsening hyperglycemia, however CXR and urine analysis were unrevealing for infection. On [MASKED] patient's anion gap increased to 20 with trace ketones present in urine. With increased fluid and short acting insulin patient's gap subsequently closed. It later became obvious patient was ordering multiple trays at meals which was driving the hyperglycemia. [MASKED] was consulted during admission due to new insulin initiation; however with improvement of sugars the patient was transitioned back to oral agents with an increase Glyburide dose of 10mg daily and plans to restart home Januvia (not on formulary inpatient) at time of discharge. Patient's blood sugars were approximately 120-250 at time of discharge, and he will require close follow up with his primary care provider for ongoing management. # Bipolar Disorder: Patient became agitated at group home resulting in foreign body ingestion. Patient was continued on home Lamotrigine and Ziprasidone and was evaluated by Psychiatry who did not recommend any acute medical changes. Patient had a 1:1 sitter while inpatient. CHRONIC ISSUES: =============== # Prader Willi Syndrome: Patient has a history of Prader Willi as well as impulsivity. Patient had a 1:1 sitter during hospitalization and was continued on home Naltrexone, ziprasidone and lamotrigine. Patient was evaluated by Psychiatry who did not recommend acute medication changes. # GERD: Patient continued home omeprazole, however Simethicone and Rulox were held while patient was waiting to pass the glass. Simethicone and Rulox were started again at time of discharge. # Insomnia: Patient continued home trazodone. Transitional Issues: ====================== Medications Stopped: -Rulox and Simethicone were held during admission but restarted at time of discharge -Januvia 100mg Daily held while inpatient, restarted at time of discharge Medications Added: -Glyburide increased from 1mg to 10mg daily []Patient's Glyburide dose increased significantly while inpatient with addition of Januvia 100mg at time of discharge. This medication change may need to be adjusted as patient returns to usual diet []Patient should check FSBG three times daily with a morning fasting glucose for the next few weeks until blood glucose stabilizes. []Patient will require close follow up by PCP for ongoing management of hyperglycemia []Patient will follow up with PCP [MASKED] [MASKED] at 1 pm Code Status: Full Code HCP: [MASKED] (mother) [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Gas Relief (simethicone) 125 mg oral TID W/MEALS 2. Calcium Carbonate 600 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. flaxseed oral unknown 5. ZIPRASidone Hydrochloride 80 mg PO BID 6. Loratadine 10 mg PO DAILY 7. Naltrexone 50 mg PO QHS 8. Fluticasone Propionate NASAL 2 SPRY NU BID 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Omeprazole 20 mg PO QAM 11. multivitamin with iron 1 tab oral DAILY 12. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID BEFORE MEALS 13. TraZODone 50 mg PO QHS 14. Vitamin D 400 UNIT PO BID 15. Januvia (SITagliptin) 100 mg oral QAM 16. Testosterone Cypionate unknown IM QMONTHLY 17. Phos-Flur (fluoride (sodium)) 0.02 % (0.044 % sod. fluoride) dental unknown 18. GlyBURIDE 1 mg PO DAILY Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 2. GlyBURIDE 10 mg PO DAILY RX glyburide 5 mg 2 tablet(s) by mouth daily Disp #60 Tablet Refills:0 3. Calcium Carbonate 600 mg PO BID 4. Docusate Sodium 100 mg PO BID 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. flaxseed oral Frequency is Unknown 7. Fluticasone Propionate NASAL 2 SPRY NU BID 8. Gas Relief (simethicone) 125 mg oral TID W/MEALS 9. Januvia (SITagliptin) 100 mg oral QAM 10. LamoTRIgine 125 mg PO BID 11. Loratadine 10 mg PO DAILY 12. multivitamin with iron 1 tab oral DAILY 13. Naltrexone 50 mg PO QHS 14. Omeprazole 20 mg PO QAM 15. Phos-Flur (fluoride (sodium)) 0.02 % (0.044 % sod. fluoride) dental unknown 16. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID BEFORE MEALS 17. Testosterone Cypionate unknown IM QMONTHLY 18. TraZODone 50 mg PO QHS 19. Vitamin D 400 UNIT PO BID 20. ZIPRASidone Hydrochloride 80 mg PO BID Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: =================== Intentional Ingestion (glass) Hyperglycemia Diabetes Mellitus Type 2 Secondary Diagnosis: =================== Prader-[MASKED] Syndrome Bipolar Disorder GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], Thank you for allowing us to be a part of your care at [MASKED] [MASKED]! Why was I in the hospital? -You were admitted to the hospital after you swallowed a piece of glass. What was done while I was in the hospital? -While you were in the hospital you were evaluated by the GI team and the Surgical team. -The GI team place a camera in your stomach but were unable to remove the glass. -We continued to watch you and you did not have belly pain or pain in your bottom. -We watched the glass as it made its way through your gut with repeat images of your belly. -You had a colonoscopy on [MASKED], but we were not able to remove the glass. -You were given back a regular diet and you were able to pass the glass on your own. -Your blood sugars were very high and we had to use insulin initially to decrease your blood sugar -We started you on new medications to decrease your blood sugars What should I do when I go home? -You should continue taking your medications as prescribed. -You should check your blood sugar first thing in the morning and two more times during the day. -You should also follow up with your primary care provider early next week to discuss your blood sugar. We wish you the best! Sincerely, Your [MASKED] Medicine Team Followup Instructions: [MASKED]	[]	[ "E1165", "E785", "G4700", "K219" ]	[ "T183XXA: Foreign body in small intestine, initial encounter", "Q871: Congenital malformation syndromes predominantly associated with short stature", "T182XXA: Foreign body in stomach, initial encounter", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Y9289: Other specified places as the place of occurrence of the external cause", "X838XXA: Intentional self-harm by other specified means, initial encounter", "F319: Bipolar disorder, unspecified", "R4587: Impulsiveness", "E785: Hyperlipidemia, unspecified", "G4700: Insomnia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F88: Other disorders of psychological development", "E875: Hyperkalemia", "Z7984: Long term (current) use of oral hypoglycemic drugs" ]
10,046,543	21,402,025	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: s/p fall, back pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ year-old woman with a history of PMR on a prednisone taper, osteoporosis, prior thoracic compression fractures who presented to the ___ ED on ___ with 3 weeks of atraumatic back pain which which acutely worsened yesterday after leaning back to sit in her recliner but fell onto her buttocks. She is typically independent and fully mobile at baseline. She was evaluated by Ortho Spine who recommended TLSO brace for comfort, ED obs for pain control and a ___ evaluation. She was evaluated by ___ who found the patient to be motivated to return home and engage in outpatient physical therapy. Today the patient has been ambulating at baseline, however, in certain positions such as leaning forward or standing her back pain increases. She states she prefers to be admitted for one more night for pain control before going home. On exam the patient still denies fevers, chills, chest pain, palpitations, nausea, vomiting, numbness, tingling, weakness, saddle anesthesia, loss of bowel or bladder function. Past Medical History: Past Medical/Surgical History: PMR Osteoporosis Thoracic compression fractures MGUS Glaucoma Social History: ___ Family History: noncontributory Physical Exam: Admission Physical Exam: Gen: NAD, A&Ox3, pleasant, conversant HEENT: Normocephalic, atraumatic, sclera anicteric Neck: Trachea midline, supple, no c-spine tenderness Resp: Breathing comfortably on room air CV: RRR Back: Tender to palpation in lower thoracic spine, upper lumber spine Abd: Soft, non-tender, non-distended Ext: Warm, well perfused, minimal edema, no abrasions or lacerations noted Discharge Physical Exam: VS: 97.6, 101/66, 79, 18, 95 Ra GEN: A&O x3. sitting up in chair NAD HEENT: WNL CV: HRR PULM: LS ctab ABD: soft NT/ND EXT: WWP no edema. Neuro: low back pain Pertinent Results: Imaging: CT Head ___: There is no evidence of acute intracranial hemorrhage, midline shift, mass effect, or acute large vascular territorial infarct. Mild periventricular and subcortical white matter hypodensities are nonspecific. Extensive calcifications are seen along the cavernous portions of the bilateral carotid arteries. Vertebral artery calcification is also noted. CT Chest ___: Compression deformities of T8, T10, and L1 vertebral bodies compatible fractures of unknown chronicity. L1 fx has acute/subacute appearance. Question of R 3rd rib nondisplaced fx. CT C-Spine ___: Multilevel degenerative changes of C-spine. No evidence of acute fx or traumatic malalignment. Brief Hospital Course: Ms. ___ is a ___ year-old woman with a history of PMR on a prednisone taper, osteoporosis, prior thoracic compression fractures who presented to the ___ ED on ___ with 3 weeks of atraumatic back pain which acutely worsened, found to have T8, T10, L1 compression fracture (acute vs subacute). She was admitted to the acute care surgery service for pain management. Ortho Spine was consulted who recommended no surgical intervention, TLSO for comfort, and no bending or twisting. On the floor, she was advanced to a regular diet, her home medication was restarted, she was started on oral medication for pain control with good affect. The TLSO brace was ordered and came to bedside but the patient stated she was unable to ___ the brace by herself. She was evaluated by physical therapy who felt she would need to go to rehab. At the time of discharge, she was afebrile and hemodynamically stable, pain was well controlled on oral medication alone, tolerating a regular diet, voiding adequately and spontaneously, she was ambulating with assistance in the TLSO, and she was deemed stable for discharge to rehab. She was discharged home with appropriate instructions and follow up and verbalized agreement with the plan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Lidocaine 5% Patch 1 PTCH TD QPM RX lidocaine [Lidocaine Pain Relief] 4 % apply one to lower back daily once a day Disp #10 Patch Refills:0 3. Polyethylene Glycol 17 g PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation 5. TraMADol ___ mg PO Q6H:PRN Pain - Severe RX tramadol 50 mg 0.5 -1 tablet(s) by mouth every six (6) hours Disp #10 Tablet Refills:0 6. Vitamin D 1000 UNIT PO DAILY 7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. PredniSONE 5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: T8, T10, L1 compression fracture subacute R 3rd rib fx 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 after you sustained a fall and were found to have a several spine compression fractures, unclear whether acute or chronic, and a subacute right 3rd rib fracture. You were treated with oral pain medication. You were seen by physical therapy who recommended you be discharged home with home physical therapy You are now ready for discharge home. Please follow these instructions to aid in a speedy recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. If you have any questions, you may reach the Acute Care Surgery Clinic at the following number: ___ Best Wishes Your ___ Surgery Team Followup Instructions: ___	[ "S2231XA", "S22069A", "S22079A", "S32019A", "W19XXXA", "Y92009", "M810", "M353" ]	Allergies: Penicillins Chief Complaint: s/p fall, back pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] year-old woman with a history of PMR on a prednisone taper, osteoporosis, prior thoracic compression fractures who presented to the [MASKED] ED on [MASKED] with 3 weeks of atraumatic back pain which which acutely worsened yesterday after leaning back to sit in her recliner but fell onto her buttocks. She is typically independent and fully mobile at baseline. She was evaluated by Ortho Spine who recommended TLSO brace for comfort, ED obs for pain control and a [MASKED] evaluation. She was evaluated by [MASKED] who found the patient to be motivated to return home and engage in outpatient physical therapy. Today the patient has been ambulating at baseline, however, in certain positions such as leaning forward or standing her back pain increases. She states she prefers to be admitted for one more night for pain control before going home. On exam the patient still denies fevers, chills, chest pain, palpitations, nausea, vomiting, numbness, tingling, weakness, saddle anesthesia, loss of bowel or bladder function. Past Medical History: Past Medical/Surgical History: PMR Osteoporosis Thoracic compression fractures MGUS Glaucoma Social History: [MASKED] Family History: noncontributory Physical Exam: Admission Physical Exam: Gen: NAD, A&Ox3, pleasant, conversant HEENT: Normocephalic, atraumatic, sclera anicteric Neck: Trachea midline, supple, no c-spine tenderness Resp: Breathing comfortably on room air CV: RRR Back: Tender to palpation in lower thoracic spine, upper lumber spine Abd: Soft, non-tender, non-distended Ext: Warm, well perfused, minimal edema, no abrasions or lacerations noted Discharge Physical Exam: VS: 97.6, 101/66, 79, 18, 95 Ra GEN: A&O x3. sitting up in chair NAD HEENT: WNL CV: HRR PULM: LS ctab ABD: soft NT/ND EXT: WWP no edema. Neuro: low back pain Pertinent Results: Imaging: CT Head [MASKED]: There is no evidence of acute intracranial hemorrhage, midline shift, mass effect, or acute large vascular territorial infarct. Mild periventricular and subcortical white matter hypodensities are nonspecific. Extensive calcifications are seen along the cavernous portions of the bilateral carotid arteries. Vertebral artery calcification is also noted. CT Chest [MASKED]: Compression deformities of T8, T10, and L1 vertebral bodies compatible fractures of unknown chronicity. L1 fx has acute/subacute appearance. Question of R 3rd rib nondisplaced fx. CT C-Spine [MASKED]: Multilevel degenerative changes of C-spine. No evidence of acute fx or traumatic malalignment. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year-old woman with a history of PMR on a prednisone taper, osteoporosis, prior thoracic compression fractures who presented to the [MASKED] ED on [MASKED] with 3 weeks of atraumatic back pain which acutely worsened, found to have T8, T10, L1 compression fracture (acute vs subacute). She was admitted to the acute care surgery service for pain management. Ortho Spine was consulted who recommended no surgical intervention, TLSO for comfort, and no bending or twisting. On the floor, she was advanced to a regular diet, her home medication was restarted, she was started on oral medication for pain control with good affect. The TLSO brace was ordered and came to bedside but the patient stated she was unable to [MASKED] the brace by herself. She was evaluated by physical therapy who felt she would need to go to rehab. At the time of discharge, she was afebrile and hemodynamically stable, pain was well controlled on oral medication alone, tolerating a regular diet, voiding adequately and spontaneously, she was ambulating with assistance in the TLSO, and she was deemed stable for discharge to rehab. She was discharged home with appropriate instructions and follow up and verbalized agreement with the plan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Lidocaine 5% Patch 1 PTCH TD QPM RX lidocaine [Lidocaine Pain Relief] 4 % apply one to lower back daily once a day Disp #10 Patch Refills:0 3. Polyethylene Glycol 17 g PO DAILY 4. Senna 8.6 mg PO BID:PRN Constipation 5. TraMADol [MASKED] mg PO Q6H:PRN Pain - Severe RX tramadol 50 mg 0.5 -1 tablet(s) by mouth every six (6) hours Disp #10 Tablet Refills:0 6. Vitamin D 1000 UNIT PO DAILY 7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. PredniSONE 5 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: T8, T10, L1 compression fracture subacute R 3rd rib fx 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 after you sustained a fall and were found to have a several spine compression fractures, unclear whether acute or chronic, and a subacute right 3rd rib fracture. You were treated with oral pain medication. You were seen by physical therapy who recommended you be discharged home with home physical therapy You are now ready for discharge home. Please follow these instructions to aid in a speedy recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. If you have any questions, you may reach the Acute Care Surgery Clinic at the following number: [MASKED] Best Wishes Your [MASKED] Surgery Team Followup Instructions: [MASKED]	[]	[]	[ "S2231XA: Fracture of one rib, right side, initial encounter for closed fracture", "S22069A: Unspecified fracture of T7-T8 vertebra, initial encounter for closed fracture", "S22079A: Unspecified fracture of T9-T10 vertebra, initial encounter for closed fracture", "S32019A: Unspecified fracture of first lumbar vertebra, initial encounter for closed fracture", "W19XXXA: Unspecified fall, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "M810: Age-related osteoporosis without current pathological fracture", "M353: Polymyalgia rheumatica" ]
10,046,592	27,003,299	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / rosuvastatin Attending: ___. Chief Complaint: weakness, nausea Major Surgical or Invasive Procedure: None History of Present Illness: ___ with T2DM, HTN, HLD, h/o stroke and ?TIA, h/o depression, PTSD, and multiple ED visits presents with dizziness and weakness here with multiple nonspecific symptoms, including weakness, dizziness, headache, and poor appetite. Her overall presentation is similar to those from prior ED visits and is most consistent with likely deconditioning and failure to thrive at home. Patient indicates that she has been experiencing weakness x ___ months, dizziness x ___ months, HA, and nausea x 1 day-3 weeks. The headache has been worse in the past week. The dizziness has not changed. The nausea is accompanied by dizziness and was accompanied by abdominal pain yesterday, prompting her ED visit. She experiences whole body weakness, particularly in her legs. Her weakness prevents her from doing activities she usually does, like lawncare, although she says she still has interest in performing those activities. Her weakness and overall health prevent her from going to ___, which she finds upsetting as she has not been able to visit her elderly aunt. She states she has lost her appetite and has lost 30 pounds (170lb-->130lb over the past two month per report). She states that she usually eats bread, tea. coffee, and food that her daughter makes. She requested a meal several times during the interview. She experiences headaches that she describes as "pain" and "pressure" and "all around" her head, traveling down her neck and back. She also feels the headache in her R ear. The headache is sometimes preceded by scalp itchiness and accompanied by nausea, but no photophobia or phonophobia. Yesterday, she experienced an episode of vertigo (room spinning). For her headaches, she uses a lidocaine patch for relief and says acetaminophen provides no relief. The headache comes and goes and occurs once a week or less. She is concerned that her headaches are indicative of cancer or a neurological problem. ___val indicates she had an episode of presyncope that was associated with some epigastric tightness, nausea, shortness of breath. Patient endorses frequent leg cramps for which she drinks water and uses ice. She states that she sometimes sleeps little. She reports occasional subjective fevers, cold sweats during the day coinciding with elevated BP, but denies night sweats. Records indicate that she did not do well with ___ and needs additional therapy but is not eligible for rehab. She states that she last had physical therapy before her husband died ___ years ago. Records state her family is "not comfortable going home with services at this time." ___ concerned about safety at home. She says she has good support at home from her children, but feels she needs more support. Three prior ED visits since ___ for similar complaints. Most recently reported to ED on ___. Physical exam was notable for (?)diffuse lower abdominal tenderness without rebound, guarding,or peritonitic signs. UA, CBC, CMP, electrolytes within normal limits. CXR and CT Abd and Pelvis both unremarkable. Case management was consulted and worked to arrange additional services at home. In the ED, she ate, remained ambulatory, and received hydration. She was discharged home the same day. Past Medical History: - DM2 - HTN - HLD - Stroke (___) - ?TIA (___) - Depression - PTSD - Glaucoma - Constipation - Headaches - Insomnia Social History: ___ Family History: - Mother (deceased at ___): MI in ___ (cause of death), HTN - Father (deceased at ___): DM (died of complications) - Son (living): HTN, ESRD - Daughter: DM - Cousin (deceased): brain cancer (cause of death) Physical Exam: Admission Exam: GENERAL: Pleasant and lying comfortably in bed. No apparent distress. HEENT: NCAT, PEERL, MMM. Oropharynx clear. Pseudonystagmus. Minimal temporal wasting. NECK: Supple, trachea midline, no cervical or supraclavicular LAD CV: RRR, no MRG. LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: Soft, NTND. EXTREMITIES: WWP. No ___ edema. Neuro: Mental status: AAOX3, good attention Strength: ___ in BUE and BLE Sensation: intact to light touch diffusely. Notes tingling in toes (longstanding due to diabetic neuropathy, per her report) Cerebellar: finger/nose testing intact CN: II-XII intact Speech: fluent, normal rate Psych: Appropriate affect and behavior but cries when discussing the remote deaths of her mother and husband and her inability to go to ___ Discharge Exam: GENERAL: Pleasant and lying comfortably in bed. No apparent distress. HEENT: NCAT, PEERL, MMM. Oropharynx clear. EOMI with minimal pseudonystagmus. Minimal temporal wasting. NECK: Supple, trachea midline, no cervical or supraclavicular LAD CV: RRR, no MRG. LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: Soft, NTND. EXTREMITIES: WWP. No ___ edema. Neuro: Mental status: AAOX3, good attention Strength: ___ in BUE and BLE Sensation: intact to light touch diffusely. Notes numbness in toes (longstanding due to diabetic neuropathy, per her report) Cerebellar: finger/nose testing intact Gait: slow, stable gait CN: II-XII intact Speech: fluent, normal rate Psych: Appropriate affect and behavior Pertinent Results: ADMISSION LABS: =============== ___ 08:15PM BLOOD %HbA1c-7.0* eAG-154* ___ 08:15PM BLOOD ___ PTT-26.8 ___ ___ 06:27PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 08:15PM BLOOD Neuts-39.6 ___ Monos-9.7 Eos-0.7* Baso-0.5 Im ___ AbsNeut-1.67 AbsLymp-2.08 AbsMono-0.41 AbsEos-0.03* AbsBaso-0.02 PERTINENT LABS: =============== ___ 02:10AM BLOOD calTIBC-293 Ferritn-127 TRF-225 ___ 08:15PM BLOOD %HbA1c-7.0* eAG-154* ___ 02:10AM BLOOD TSH-1.7 ___ 07:26AM BLOOD Cortsol-18.2 ___ 08:15PM BLOOD HIV Ab-NEG DISCHARGE LABS: =============== ___ 07:16AM BLOOD Glucose-151* UreaN-12 Creat-0.8 Na-139 K-4.2 Cl-101 HCO3-25 AnGap-13 ___ 07:16AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.1 IMAGING/REPORTS: ================ CT chest (___): : Impression: No acute intrathoracic process. CT abdomen (___) Impression: No acute intra-abdominal process, no findings to explain symptoms. MICROBIOLOGY: ============= None Brief Hospital Course: ==================== SUMMARY: ==================== Ms. ___ is a ___ year old woman with T2DM, HTN, HLD, h/o stroke and ?TIA, depression, PTSD, and multiple recent ED visits with dizziness and weakness here with multiple similar complaints, including weakness, dizziness, headache, and poor appetite. Her overall presentation was concerning for deconditioning and failure to thrive from lack of significant support at home. Her home antihypertensives were held as patient's BP was soft at times. She was neurologically without concerning findings. Monitored on telemetry without significant events. Discharged home per recommendation of Physical Therapy. ================== ACUTE ISSUES ================== #Weakness #Failure to thrive Patient had presented to the ED multiple times for similar complaints of chronic weakness. Neurological exam was notable for ___ strength diffusely and lack of significant neurological deficits. Physical Therapy evaluated the patient and recommended rehab to increase stamina. On review of her social situation and per discussion with her primary providers, there is concern that the patient is not receiving a sufficient level of support at home from her daughter who lives with her and her younger daughter, who lives downstairs. Social work met with her and shared information for elder services referral with pt and daughter ___. Pt does not require ___ at this time. Per discussion with daughter, pts children are available to assist with medication management and meals, but that pt denies problems with hoarding and is unlikely to allow family or outside providers to address excess of belongings in her home. #Dizziness #Relative hypotension #History of hypertension Neurologically intact on admission and throughout admission. BP was soft to the ___ initially after receiving her home amlodipine and chlorthalidone in the ED. Per collateral, patient self-titrates antihypertensives at home. Suspect that she has relative hypotension that is causing her dizziness. No neurological exam findings hence low concern for neurological process. Morning cortisol normal. Given IVF resuscitation and stopped home antihypertensives this admission with normalization of BPs. #Loss of appetite #Report of weight loss Patient reports subjective weight loss of 30 lbs in the past 2 months but OMR records do not indicate significant weight change. She does appears malnourished, and she may indeed by having some component of weight loss, associated with improved A1c from ~10 to 7 in less than a year while on glyburide. Etiology of loss of appetite is multifactorial, including from potentially untreated depression and a component that is secondary to her background social situation. Has undergone routine mammography; CT A/P without alarming findings. No recent vaginal bleeding and no history of smoking or alcohol use, hence overall felt that her risk of advanced malignancy to be very low. CXR clear and no other findings to suggest advanced disseminated TB. HIV negative. TSH normal. Morning cortisol normal. Nutrition saw the patient and provided supplements. #Headache Appear tension-type vs. caffeine withdrawal. Patient notes that she drinks ___ cups of coffee a day at home. No neurological signs. No evidence of significant nausea or vomiting to suggest increased intracranial pressure, and head CT around 2.5 weeks before admission as without significant findings. Given Tylenol, small-dose ibuprofen, and topical agents this admission. Encouraged to drink coffee in-house. #Subjective fevers Per patient. None measured at home or recorded in-house. #Depression #PTSD At presentation, patient was teary discussing the death of her husband ___ years ago, the death of her mother in ___, and her inability to return home to ___ and visit her elderly aunt in ___. PHQ-9 13 this admission, though many of her findings were attributed to feeling weak. Does not appear psychosocially slow and she often has a positive affect. Social Work ***** #Constipation Put on standing bowel regimen with improvement. ================== CHRONIC ISSUES: ================== #T2DM Glipizide may be contributing to presentation. A1c in ___ at 9.8%, 7.0% this admission. Stopped home glyburide and put on Humalog sliding scale. #HLD Prescribed rosuvastatin at home but there is a listed allergy (nausea/vomiting). Patient refused rosuvastatin. OMR indicates she was on rosuvastatin initially but switched to a different statin as rosuvastatin made her vomit. At one point, she was on atorvastatin but requested to be switched back to rosuvastatin. In the past, she has taken pravastatin and simvastatin, which made her mouth burn. Home rosuvastatin was held and patient is encouraged to discuss statin choice with PCP. ==================== TRANSITIONAL ISSUES: ==================== [] Please discuss switching from rosuvastatin to a different statin. [] Please discuss therapy and antidepressants in order to address patients depressed mood. >30 min spent on discharge planning including face to face time Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. brimonidine 0.2 % ophthalmic (eye) BID 4. Chlorthalidone 25 mg PO DAILY 5. GlipiZIDE 10 mg PO BID 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Rosuvastatin Calcium 20 mg PO QPM 8. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Ondansetron ODT ___ mg PO Q8H:PRN Nausea/Vomiting - First Line RX ondansetron 4 mg 1 tablet(s) by mouth three times per day Disp #10 Tablet Refills:0 3. Polyethylene Glycol 17 g PO BID 4. Simethicone 40-80 mg PO QID:PRN gas 5. Senna 17.2 mg PO BID 6. Aspirin 81 mg PO DAILY 7. brimonidine 0.2 % ophthalmic (eye) BID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do not restart amLODIPine until talking with your doctor 10. HELD- Chlorthalidone 25 mg PO DAILY This medication was held. Do not restart Chlorthalidone until talking with your doctor 11. HELD- GlipiZIDE 10 mg PO BID This medication was held. Do not restart GlipiZIDE until talking with your doctor 12. HELD- Rosuvastatin Calcium 20 mg PO QPM This medication was held. Do not restart Rosuvastatin Calcium until talking with your doctor Discharge Disposition: Home Discharge Diagnosis: Failure to thrive 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 our pleasure taking care of you at the ___ ___! WHAT BROUGHT YOU TO THE HOSPITAL? - You were having dizziness, headaches, weakness, and poor appetite at home. WHAT HAPPENED IN THE HOSPITAL? - We examined you and found your neurological exam to be normal. - We determined that your blood pressure was lower than your usual. This likely is causing your dizziness. We stopped your blood pressure medications, and your blood pressure became better. - We gave you medications and topical agents for your headache. - We monitored your heart rhythm using a monitor and did not find significant abnormalities. - We checked your blood work consistently and did not find significant abnormalities. - Our Physical Therapists saw you and recommended that you get stronger in rehab. - Our Nutritionists saw you and provided recommendations about how to improve your nutrition. - Our Social Workers **** WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL? - Please take your medications as prescribed and attend doctor's appointments. - Please work hard in rehab to get stronger. We wish you all the best! Your ___ Care Team Followup Instructions: ___	[ "R627", "E440", "I10", "Z8673", "R110", "R42", "Z7984", "I951", "E1142", "K5900", "G44209", "E785", "F329", "F4310" ]	Allergies: lisinopril / rosuvastatin Chief Complaint: weakness, nausea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with T2DM, HTN, HLD, h/o stroke and ?TIA, h/o depression, PTSD, and multiple ED visits presents with dizziness and weakness here with multiple nonspecific symptoms, including weakness, dizziness, headache, and poor appetite. Her overall presentation is similar to those from prior ED visits and is most consistent with likely deconditioning and failure to thrive at home. Patient indicates that she has been experiencing weakness x [MASKED] months, dizziness x [MASKED] months, HA, and nausea x 1 day-3 weeks. The headache has been worse in the past week. The dizziness has not changed. The nausea is accompanied by dizziness and was accompanied by abdominal pain yesterday, prompting her ED visit. She experiences whole body weakness, particularly in her legs. Her weakness prevents her from doing activities she usually does, like lawncare, although she says she still has interest in performing those activities. Her weakness and overall health prevent her from going to [MASKED], which she finds upsetting as she has not been able to visit her elderly aunt. She states she has lost her appetite and has lost 30 pounds (170lb-->130lb over the past two month per report). She states that she usually eats bread, tea. coffee, and food that her daughter makes. She requested a meal several times during the interview. She experiences headaches that she describes as "pain" and "pressure" and "all around" her head, traveling down her neck and back. She also feels the headache in her R ear. The headache is sometimes preceded by scalp itchiness and accompanied by nausea, but no photophobia or phonophobia. Yesterday, she experienced an episode of vertigo (room spinning). For her headaches, she uses a lidocaine patch for relief and says acetaminophen provides no relief. The headache comes and goes and occurs once a week or less. She is concerned that her headaches are indicative of cancer or a neurological problem. val indicates she had an episode of presyncope that was associated with some epigastric tightness, nausea, shortness of breath. Patient endorses frequent leg cramps for which she drinks water and uses ice. She states that she sometimes sleeps little. She reports occasional subjective fevers, cold sweats during the day coinciding with elevated BP, but denies night sweats. Records indicate that she did not do well with [MASKED] and needs additional therapy but is not eligible for rehab. She states that she last had physical therapy before her husband died [MASKED] years ago. Records state her family is "not comfortable going home with services at this time." [MASKED] concerned about safety at home. She says she has good support at home from her children, but feels she needs more support. Three prior ED visits since [MASKED] for similar complaints. Most recently reported to ED on [MASKED]. Physical exam was notable for (?)diffuse lower abdominal tenderness without rebound, guarding,or peritonitic signs. UA, CBC, CMP, electrolytes within normal limits. CXR and CT Abd and Pelvis both unremarkable. Case management was consulted and worked to arrange additional services at home. In the ED, she ate, remained ambulatory, and received hydration. She was discharged home the same day. Past Medical History: - DM2 - HTN - HLD - Stroke ([MASKED]) - ?TIA ([MASKED]) - Depression - PTSD - Glaucoma - Constipation - Headaches - Insomnia Social History: [MASKED] Family History: - Mother (deceased at [MASKED]): MI in [MASKED] (cause of death), HTN - Father (deceased at [MASKED]): DM (died of complications) - Son (living): HTN, ESRD - Daughter: DM - Cousin (deceased): brain cancer (cause of death) Physical Exam: Admission Exam: GENERAL: Pleasant and lying comfortably in bed. No apparent distress. HEENT: NCAT, PEERL, MMM. Oropharynx clear. Pseudonystagmus. Minimal temporal wasting. NECK: Supple, trachea midline, no cervical or supraclavicular LAD CV: RRR, no MRG. LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: Soft, NTND. EXTREMITIES: WWP. No [MASKED] edema. Neuro: Mental status: AAOX3, good attention Strength: [MASKED] in BUE and BLE Sensation: intact to light touch diffusely. Notes tingling in toes (longstanding due to diabetic neuropathy, per her report) Cerebellar: finger/nose testing intact CN: II-XII intact Speech: fluent, normal rate Psych: Appropriate affect and behavior but cries when discussing the remote deaths of her mother and husband and her inability to go to [MASKED] Discharge Exam: GENERAL: Pleasant and lying comfortably in bed. No apparent distress. HEENT: NCAT, PEERL, MMM. Oropharynx clear. EOMI with minimal pseudonystagmus. Minimal temporal wasting. NECK: Supple, trachea midline, no cervical or supraclavicular LAD CV: RRR, no MRG. LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: Soft, NTND. EXTREMITIES: WWP. No [MASKED] edema. Neuro: Mental status: AAOX3, good attention Strength: [MASKED] in BUE and BLE Sensation: intact to light touch diffusely. Notes numbness in toes (longstanding due to diabetic neuropathy, per her report) Cerebellar: finger/nose testing intact Gait: slow, stable gait CN: II-XII intact Speech: fluent, normal rate Psych: Appropriate affect and behavior Pertinent Results: ADMISSION LABS: =============== [MASKED] 08:15PM BLOOD %HbA1c-7.0* eAG-154* [MASKED] 08:15PM BLOOD [MASKED] PTT-26.8 [MASKED] [MASKED] 06:27PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 08:15PM BLOOD Neuts-39.6 [MASKED] Monos-9.7 Eos-0.7* Baso-0.5 Im [MASKED] AbsNeut-1.67 AbsLymp-2.08 AbsMono-0.41 AbsEos-0.03* AbsBaso-0.02 PERTINENT LABS: =============== [MASKED] 02:10AM BLOOD calTIBC-293 Ferritn-127 TRF-225 [MASKED] 08:15PM BLOOD %HbA1c-7.0* eAG-154* [MASKED] 02:10AM BLOOD TSH-1.7 [MASKED] 07:26AM BLOOD Cortsol-18.2 [MASKED] 08:15PM BLOOD HIV Ab-NEG DISCHARGE LABS: =============== [MASKED] 07:16AM BLOOD Glucose-151* UreaN-12 Creat-0.8 Na-139 K-4.2 Cl-101 HCO3-25 AnGap-13 [MASKED] 07:16AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.1 IMAGING/REPORTS: ================ CT chest ([MASKED]): : Impression: No acute intrathoracic process. CT abdomen ([MASKED]) Impression: No acute intra-abdominal process, no findings to explain symptoms. MICROBIOLOGY: ============= None Brief Hospital Course: ==================== SUMMARY: ==================== Ms. [MASKED] is a [MASKED] year old woman with T2DM, HTN, HLD, h/o stroke and ?TIA, depression, PTSD, and multiple recent ED visits with dizziness and weakness here with multiple similar complaints, including weakness, dizziness, headache, and poor appetite. Her overall presentation was concerning for deconditioning and failure to thrive from lack of significant support at home. Her home antihypertensives were held as patient's BP was soft at times. She was neurologically without concerning findings. Monitored on telemetry without significant events. Discharged home per recommendation of Physical Therapy. ================== ACUTE ISSUES ================== #Weakness #Failure to thrive Patient had presented to the ED multiple times for similar complaints of chronic weakness. Neurological exam was notable for [MASKED] strength diffusely and lack of significant neurological deficits. Physical Therapy evaluated the patient and recommended rehab to increase stamina. On review of her social situation and per discussion with her primary providers, there is concern that the patient is not receiving a sufficient level of support at home from her daughter who lives with her and her younger daughter, who lives downstairs. Social work met with her and shared information for elder services referral with pt and daughter [MASKED]. Pt does not require [MASKED] at this time. Per discussion with daughter, pts children are available to assist with medication management and meals, but that pt denies problems with hoarding and is unlikely to allow family or outside providers to address excess of belongings in her home. #Dizziness #Relative hypotension #History of hypertension Neurologically intact on admission and throughout admission. BP was soft to the [MASKED] initially after receiving her home amlodipine and chlorthalidone in the ED. Per collateral, patient self-titrates antihypertensives at home. Suspect that she has relative hypotension that is causing her dizziness. No neurological exam findings hence low concern for neurological process. Morning cortisol normal. Given IVF resuscitation and stopped home antihypertensives this admission with normalization of BPs. #Loss of appetite #Report of weight loss Patient reports subjective weight loss of 30 lbs in the past 2 months but OMR records do not indicate significant weight change. She does appears malnourished, and she may indeed by having some component of weight loss, associated with improved A1c from ~10 to 7 in less than a year while on glyburide. Etiology of loss of appetite is multifactorial, including from potentially untreated depression and a component that is secondary to her background social situation. Has undergone routine mammography; CT A/P without alarming findings. No recent vaginal bleeding and no history of smoking or alcohol use, hence overall felt that her risk of advanced malignancy to be very low. CXR clear and no other findings to suggest advanced disseminated TB. HIV negative. TSH normal. Morning cortisol normal. Nutrition saw the patient and provided supplements. #Headache Appear tension-type vs. caffeine withdrawal. Patient notes that she drinks [MASKED] cups of coffee a day at home. No neurological signs. No evidence of significant nausea or vomiting to suggest increased intracranial pressure, and head CT around 2.5 weeks before admission as without significant findings. Given Tylenol, small-dose ibuprofen, and topical agents this admission. Encouraged to drink coffee in-house. #Subjective fevers Per patient. None measured at home or recorded in-house. #Depression #PTSD At presentation, patient was teary discussing the death of her husband [MASKED] years ago, the death of her mother in [MASKED], and her inability to return home to [MASKED] and visit her elderly aunt in [MASKED]. PHQ-9 13 this admission, though many of her findings were attributed to feeling weak. Does not appear psychosocially slow and she often has a positive affect. Social Work ***** #Constipation Put on standing bowel regimen with improvement. ================== CHRONIC ISSUES: ================== #T2DM Glipizide may be contributing to presentation. A1c in [MASKED] at 9.8%, 7.0% this admission. Stopped home glyburide and put on Humalog sliding scale. #HLD Prescribed rosuvastatin at home but there is a listed allergy (nausea/vomiting). Patient refused rosuvastatin. OMR indicates she was on rosuvastatin initially but switched to a different statin as rosuvastatin made her vomit. At one point, she was on atorvastatin but requested to be switched back to rosuvastatin. In the past, she has taken pravastatin and simvastatin, which made her mouth burn. Home rosuvastatin was held and patient is encouraged to discuss statin choice with PCP. ==================== TRANSITIONAL ISSUES: ==================== [] Please discuss switching from rosuvastatin to a different statin. [] Please discuss therapy and antidepressants in order to address patients depressed mood. >30 min spent on discharge planning including face to face time Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. brimonidine 0.2 % ophthalmic (eye) BID 4. Chlorthalidone 25 mg PO DAILY 5. GlipiZIDE 10 mg PO BID 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Rosuvastatin Calcium 20 mg PO QPM 8. Senna 8.6 mg PO BID:PRN Constipation - First Line Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Ondansetron ODT [MASKED] mg PO Q8H:PRN Nausea/Vomiting - First Line RX ondansetron 4 mg 1 tablet(s) by mouth three times per day Disp #10 Tablet Refills:0 3. Polyethylene Glycol 17 g PO BID 4. Simethicone 40-80 mg PO QID:PRN gas 5. Senna 17.2 mg PO BID 6. Aspirin 81 mg PO DAILY 7. brimonidine 0.2 % ophthalmic (eye) BID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do not restart amLODIPine until talking with your doctor 10. HELD- Chlorthalidone 25 mg PO DAILY This medication was held. Do not restart Chlorthalidone until talking with your doctor 11. HELD- GlipiZIDE 10 mg PO BID This medication was held. Do not restart GlipiZIDE until talking with your doctor 12. HELD- Rosuvastatin Calcium 20 mg PO QPM This medication was held. Do not restart Rosuvastatin Calcium until talking with your doctor Discharge Disposition: Home Discharge Diagnosis: Failure to thrive 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 our pleasure taking care of you at the [MASKED] [MASKED]! WHAT BROUGHT YOU TO THE HOSPITAL? - You were having dizziness, headaches, weakness, and poor appetite at home. WHAT HAPPENED IN THE HOSPITAL? - We examined you and found your neurological exam to be normal. - We determined that your blood pressure was lower than your usual. This likely is causing your dizziness. We stopped your blood pressure medications, and your blood pressure became better. - We gave you medications and topical agents for your headache. - We monitored your heart rhythm using a monitor and did not find significant abnormalities. - We checked your blood work consistently and did not find significant abnormalities. - Our Physical Therapists saw you and recommended that you get stronger in rehab. - Our Nutritionists saw you and provided recommendations about how to improve your nutrition. - Our Social Workers **** WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL? - Please take your medications as prescribed and attend doctor's appointments. - Please work hard in rehab to get stronger. We wish you all the best! Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I10", "Z8673", "K5900", "E785", "F329" ]	[ "R627: Adult failure to thrive", "E440: Moderate protein-calorie malnutrition", "I10: Essential (primary) hypertension", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "R110: Nausea", "R42: Dizziness and giddiness", "Z7984: Long term (current) use of oral hypoglycemic drugs", "I951: Orthostatic hypotension", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "K5900: Constipation, unspecified", "G44209: Tension-type headache, unspecified, not intractable", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F4310: Post-traumatic stress disorder, unspecified" ]
10,046,592	29,327,270	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: lisinopril Attending: ___ Chief Complaint: dysarthria Major Surgical or Invasive Procedure: none History of Present Illness: She states around 12am last night she suddenly noticed that her mouth felt very heavy. Her daughter asked if she took her BP medication yet, she had not so proceeded to do so. She states she felt better after taking medication. In the morning she continued to have these symptoms, so she called her brother who told her to call ___. Other family noted slurred speech when she spoke to her somewhere between ___ today. She denies numbness. States it just felt heavy in her mouth. States she has coughing after swallowing things occasionally, not sure if it is new today. During interview, she is coughing a lot after getting medications with water from nursing. She denies any other symptoms. Denies weakness or numbness. No problems with language. No double vision. Reports she has intermittent dizziness if she doesn't take one of her medications. She is not sure which one of these medications helps with dizziness. Denies room spinning. More of a lightheadedness. Family does not think speech is currently at baseline, and think she sounds dysarthric. Her bottom dentures are not in right now. She doesn't normally keep the bottom ones in. Family states speech is different compared to when she doesn't wear bottom denture as well. They think it seems like she is talking from the side of her mouth. During interview she states the heaviness in her mouth has felt improved since she came to the ED. Denies dysuria. Reports urinary frequency. Denies having TIA in the past. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: T2Dm HLD HTN Social History: ___ Family History: Relative Status Age Problem Onset Comments Other SH, FH Son Living HYPERTENSION END STAGE RENAL on HD DISEASE Physical Exam: Admission Physical Exam: Vitals: T: P: R: 16 BP: SaO2: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented ___ ___. Able to relate history without difficulty. Attentive, able to name ___ backward somewhat slowly.. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was perhaps slightly dysarthric per family. Somewhat difficult to understand due to accent for interviewer. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity ___ bilaterally. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to ___ bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L ___ 1 1 R 1 1 1 1 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. ___, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Discharge Physical Exam =================== Physical Exam: Vitals: 24 HR Data (last updated ___ @ 1246) Temp: 97.6 (Tm 98.9), BP: 114/74 (___), HR: 66 (___), RR: 18 (___), O2 sat: 100% (___), O2 delivery: Ra, Wt: 152.34 lb/69.1 kg General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: breathing comfortably on room air Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: non distended Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: awake and alert, Able to relate history without difficulty. Attentive, Language is fluent, Normal prosody. There were no paraphasic errors. No dysarthria noted -Cranial Nerves: EOMI, left facial droop, improved from prior, tongue midline -Motor: Normal bulk, tone throughout. No pronator drift bilaterally.No adventitious movements, such as tremor, noted. No asterixis noted. -Sensory: No deficits to light touch -DTRs: deferred -___: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. ___, normal stride and arm swing. Able to walk in tandem without difficulty. Pertinent Results: Admission Labs ============ ___ 10:36AM BLOOD ___ ___ Plt ___ ___ 10:36AM BLOOD ___ ___ Im ___ ___ ___ 07:55AM BLOOD ___ ___ ___ 10:36AM BLOOD ___ ___ ___ 10:36AM BLOOD ___ Important Labs ============= ___ 07:55AM BLOOD ___ ___ 07:55AM BLOOD ___ ___ ___ 07:55AM BLOOD ___ Imaging ======= ___ CTA head and neck CT head shows no evidence of hemorrhage, or loss of ___ matter differentiation. No midline shift or hydrocephalus seen. CT angiography of the neck shows normal appearance of the carotid and vertebral arteries without stenosis or occlusion or dissection. Mild vascular calcifications are seen. CT angiography of the head shows normal appearance of the arteries of the anterior and posterior circulation without stenosis or occlusion or aneurysm greater than 3 mm in size. Mild vascular calcifications are seen at the cavernous carotid artery. IMPRESSION: No significant abnormalities on CT of the head without contrast. No significant abnormalities on CT angiography of the head and neck. ___ TTE The left atrial volume index is normal. No thrombus/mass is seen in the body of the left atrium (best excluded by TEE) There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. No thrombus or mass is seen in the left ventricle. The visually estimated left ventricular ejection fraction is 60%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) appear structurally normal. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. There is trace aortic regurgitation.The mitral valve leaflets appear structurally normal with no mitral valve prolapse. No masses or vegetationsare seen on the mitral valve. There is trivial mitral regurgitation. The tricuspid valve leaflets appeastructurally normal. No mass/vegetation are seen on the tricuspid valve. There is physiologic tricuspidregurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. I MPRESSION: Normal biventricular cavity sizes, regional/global systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure. No structural cardiac source of embolism (e.g.patent foramen ovale/atrial septal defect, intracardiac thrombus, or vegetation) seen. No prior TTE available for comparison. ___ MRI head There is restricted diffusion right corona radiata and right putamen with associated T2 signal hyperintensity, consistent with an early subacute infarct (04:19). Evaluation for intracranial hemorrhage is limited as GRE sequence was not obtained. There is no T1 hypointensity to suggest subacute blood. There is no significant mass effect. There is mild prominence of the ventricles and sulci consistent with ___ involutional changes. Numerous subcortical, deep, and periventricular white matter, and pontine T2, signal hyperintensities are nonspecific, however likely represent sequela of chronic small vessel ischemic disease. The major intracranial flow voids are preserved. There is minimal mucosal thickening in the ethmoid air cells. There is trace fluid in the right mastoid air cells. The orbits are grossly unremarkable. IMPRESSION: 1. Incomplete exam. 2. Early subacute infarct in right corona radiata and right putamen. No significant mass effect. Brief Hospital Course: ___ F w/ PMH T2DM, HTN, HLD presents with acute onset mouth heaviness and dysphagia found to have acute ischemic stroke. PLAN: #right corona radiata and right putamen: Initial imaging showed some atherosclerotic disease on CT. She did not receive TPA, or thrombectomy because there was not LVO, she was outside window for TPA, and NIHSS was too low. MRI showed right corona radiate and right putamen acute infarct. MRI was incomplete so no GRE sequence was done. TTE was negative for any cardiac source of embolus. She was continued on aspirin 81mg as patient was not taking medications as prescribed at home. Risk factors were checked and were LDL 152, HgbA1c 9.7 Etiology of stroke was felt to be small vessel iso uncontrolled HTN, diabetes, and hyperlipidemia. She was switched from pravastatin to rosuvastatin. She was initially started on atorvastatin but this caused GI upset. #HTN: Blood pressure was allowed to autoregulate after acute ischemic stroke. She was restarted on half amlodipine dose at discharge. SBP during admission ranged from ___. She will follow up with her PCP for further management of blood pressure. # Diabetes: HgbA1c checked and was elevated to 9.7, looking back through notes patient has had difficulty controlling diabetes and frequently does not take her medications. She was seen by ___ while inpatient. She was requiring very minimal correction doses of sliding scale insulin. Per patient she has not been taking her metformin because it causes significant GI upset. In addition, it is unclear how often patient takes glipizide as well. Therefore, given minimal insulin requirements it was felt that patient could be discharged on glipizide once a day only and this should control her blood glucose if she is compliant. She was told this and encouraged to take her medications as prescribed. She will be discharged with ___ to help with medication compliance and to monitor if she is tolerating medications. In addition, she was enrolled in elder services and social work will follow as an outpatient. #UTI: UA was consistent with infection and culture grew Ecoli. She was treated with ceftriaxone for 3 day course. Transitional Issues ==================== [] Patient discharged with home services and home social work. In addition she was enrolled in elder services [] Consider medication delivery in blister package to help with compliance [] Patient discharged on 2.5mg amlodipine after acute infarct. Can increase as needed for blood pressure control. [] please assess if patient is tolerating medications. If she is continuing to get GI upset with diabetes medications can consider switching to injectable [] Speech and swallow recommended soft solids with thin liquids and for medications to be taken whole in puree. 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 = 152) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] ___ less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) ___ - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] ___ less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 4. Chlorthalidone 12.5 mg PO DAILY 5. GlipiZIDE 5 mg PO BID 6. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 7. Pravastatin 20 mg PO QPM Discharge Medications: 1. Rosuvastatin Calcium 20 mg PO QPM RX rosuvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:2 2. amLODIPine 2.5 mg PO DAILY RX amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. GlipiZIDE 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 6. HELD- Chlorthalidone 12.5 mg PO DAILY This medication was held. Do not restart Chlorthalidone until you follow up with your PCP ___: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis ================== Acute ischemic stroke Secondary Diagnosis ==================== HTN HLD Diabetes type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of difficulty speaking and eating 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 - High Lipids - Diabetes We are changing your medications as follows: - Stop taking pravastatin, start taking Rosuvastatin - Your dose of amlodipine was decreased to 2.5mg, please take this until you see your PCP - ___ glipizide dose was reduced. Please only take this once a day. - Please take your aspirin, diabetes medications, and blood pressure medications as directed. This is very important. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___	[ "I639", "N390", "E1165", "R1310", "I10", "E785", "B9620", "T383X6A", "R471", "R29702", "R29810", "Z91128", "Y92009" ]	Allergies: lisinopril Chief Complaint: dysarthria Major Surgical or Invasive Procedure: none History of Present Illness: She states around 12am last night she suddenly noticed that her mouth felt very heavy. Her daughter asked if she took her BP medication yet, she had not so proceeded to do so. She states she felt better after taking medication. In the morning she continued to have these symptoms, so she called her brother who told her to call [MASKED]. Other family noted slurred speech when she spoke to her somewhere between [MASKED] today. She denies numbness. States it just felt heavy in her mouth. States she has coughing after swallowing things occasionally, not sure if it is new today. During interview, she is coughing a lot after getting medications with water from nursing. She denies any other symptoms. Denies weakness or numbness. No problems with language. No double vision. Reports she has intermittent dizziness if she doesn't take one of her medications. She is not sure which one of these medications helps with dizziness. Denies room spinning. More of a lightheadedness. Family does not think speech is currently at baseline, and think she sounds dysarthric. Her bottom dentures are not in right now. She doesn't normally keep the bottom ones in. Family states speech is different compared to when she doesn't wear bottom denture as well. They think it seems like she is talking from the side of her mouth. During interview she states the heaviness in her mouth has felt improved since she came to the ED. Denies dysuria. Reports urinary frequency. Denies having TIA in the past. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: T2Dm HLD HTN Social History: [MASKED] Family History: Relative Status Age Problem Onset Comments Other SH, FH Son Living HYPERTENSION END STAGE RENAL on HD DISEASE Physical Exam: Admission Physical Exam: Vitals: T: P: R: 16 BP: SaO2: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No [MASKED] edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented [MASKED] [MASKED]. Able to relate history without difficulty. Attentive, able to name [MASKED] backward somewhat slowly.. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was perhaps slightly dysarthric per family. Somewhat difficult to understand due to accent for interviewer. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity [MASKED] bilaterally. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to [MASKED] bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri [MASKED] Pat Ach L [MASKED] 1 1 R 1 1 1 1 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. [MASKED], normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Discharge Physical Exam =================== Physical Exam: Vitals: 24 HR Data (last updated [MASKED] @ 1246) Temp: 97.6 (Tm 98.9), BP: 114/74 ([MASKED]), HR: 66 ([MASKED]), RR: 18 ([MASKED]), O2 sat: 100% ([MASKED]), O2 delivery: Ra, Wt: 152.34 lb/69.1 kg General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: breathing comfortably on room air Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: non distended Extremities: No [MASKED] edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: awake and alert, Able to relate history without difficulty. Attentive, Language is fluent, Normal prosody. There were no paraphasic errors. No dysarthria noted -Cranial Nerves: EOMI, left facial droop, improved from prior, tongue midline -Motor: Normal bulk, tone throughout. No pronator drift bilaterally.No adventitious movements, such as tremor, noted. No asterixis noted. -Sensory: No deficits to light touch -DTRs: deferred -[MASKED]: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. [MASKED], normal stride and arm swing. Able to walk in tandem without difficulty. Pertinent Results: Admission Labs ============ [MASKED] 10:36AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 10:36AM BLOOD [MASKED] [MASKED] Im [MASKED] [MASKED] [MASKED] 07:55AM BLOOD [MASKED] [MASKED] [MASKED] 10:36AM BLOOD [MASKED] [MASKED] [MASKED] 10:36AM BLOOD [MASKED] Important Labs ============= [MASKED] 07:55AM BLOOD [MASKED] [MASKED] 07:55AM BLOOD [MASKED] [MASKED] [MASKED] 07:55AM BLOOD [MASKED] Imaging ======= [MASKED] CTA head and neck CT head shows no evidence of hemorrhage, or loss of [MASKED] matter differentiation. No midline shift or hydrocephalus seen. CT angiography of the neck shows normal appearance of the carotid and vertebral arteries without stenosis or occlusion or dissection. Mild vascular calcifications are seen. CT angiography of the head shows normal appearance of the arteries of the anterior and posterior circulation without stenosis or occlusion or aneurysm greater than 3 mm in size. Mild vascular calcifications are seen at the cavernous carotid artery. IMPRESSION: No significant abnormalities on CT of the head without contrast. No significant abnormalities on CT angiography of the head and neck. [MASKED] TTE The left atrial volume index is normal. No thrombus/mass is seen in the body of the left atrium (best excluded by TEE) There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. No thrombus or mass is seen in the left ventricle. The visually estimated left ventricular ejection fraction is 60%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) appear structurally normal. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. There is trace aortic regurgitation.The mitral valve leaflets appear structurally normal with no mitral valve prolapse. No masses or vegetationsare seen on the mitral valve. There is trivial mitral regurgitation. The tricuspid valve leaflets appeastructurally normal. No mass/vegetation are seen on the tricuspid valve. There is physiologic tricuspidregurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. I MPRESSION: Normal biventricular cavity sizes, regional/global systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure. No structural cardiac source of embolism (e.g.patent foramen ovale/atrial septal defect, intracardiac thrombus, or vegetation) seen. No prior TTE available for comparison. [MASKED] MRI head There is restricted diffusion right corona radiata and right putamen with associated T2 signal hyperintensity, consistent with an early subacute infarct (04:19). Evaluation for intracranial hemorrhage is limited as GRE sequence was not obtained. There is no T1 hypointensity to suggest subacute blood. There is no significant mass effect. There is mild prominence of the ventricles and sulci consistent with [MASKED] involutional changes. Numerous subcortical, deep, and periventricular white matter, and pontine T2, signal hyperintensities are nonspecific, however likely represent sequela of chronic small vessel ischemic disease. The major intracranial flow voids are preserved. There is minimal mucosal thickening in the ethmoid air cells. There is trace fluid in the right mastoid air cells. The orbits are grossly unremarkable. IMPRESSION: 1. Incomplete exam. 2. Early subacute infarct in right corona radiata and right putamen. No significant mass effect. Brief Hospital Course: [MASKED] F w/ PMH T2DM, HTN, HLD presents with acute onset mouth heaviness and dysphagia found to have acute ischemic stroke. PLAN: #right corona radiata and right putamen: Initial imaging showed some atherosclerotic disease on CT. She did not receive TPA, or thrombectomy because there was not LVO, she was outside window for TPA, and NIHSS was too low. MRI showed right corona radiate and right putamen acute infarct. MRI was incomplete so no GRE sequence was done. TTE was negative for any cardiac source of embolus. She was continued on aspirin 81mg as patient was not taking medications as prescribed at home. Risk factors were checked and were LDL 152, HgbA1c 9.7 Etiology of stroke was felt to be small vessel iso uncontrolled HTN, diabetes, and hyperlipidemia. She was switched from pravastatin to rosuvastatin. She was initially started on atorvastatin but this caused GI upset. #HTN: Blood pressure was allowed to autoregulate after acute ischemic stroke. She was restarted on half amlodipine dose at discharge. SBP during admission ranged from [MASKED]. She will follow up with her PCP for further management of blood pressure. # Diabetes: HgbA1c checked and was elevated to 9.7, looking back through notes patient has had difficulty controlling diabetes and frequently does not take her medications. She was seen by [MASKED] while inpatient. She was requiring very minimal correction doses of sliding scale insulin. Per patient she has not been taking her metformin because it causes significant GI upset. In addition, it is unclear how often patient takes glipizide as well. Therefore, given minimal insulin requirements it was felt that patient could be discharged on glipizide once a day only and this should control her blood glucose if she is compliant. She was told this and encouraged to take her medications as prescribed. She will be discharged with [MASKED] to help with medication compliance and to monitor if she is tolerating medications. In addition, she was enrolled in elder services and social work will follow as an outpatient. #UTI: UA was consistent with infection and culture grew Ecoli. She was treated with ceftriaxone for 3 day course. Transitional Issues ==================== [] Patient discharged with home services and home social work. In addition she was enrolled in elder services [] Consider medication delivery in blister package to help with compliance [] Patient discharged on 2.5mg amlodipine after acute infarct. Can increase as needed for blood pressure control. [] please assess if patient is tolerating medications. If she is continuing to get GI upset with diabetes medications can consider switching to injectable [] Speech and swallow recommended soft solids with thin liquids and for medications to be taken whole in puree. 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 = 152) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] [MASKED] less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) [MASKED] - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] [MASKED] less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 4. Chlorthalidone 12.5 mg PO DAILY 5. GlipiZIDE 5 mg PO BID 6. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 7. Pravastatin 20 mg PO QPM Discharge Medications: 1. Rosuvastatin Calcium 20 mg PO QPM RX rosuvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:2 2. amLODIPine 2.5 mg PO DAILY RX amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. GlipiZIDE 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 6. HELD- Chlorthalidone 12.5 mg PO DAILY This medication was held. Do not restart Chlorthalidone until you follow up with your PCP [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis ================== Acute ischemic stroke Secondary Diagnosis ==================== HTN HLD Diabetes type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were hospitalized due to symptoms of difficulty speaking and eating 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 - High Lipids - Diabetes We are changing your medications as follows: - Stop taking pravastatin, start taking Rosuvastatin - Your dose of amlodipine was decreased to 2.5mg, please take this until you see your PCP - [MASKED] glipizide dose was reduced. Please only take this once a day. - Please take your aspirin, diabetes medications, and blood pressure medications as directed. This is very important. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]	[]	[ "N390", "E1165", "I10", "E785" ]	[ "I639: Cerebral infarction, unspecified", "N390: Urinary tract infection, site not specified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "R1310: Dysphagia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "T383X6A: Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter", "R471: Dysarthria and anarthria", "R29702: NIHSS score 2", "R29810: Facial weakness", "Z91128: Patient's intentional underdosing of medication regimen for other reason", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,046,630	20,836,768	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hip pain Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ w/ hx of HTN presented to the ED with pelvis pain and was found to be confused so was admitted to medicine for pain control and confusion workup. He was seen here on ___ with a diagnosis of pelvic ramus fracture. Kept overnight for ___ and CM; sent home with a walker and home services. He returned today with continued pain. He says it is not worse, but it is not better either and it is limiting his ability to function at home. He has been taking Tylenol and ibuprofen. Is still able to ambulate. In the ED, initial vitals were: 97.4 68 180/80 20 98% RA His labs revealed H/H of 12.___, chem7 wnl Imaging revealed - Bilateral LENIS - distal isolated tibial vein thrombosis. No evidence DVT. - Hip/pelvic films - Minimally displaced and comminuted fractures involving the left superior and inferior pubic rami not significantly changed in overall appearance relative to prior examinations dated ___. No new fracture is seen. He received: ___ 16:22 PO TraMADOL (Ultram) 25 mg ___ 20:58 PO TraMADOL (Ultram) 25 mg ___ 20:58 PO Acetaminophen 1000 mg ___ 01:32 PO/NG Acetaminophen 650 mg ___ 01:32 PO OLANZapine 5 mg ___ 10:48 IVF 20 mEq Potassium Chloride / 1000 mL ___ NS He was going to be discharged from the ED, however woke up this morning altered. Head CT was negative. He was admitted to the floor for further work up for altered mental status. On the floor, with the assistance of a ___ interpreter, the patient says that he has pain in his legs. He is confused so did not answer any other ROS questions. Past Medical History: Per wife, HTN only Social History: ___ Family History: not pertinent to current admission Physical Exam: ADMISSION EXAM ============== Vital Signs: 98.4 180/95 64 16 99% RA General: Lying in bed, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, no JVD. PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no w/r/c 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: CN II-XII grossly intact. ___ strength in upper extremities, lower extremity exam limited by pain but has ___ strength on plantarflexion of feet DISCHARGE EXAM ============== Vital Signs: 97.8 66-71 ___ 20 96-100% RA General: Lying in bed, appears comfortable HEENT: Head AT/NC, PERRL, EOMI CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB anteriorly only, no w/r/c Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Legs slightly cool to touch, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact, moving all extremities spontaneously, A&Ox3 Pertinent Results: ADMISSION LABS ============== ___ 04:35PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-138 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 ___ 04:35PM WBC-7.3 RBC-3.63* HGB-11.0* HCT-32.7* MCV-90 MCH-30.3 MCHC-33.6 RDW-13.2 RDWSD-43.0 ___ 04:35PM NEUTS-85.8* LYMPHS-4.6* MONOS-8.6 EOS-0.3* BASOS-0.3 IM ___ AbsNeut-6.28* AbsLymp-0.34* AbsMono-0.63 AbsEos-0.02* AbsBaso-0.02 ___ 04:35PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-138 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 ___ 04:47PM URINE RBC-2 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 ___ 04:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 04:47PM URINE COLOR-Yellow APPEAR-Clear SP ___ DISCHARGE LABS ============== ___ 07:34AM BLOOD WBC-7.8 RBC-3.65* Hgb-10.9* Hct-33.1* MCV-91 MCH-29.9 MCHC-32.9 RDW-13.2 RDWSD-43.7 Plt ___ ___ 07:34AM BLOOD Glucose-118* UreaN-28* Creat-0.9 Na-135 K-3.9 Cl-102 HCO3-26 AnGap-11 ___ 07:34AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0 IMAGING ======= ___ CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial process. Small vessel disease with age related involutional change. ___ CHEST (SINGLE VIEW) No acute intrathoracic process ___ BILAT LOWER EXT VEINS IMPRESSION: 1. Nonocclusive thrombus in a single posterior tibial vein on the left. 2. No evidence of deep venous thrombosis in the right lower extremity veins. ___ DX PELVIS & HIP UNILATE IMPRESSION: Minimally displaced and comminuted fractures involving the left superior and inferior pubic rami not significantly changed in overall appearance relative to prior examinations dated ___. No new fracture is seen. MICROBIOLOGY ============ UCx ___ - consistent with skin flora BCx ___ x 2, NGTD Brief Hospital Course: BRIEF SUMMARY ============== Mr. ___ is a pleasant ___ M s/p fall and fracture of the left inferior and superior pubic rami on ___, who presented with ongoing pain hip pain and was noted to be confused while in the ED and was found to have a superficial clot of the right lower tibial vein. He was evaluated for causes of delirium with no obvious abnormality. The likely cause of his delirium was pain, medication effect (he was initially treated with oxycodone 2.5 mg for pain), lack of sleep (he did not sleep at all the night prior to his confusion), and being hospitalized in the setting of chronic small vessel disease of the brain. With normalization of his sleep-wake cycle, limiting sedating medications, and administration of fluids he had significant improvement in his mental status and was discharged to rehab. ACUTE ISSUES ============ #Delirium: The patient was noted to be confused upon waking the morning after being seen in the emergency department for continued hip pain in the setting of a pubic ramus fracture two weeks prior to admission. He was admitted to the medicine service, where he underwent a workup for causes of delirium. While on the floor, he exhibited waxing and waning of his mental status, ranging from A&Ox3 to somnolent and barely interactive. A general delirium workup was performed and was negative (see labs for further details). The likely cause of his delirium was a combination of pain, medication effect (he was initially treated with oxycodone 2.5 mg for pain), lack of sleep (he did not sleep at all the night prior to his confusion), and being hospitalized in the setting of chronic small vessel disease of the brain. He underwent a head CT in the ED, which was negative for acute findings. We acquired records from a stay at ___. ___ in ___ at which time he was evaluated for slowing of speech/movement with concern for ___ Disease; an MRI brain from that stay showed enlarged cerebral ventricles, with question of NPH. Given that he was acutely delirious, had fallen recently, and was having incontinence while on the floor, we had our radiologists read the MRI from the outside hospital. They felt that there was no change in the size of his ventricles from this MRI versus his CT scan this admission. The patient was given fluids, Seroquel for sleep, and was put on delirium precautions with improvement in his mental status. He was discharged to rehab and will follow up at ___ with a neurologist later in the month for further evaluation per the patient's wife. #TIBIAL VEIN THROMBOSIS: The patient has a superficial tibial vein thrombosis but with no evidence of DVT. No need to anticoagulate given superficiality of clot. #PELVIC FRACTURE: Sustained fracture of his superior and inferior left pelvic ramus on ___, with no need for operative management per orthopedics. He went home with a walker but had continued pain so returned as above. His pain was initially treated with oxycodone 2.5 mg and standing tylenol, but the oxycodone was discontinued due to concern for worsening of his delirium as above. CHRONIC ISSUES #HYPERTENSION: The patient has a hx of HTN, controlled with PRN metoprolol per wife. On presentation to the floor, patient had SBP to 180 so was give 12.5 mg of PO captopril. He was placed on captopril 6.25 mg TID with improvement in pressures, however he did experience SBPs in the ___ so his captopril was discontinued. He may need addition of an antihypertensive as an outpatient depending on his blood pressure control. #Normocytic anemia: Iron studies were performed and were consistent with anemia of chronic disease; his iron was wnl, TIBC low normal, and ferritin elevated. His H/H remained stable during his course TRANSITIONAL ISSUES =================== - The patient was noted to have labile blood pressures, with his initial SBP at 180. He was placed on captopril 6.25 mg TID with improvement in his pressures, but did experience a couple of SBPs in the ___. This medication was discontinued prior to discharge, and his blood pressures should be further evaluated with possible addition of antihypertensive medication. - The patient was noted to have a normocytic anemia with Hgbs in the ___. Iron studies were consistent with anemia of chronic disease - The patient was evaluated for possible ___ disease at ___ in ___ after experiencing slowing of speech/movement. Per his wife, he has an appointment w/ neurology at ___ on ___ for further evaluation. - The patient was started on Seroquel 25 mg QHS for problems with sleep/wake cycle, however he experienced cognitive slowing so this was discontinued. He may be sensitive to antipsychotics given his possible ___ Disease - Per the patient's PCP, he takes Sinemet ___ 0.5 tab BID for ?___ Disease but the patient was reluctant to take any psychoactive medications due to concern for possible cognitive side-effects # CODE: Full # CONTACT: ___, wife, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID 5. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Vitamin D 1000 UNIT PO DAILY 4. Acetaminophen 650 mg PO Q6H 5. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID 6. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: #delirium #Superficial tibial vein thrombosis #hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, you were admitted to the hospital after you were found to be confused while visiting the emergency department due to leg pain. We performed several tests to identify the cause of your confusion, but no cause was found. It is likely that your confusion was caused by a combination of pain, pain medications (which can be sedating), being in a different environment, lack of sleep, and having some chronic age-related brain changes. You were also found to have a small clot in your right leg, but this did not need treatment. You were seen by our physical therapists who recommended rehab. You were discharged to a rehab facility to help you get stronger. We wish you the best, Your ___ Care Team Followup Instructions: ___	[ "R410", "I82812", "I10", "S32592D", "W19XXXD", "D649", "G9340" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: hip pain Major Surgical or Invasive Procedure: NONE History of Present Illness: [MASKED] w/ hx of HTN presented to the ED with pelvis pain and was found to be confused so was admitted to medicine for pain control and confusion workup. He was seen here on [MASKED] with a diagnosis of pelvic ramus fracture. Kept overnight for [MASKED] and CM; sent home with a walker and home services. He returned today with continued pain. He says it is not worse, but it is not better either and it is limiting his ability to function at home. He has been taking Tylenol and ibuprofen. Is still able to ambulate. In the ED, initial vitals were: 97.4 68 180/80 20 98% RA His labs revealed H/H of 12.[MASKED], chem7 wnl Imaging revealed - Bilateral LENIS - distal isolated tibial vein thrombosis. No evidence DVT. - Hip/pelvic films - Minimally displaced and comminuted fractures involving the left superior and inferior pubic rami not significantly changed in overall appearance relative to prior examinations dated [MASKED]. No new fracture is seen. He received: [MASKED] 16:22 PO TraMADOL (Ultram) 25 mg [MASKED] 20:58 PO TraMADOL (Ultram) 25 mg [MASKED] 20:58 PO Acetaminophen 1000 mg [MASKED] 01:32 PO/NG Acetaminophen 650 mg [MASKED] 01:32 PO OLANZapine 5 mg [MASKED] 10:48 IVF 20 mEq Potassium Chloride / 1000 mL [MASKED] NS He was going to be discharged from the ED, however woke up this morning altered. Head CT was negative. He was admitted to the floor for further work up for altered mental status. On the floor, with the assistance of a [MASKED] interpreter, the patient says that he has pain in his legs. He is confused so did not answer any other ROS questions. Past Medical History: Per wife, HTN only Social History: [MASKED] Family History: not pertinent to current admission Physical Exam: ADMISSION EXAM ============== Vital Signs: 98.4 180/95 64 16 99% RA General: Lying in bed, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, no JVD. PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no w/r/c 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: CN II-XII grossly intact. [MASKED] strength in upper extremities, lower extremity exam limited by pain but has [MASKED] strength on plantarflexion of feet DISCHARGE EXAM ============== Vital Signs: 97.8 66-71 [MASKED] 20 96-100% RA General: Lying in bed, appears comfortable HEENT: Head AT/NC, PERRL, EOMI CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB anteriorly only, no w/r/c Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Legs slightly cool to touch, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact, moving all extremities spontaneously, A&Ox3 Pertinent Results: ADMISSION LABS ============== [MASKED] 04:35PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-138 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 [MASKED] 04:35PM WBC-7.3 RBC-3.63* HGB-11.0* HCT-32.7* MCV-90 MCH-30.3 MCHC-33.6 RDW-13.2 RDWSD-43.0 [MASKED] 04:35PM NEUTS-85.8* LYMPHS-4.6* MONOS-8.6 EOS-0.3* BASOS-0.3 IM [MASKED] AbsNeut-6.28* AbsLymp-0.34* AbsMono-0.63 AbsEos-0.02* AbsBaso-0.02 [MASKED] 04:35PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-138 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 [MASKED] 04:47PM URINE RBC-2 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 [MASKED] 04:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 04:47PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] DISCHARGE LABS ============== [MASKED] 07:34AM BLOOD WBC-7.8 RBC-3.65* Hgb-10.9* Hct-33.1* MCV-91 MCH-29.9 MCHC-32.9 RDW-13.2 RDWSD-43.7 Plt [MASKED] [MASKED] 07:34AM BLOOD Glucose-118* UreaN-28* Creat-0.9 Na-135 K-3.9 Cl-102 HCO3-26 AnGap-11 [MASKED] 07:34AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0 IMAGING ======= [MASKED] CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial process. Small vessel disease with age related involutional change. [MASKED] CHEST (SINGLE VIEW) No acute intrathoracic process [MASKED] BILAT LOWER EXT VEINS IMPRESSION: 1. Nonocclusive thrombus in a single posterior tibial vein on the left. 2. No evidence of deep venous thrombosis in the right lower extremity veins. [MASKED] DX PELVIS & HIP UNILATE IMPRESSION: Minimally displaced and comminuted fractures involving the left superior and inferior pubic rami not significantly changed in overall appearance relative to prior examinations dated [MASKED]. No new fracture is seen. MICROBIOLOGY ============ UCx [MASKED] - consistent with skin flora BCx [MASKED] x 2, NGTD Brief Hospital Course: BRIEF SUMMARY ============== Mr. [MASKED] is a pleasant [MASKED] M s/p fall and fracture of the left inferior and superior pubic rami on [MASKED], who presented with ongoing pain hip pain and was noted to be confused while in the ED and was found to have a superficial clot of the right lower tibial vein. He was evaluated for causes of delirium with no obvious abnormality. The likely cause of his delirium was pain, medication effect (he was initially treated with oxycodone 2.5 mg for pain), lack of sleep (he did not sleep at all the night prior to his confusion), and being hospitalized in the setting of chronic small vessel disease of the brain. With normalization of his sleep-wake cycle, limiting sedating medications, and administration of fluids he had significant improvement in his mental status and was discharged to rehab. ACUTE ISSUES ============ #Delirium: The patient was noted to be confused upon waking the morning after being seen in the emergency department for continued hip pain in the setting of a pubic ramus fracture two weeks prior to admission. He was admitted to the medicine service, where he underwent a workup for causes of delirium. While on the floor, he exhibited waxing and waning of his mental status, ranging from A&Ox3 to somnolent and barely interactive. A general delirium workup was performed and was negative (see labs for further details). The likely cause of his delirium was a combination of pain, medication effect (he was initially treated with oxycodone 2.5 mg for pain), lack of sleep (he did not sleep at all the night prior to his confusion), and being hospitalized in the setting of chronic small vessel disease of the brain. He underwent a head CT in the ED, which was negative for acute findings. We acquired records from a stay at [MASKED]. [MASKED] in [MASKED] at which time he was evaluated for slowing of speech/movement with concern for [MASKED] Disease; an MRI brain from that stay showed enlarged cerebral ventricles, with question of NPH. Given that he was acutely delirious, had fallen recently, and was having incontinence while on the floor, we had our radiologists read the MRI from the outside hospital. They felt that there was no change in the size of his ventricles from this MRI versus his CT scan this admission. The patient was given fluids, Seroquel for sleep, and was put on delirium precautions with improvement in his mental status. He was discharged to rehab and will follow up at [MASKED] with a neurologist later in the month for further evaluation per the patient's wife. #TIBIAL VEIN THROMBOSIS: The patient has a superficial tibial vein thrombosis but with no evidence of DVT. No need to anticoagulate given superficiality of clot. #PELVIC FRACTURE: Sustained fracture of his superior and inferior left pelvic ramus on [MASKED], with no need for operative management per orthopedics. He went home with a walker but had continued pain so returned as above. His pain was initially treated with oxycodone 2.5 mg and standing tylenol, but the oxycodone was discontinued due to concern for worsening of his delirium as above. CHRONIC ISSUES #HYPERTENSION: The patient has a hx of HTN, controlled with PRN metoprolol per wife. On presentation to the floor, patient had SBP to 180 so was give 12.5 mg of PO captopril. He was placed on captopril 6.25 mg TID with improvement in pressures, however he did experience SBPs in the [MASKED] so his captopril was discontinued. He may need addition of an antihypertensive as an outpatient depending on his blood pressure control. #Normocytic anemia: Iron studies were performed and were consistent with anemia of chronic disease; his iron was wnl, TIBC low normal, and ferritin elevated. His H/H remained stable during his course TRANSITIONAL ISSUES =================== - The patient was noted to have labile blood pressures, with his initial SBP at 180. He was placed on captopril 6.25 mg TID with improvement in his pressures, but did experience a couple of SBPs in the [MASKED]. This medication was discontinued prior to discharge, and his blood pressures should be further evaluated with possible addition of antihypertensive medication. - The patient was noted to have a normocytic anemia with Hgbs in the [MASKED]. Iron studies were consistent with anemia of chronic disease - The patient was evaluated for possible [MASKED] disease at [MASKED] in [MASKED] after experiencing slowing of speech/movement. Per his wife, he has an appointment w/ neurology at [MASKED] on [MASKED] for further evaluation. - The patient was started on Seroquel 25 mg QHS for problems with sleep/wake cycle, however he experienced cognitive slowing so this was discontinued. He may be sensitive to antipsychotics given his possible [MASKED] Disease - Per the patient's PCP, he takes Sinemet [MASKED] 0.5 tab BID for ?[MASKED] Disease but the patient was reluctant to take any psychoactive medications due to concern for possible cognitive side-effects # CODE: Full # CONTACT: [MASKED], wife, [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Carbidopa-Levodopa ([MASKED]) 0.5 TAB PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID 5. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Vitamin D 1000 UNIT PO DAILY 4. Acetaminophen 650 mg PO Q6H 5. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID 6. Carbidopa-Levodopa ([MASKED]) 0.5 TAB PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: #delirium #Superficial tibial vein thrombosis #hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], you were admitted to the hospital after you were found to be confused while visiting the emergency department due to leg pain. We performed several tests to identify the cause of your confusion, but no cause was found. It is likely that your confusion was caused by a combination of pain, pain medications (which can be sedating), being in a different environment, lack of sleep, and having some chronic age-related brain changes. You were also found to have a small clot in your right leg, but this did not need treatment. You were seen by our physical therapists who recommended rehab. You were discharged to a rehab facility to help you get stronger. We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I10", "D649" ]	[ "R410: Disorientation, unspecified", "I82812: Embolism and thrombosis of superficial veins of left lower extremity", "I10: Essential (primary) hypertension", "S32592D: Other specified fracture of left pubis, subsequent encounter for fracture with routine healing", "W19XXXD: Unspecified fall, subsequent encounter", "D649: Anemia, unspecified", "G9340: Encephalopathy, unspecified" ]
10,046,679	28,668,282	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending: ___ Chief Complaint: stercoral perforation Major Surgical or Invasive Procedure: ___ Sigmoid resection, end colostomy History of Present Illness: Mr ___ is ___, PMH significant for erectile dysfunction (s/p inflatable penile prosthesis ___ years ago), CLL, severe respiratory compromise, Afib on coumadin, who presented to ___ ___ for abdominal distention, pain, and acute urinary retention. Patient relays that he has not voided since yesterday. Multiple catheterization attempts failed and urology was consulted for foley placement. This was performed without issues. Past Medical History: PAST MEDICAL HISTORY Allergic rhinitis Asthma Chronic lymphocytic leukemia HLD HTN Insomnia Sleep apnea Back pain with lumbar radiculopathy Shoulder pain Spinal stenosis Congestive heart failure Atrial fibrillation Restless leg syndrome PAST SURGICAL HISTORY Penile prostesis ___ years ago) Social History: ___ Family History: nc Physical Exam: Deceased Pertinent Results: N/A Brief Hospital Course: Mr. ___ was admitted on ___ for sterocoral perforation of unknown etiology. He underwent emergent sigmoid resection, end colostomy on the same date. His postoperative course was complicated by afib w/ RVR for which he was transferred to the ICU and placed on dilt gtt. He experienced some respiratory decline requiring solumedrol, BiPAP, and additional diuresis with Lasix. Over the preceding few days he became intermittently febrile and hypotensive requiring pressors, hypoxic requiring intubation and ventilator support. He was cdiff positive and treatment was initiated. The appropriate consult services' assistance were sought including renal, hematology. On the evening of ___ Mr. ___ worsening clinical status and goals of care were discussed with his wife and other family members present at bedside, and they made the decision to terminally extubate him, initiate CMO care, and start morphine gtt. He was pronounced dead appx 3 hours following extubation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 2. Temazepam 30 mg PO QHS:PRN insomnia 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 4. Bumetanide 1 mg PO BID 5. Gabapentin 200 mg PO QAM 6. Gabapentin 900 mg PO Q5PM 7. Gabapentin 900 mg PO QHS 8. azelastine 137 mcg (0.1 %) nasal DAILY 9. rOPINIRole 1 mg PO QPM 10. Warfarin 5 mg PO DAILY16 11. Mirtazapine 15 mg PO QHS 12. Tamsulosin 0.4 mg PO QHS 13. Simvastatin 10 mg PO QPM 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY 15. Diltiazem Extended-Release 120 mg PO DAILY 16. Montelukast 10 mg PO DAILY 17. Finasteride 5 mg PO DAILY 18. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Mild Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: NA Followup Instructions: ___	[ "K5721", "J9601", "I2699", "N170", "E870", "A047", "C9110", "I959", "K633", "I5032", "E872", "R7881", "I4891", "G2581", "I10", "I272", "Z7901", "J45909", "E785", "Z515", "G4733", "M4806", "N529", "Z9689", "Z9114", "K6389", "J45998", "Z781", "E875", "Z87891" ]	Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Chief Complaint: stercoral perforation Major Surgical or Invasive Procedure: [MASKED] Sigmoid resection, end colostomy History of Present Illness: Mr [MASKED] is [MASKED], PMH significant for erectile dysfunction (s/p inflatable penile prosthesis [MASKED] years ago), CLL, severe respiratory compromise, Afib on coumadin, who presented to [MASKED] [MASKED] for abdominal distention, pain, and acute urinary retention. Patient relays that he has not voided since yesterday. Multiple catheterization attempts failed and urology was consulted for foley placement. This was performed without issues. Past Medical History: PAST MEDICAL HISTORY Allergic rhinitis Asthma Chronic lymphocytic leukemia HLD HTN Insomnia Sleep apnea Back pain with lumbar radiculopathy Shoulder pain Spinal stenosis Congestive heart failure Atrial fibrillation Restless leg syndrome PAST SURGICAL HISTORY Penile prostesis [MASKED] years ago) Social History: [MASKED] Family History: nc Physical Exam: Deceased Pertinent Results: N/A Brief Hospital Course: Mr. [MASKED] was admitted on [MASKED] for sterocoral perforation of unknown etiology. He underwent emergent sigmoid resection, end colostomy on the same date. His postoperative course was complicated by afib w/ RVR for which he was transferred to the ICU and placed on dilt gtt. He experienced some respiratory decline requiring solumedrol, BiPAP, and additional diuresis with Lasix. Over the preceding few days he became intermittently febrile and hypotensive requiring pressors, hypoxic requiring intubation and ventilator support. He was cdiff positive and treatment was initiated. The appropriate consult services' assistance were sought including renal, hematology. On the evening of [MASKED] Mr. [MASKED] worsening clinical status and goals of care were discussed with his wife and other family members present at bedside, and they made the decision to terminally extubate him, initiate CMO care, and start morphine gtt. He was pronounced dead appx 3 hours following extubation. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 2. Temazepam 30 mg PO QHS:PRN insomnia 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 4. Bumetanide 1 mg PO BID 5. Gabapentin 200 mg PO QAM 6. Gabapentin 900 mg PO Q5PM 7. Gabapentin 900 mg PO QHS 8. azelastine 137 mcg (0.1 %) nasal DAILY 9. rOPINIRole 1 mg PO QPM 10. Warfarin 5 mg PO DAILY16 11. Mirtazapine 15 mg PO QHS 12. Tamsulosin 0.4 mg PO QHS 13. Simvastatin 10 mg PO QPM 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY 15. Diltiazem Extended-Release 120 mg PO DAILY 16. Montelukast 10 mg PO DAILY 17. Finasteride 5 mg PO DAILY 18. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Mild Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: NA Followup Instructions: [MASKED]	[]	[ "J9601", "I5032", "E872", "I4891", "I10", "Z7901", "J45909", "E785", "Z515", "G4733", "Z87891" ]	[ "K5721: Diverticulitis of large intestine with perforation and abscess with bleeding", "J9601: Acute respiratory failure with hypoxia", "I2699: Other pulmonary embolism without acute cor pulmonale", "N170: Acute kidney failure with tubular necrosis", "E870: Hyperosmolality and hypernatremia", "A047: Enterocolitis due to Clostridium difficile", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "I959: Hypotension, unspecified", "K633: Ulcer of intestine", "I5032: Chronic diastolic (congestive) heart failure", "E872: Acidosis", "R7881: Bacteremia", "I4891: Unspecified atrial fibrillation", "G2581: Restless legs syndrome", "I10: Essential (primary) hypertension", "I272: Other secondary pulmonary hypertension", "Z7901: Long term (current) use of anticoagulants", "J45909: Unspecified asthma, uncomplicated", "E785: Hyperlipidemia, unspecified", "Z515: Encounter for palliative care", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M4806: Spinal stenosis, lumbar region", "N529: Male erectile dysfunction, unspecified", "Z9689: Presence of other specified functional implants", "Z9114: Patient's other noncompliance with medication regimen", "K6389: Other specified diseases of intestine", "J45998: Other asthma", "Z781: Physical restraint status", "E875: Hyperkalemia", "Z87891: Personal history of nicotine dependence" ]
10,046,724	25,792,614	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending: ___ Chief Complaint: Found AMS Major Surgical or Invasive Procedure: ___ Left Craniotomy for subdural hematoma evacuation. History of Present Illness: ___ M with Hx of alcohol abuse, was found altered by his friend on the morning of ___ with Right sided weakness. He was brought to ___ where a CT brain was obtained which demonstrated an acute L SDH with max diameter 2cm and 1cm midline shift. EtOH 240, was transferred to ___. Past Medical History: EtOH abuse Social History: ___ Family History: noncontributory Physical Exam: ON ADMISSION: GCS 12 right facial weakness tongue protrudes midline speech slurred, confused follows commands RUE ___, RLE ___ LUE ___, LL%E ___ Babinski + R tremorous ON DISCHARGE: Alert, oriented x3 PERRL. EOMI. ___. TML. Strength ___ throughout Sensation grossly intact no pronator drift left crani incision c/d/I - staples removed. no erythema or discharge Pertinent Results: Please refer to OMR for pertinent imaging and lab results. Brief Hospital Course: ___ is a ___ year old male who was transferred from ___. ___, after being found with altered mental status, and new CT findings of Left subdural hematoma. #Left subdural hematoma Mr. ___ was transferred from ___ on ___ with CT findings of Left SDH max diameter 2mm with 1mm midline shift. Patient's ___ score was 12 at initial presentation. Patient was intubated, and it was determined that the patient needed emergent surgical intervention, and he was immediately taken to the OR that day for a Left Craniotomy and Subdural Hematoma Evacuation with a JP drain placed intra-operatively. Mr. ___ was transferred to the Neuro ICU post-operativly for further management and was started on Keppra for seizure prophylaxis. On ___ Mr. ___ was extubated and JP drain was removed with no complications. Patient remained neuro intact and was transferred out of the ICU to the neurosurgery floor on ___. Mr. ___ remained stable through the rest of his admission. He was evaluated by ___ and OT who recommended him to be discharge home with ___ services. Patient was medically cleared for discharge home on ___. Staples were removed prior to discharge - incision remained c/d/I. #EtOH withdrawal At the time of admission patient blood alcohol content was 240. Once patient was neurosurgically stable, he was started on multivitamins, thiamine and folic acid. Patient was started on phenobarbital before coming out of the ICU for withdrawals. Mr. ___ continued on a phenobarbital taper ___ and remained medically stable. #Anxiety Mr. ___ continues to take his home Valproic Acid for management of anxiety during his admission. Medications on Admission: Divalproex, Gabapentin, Trazodone Discharge Medications: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q4H:PRN Headache RX butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) by mouth every 4 hours as needed Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth pain, headache Disp #32 Tablet Refills:0 5. Senna 8.6 mg PO BID:PRN constipation 6. Gabapentin 300 mg PO TID 7. Valproic Acid ___ mg PO ASDIR 250mg qAM, 250mg at 3pm, 500mg qHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subdural Hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery You underwent a surgery called a craniotomy to have blood removed from your brain. Your staples were removed prior to discharge. You may shower. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptoms after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___	[ "S065X0A", "G935", "F10239", "I10", "Y929", "W19XXXA", "R29810", "R4781", "R531", "D649", "Z23", "F17200", "F419", "G4700" ]	Allergies: Penicillins Chief Complaint: Found AMS Major Surgical or Invasive Procedure: [MASKED] Left Craniotomy for subdural hematoma evacuation. History of Present Illness: [MASKED] M with Hx of alcohol abuse, was found altered by his friend on the morning of [MASKED] with Right sided weakness. He was brought to [MASKED] where a CT brain was obtained which demonstrated an acute L SDH with max diameter 2cm and 1cm midline shift. EtOH 240, was transferred to [MASKED]. Past Medical History: EtOH abuse Social History: [MASKED] Family History: noncontributory Physical Exam: ON ADMISSION: GCS 12 right facial weakness tongue protrudes midline speech slurred, confused follows commands RUE [MASKED], RLE [MASKED] LUE [MASKED], LL%E [MASKED] Babinski + R tremorous ON DISCHARGE: Alert, oriented x3 PERRL. EOMI. [MASKED]. TML. Strength [MASKED] throughout Sensation grossly intact no pronator drift left crani incision c/d/I - staples removed. no erythema or discharge Pertinent Results: Please refer to OMR for pertinent imaging and lab results. Brief Hospital Course: [MASKED] is a [MASKED] year old male who was transferred from [MASKED]. [MASKED], after being found with altered mental status, and new CT findings of Left subdural hematoma. #Left subdural hematoma Mr. [MASKED] was transferred from [MASKED] on [MASKED] with CT findings of Left SDH max diameter 2mm with 1mm midline shift. Patient's [MASKED] score was 12 at initial presentation. Patient was intubated, and it was determined that the patient needed emergent surgical intervention, and he was immediately taken to the OR that day for a Left Craniotomy and Subdural Hematoma Evacuation with a JP drain placed intra-operatively. Mr. [MASKED] was transferred to the Neuro ICU post-operativly for further management and was started on Keppra for seizure prophylaxis. On [MASKED] Mr. [MASKED] was extubated and JP drain was removed with no complications. Patient remained neuro intact and was transferred out of the ICU to the neurosurgery floor on [MASKED]. Mr. [MASKED] remained stable through the rest of his admission. He was evaluated by [MASKED] and OT who recommended him to be discharge home with [MASKED] services. Patient was medically cleared for discharge home on [MASKED]. Staples were removed prior to discharge - incision remained c/d/I. #EtOH withdrawal At the time of admission patient blood alcohol content was 240. Once patient was neurosurgically stable, he was started on multivitamins, thiamine and folic acid. Patient was started on phenobarbital before coming out of the ICU for withdrawals. Mr. [MASKED] continued on a phenobarbital taper [MASKED] and remained medically stable. #Anxiety Mr. [MASKED] continues to take his home Valproic Acid for management of anxiety during his admission. Medications on Admission: Divalproex, Gabapentin, Trazodone Discharge Medications: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q4H:PRN Headache RX butalbital-acetaminophen-caff 50 mg-325 mg-40 mg [MASKED] tablet(s) by mouth every 4 hours as needed Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg [MASKED] tablet(s) by mouth pain, headache Disp #32 Tablet Refills:0 5. Senna 8.6 mg PO BID:PRN constipation 6. Gabapentin 300 mg PO TID 7. Valproic Acid [MASKED] mg PO ASDIR 250mg qAM, 250mg at 3pm, 500mg qHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Subdural Hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery You underwent a surgery called a craniotomy to have blood removed from your brain. Your staples were removed prior to discharge. You may shower. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. [MASKED] try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptoms after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at [MASKED] for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call [MASKED] and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: [MASKED]	[]	[ "I10", "Y929", "D649", "F419", "G4700" ]	[ "S065X0A: Traumatic subdural hemorrhage without loss of consciousness, initial encounter", "G935: Compression of brain", "F10239: Alcohol dependence with withdrawal, unspecified", "I10: Essential (primary) hypertension", "Y929: Unspecified place or not applicable", "W19XXXA: Unspecified fall, initial encounter", "R29810: Facial weakness", "R4781: Slurred speech", "R531: Weakness", "D649: Anemia, unspecified", "Z23: Encounter for immunization", "F17200: Nicotine dependence, unspecified, uncomplicated", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified" ]
10,047,118	21,978,955	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Aspirin / Meperidine / Gabapentin / Wellbutrin / Nsaids / hydromorphone / ibuprofen / ceftriaxone / atorvastatin / bupropriom Attending: ___ Chief Complaint: Diffuse stiffness and musculoskeletal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___, with RA (on intermittent prednisone), IDDM, who presents with diffuse musculoskeletal joint pain x 3 weeks. She reports that her RA is worse than usual. In the past three weeks, she has recently visited ___ to help manage her RA. Her most recent admission to ___ was for ___ days for steroid-induced hyperglycemia. Upon discharge on ___, she was asked to continue taking prednisone however she reports not taking any prednisone since this time. (She was on 10mg prednisone during her hospital stay). She says that she was using tramadol, which has not resolved her pain. She was unable to walk this AM upon wakening. She reports that upon coming to the hospital, she had ___ bodily pain. She clarifies that she has joint pain in her elbows, wrists, knees, and feet. She has left knee swelling that started 2 weeks ago. She describes intermittent swelling of her joints in the past. She describes generalized joint stiffness. She has muscle pain in her arms. She was seen yesterday in the ___ ED for arm injury. She reports diffuse stiffness in her joints. She denies a history of trauma. She reports blurry vision, that resolved with insulin (however, she did not receive any insulin in the ED and per the ED note, her blurry vision resolved with fluids). She reports a headache. She does feel nausea that started yesterday, and did have an episode of emesis before coming to the hospital. She does not currently feel chest pain, shortness of breath. She has no cough. She does not feel chills, but per what was told to her during hospital admissions, she has had low-grade temperatures. Her last BM was yesterday- she has on average, ___ BMs/day. Her last meal was this evening. She has not had any urinary output today (she says she has had an overactive bladder in the past three weeks). She reports being sweaty ___. She reports that she has had a rash around her neck "forever", and that a component of photosensitivity is involved. She reports that she first noticed the rash on her face a week ago, after putting on a cream. Of note, the patient was somnolent during the HPI, as she had just received morphine in the ED, and it was difficult to elicit reliable history. For example, she describes that she was not prescribed prednisone upon being discharged from ___, but she was prescribed 10 mg prednisone. She has not had taken her home medications prior to admission. In the ED, initial VS were 97.8F, 96 HR, 18 RR, 114/68, 100% sat on RA. Exam notable for left knee swelling. Labs showed FSGS 236. LFTs were notable for AST 57, AP 155 , Alb 3.3. K+ normal @ 4.1. No imaging taken. She received IV morphine sulfate 4mg x2, IV Zofran 4mg, IV NS (500 mL), tramadol 50 mg. Transfer VS were 97.5, 81 HR, 125/78, RR 18, 95% RA. On arrival to the floor, patient reports that her pain is well-controlled and asked for some ginger ale. Past Medical History: Rheumatoid Arthritis HFrEF s/p ICD HTN IDDM Obesity ADHD Depression Dermatitis ___ MTX NASH Hepatitis A Arthralgias of hand R then L ___ Carpal tunnel syndrom ___ HLD Hypertrygliceridemia Social History: ___ Family History: No autoimmune disorders, no RA Mother and brother-DM and CAD Father- CAD, colon cancer Physical Exam: ================================ ADMISSION EXAM: ================================ VS: 97.7 ___ 20 92 Ra General: NAD, laying supine, snoring, obese HEENT: EOMI (grossly intact), pinpoint pupils, anicteric sclera, dry mucous membranes NECK: supple, thick soft neck folds HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB anterior and posteriorly, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses on R, but not left, 2+ pulses radially NEURO: moving all 4 extremities spontaneously MSK: Left knee swelling, nontender, nonerythematous Hands: No ulnar deviation, L ___ digit swan neck deviation. PIP enlarged, tender to palpation. SKIN: warm and well perfused, no excoriations or lesions, erythematous rash over neck/shoulders. nasal sparing malar rash. ================================ DISCHARGE EXAM: ================================ Vitals: 97.9 120 / 72 69 18 93%Ra General: NAD, laying supine HEENT: EOMI grossly intact, dry mucous membranes NECK: supple, JVP 8-9cm HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Good air movement bilaterally, rales at L lung base, none on right. No wheezes or rhonchi. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding. EXTREMITIES: boggy synovia still noted at MCP's and PIP's bilaterally, contracture of ___ digit on L hand, No ulnar deviation, L ___ digit swan neck deviation. PULSES: 2+ DP pulses on R, but not left, 2+ pulses radially NEURO: moving all 4 extremities spontaneously MSK: Improved left knee swelling with minimal effusion, nontender, nonerythematous SKIN: Erythematous over neck/shoulders. No extensor surface nodules noted. Warm and well perfused, no excoriations or lesions, nasal sparing malar rash. Pertinent Results: ==================================== ADMISSION LABS: ==================================== ___ 03:03PM BLOOD WBC-6.7 RBC-4.72 Hgb-13.1 Hct-41.6 MCV-88 MCH-27.8 MCHC-31.5* RDW-14.0 RDWSD-45.4 Plt ___ ___ 03:03PM BLOOD Neuts-67 Bands-0 ___ Monos-10 Eos-3 Baso-0 ___ Metas-1* Myelos-0 Im ___ AbsNeut-4.49 AbsLymp-1.27 AbsMono-0.67 AbsEos-0.20 AbsBaso-0.00* ___ 03:03PM BLOOD Glucose-235* UreaN-12 Creat-0.5 Na-134 K-7.3* Cl-97 HCO3-23 AnGap-14 ___ 03:03PM BLOOD ALT-29 AST-57* AlkPhos-155* TotBili-0.6 ___ 03:03PM BLOOD Albumin-3.3* ==================================== INTERVAL LABS: ==================================== ___ 06:25AM BLOOD ALT-22 AST-13 LD(___)-201 CK(CPK)-16* AlkPhos-151* TotBili-0.5 ___ 06:25AM BLOOD CRP-99.3* ___ 06:25AM BLOOD TSH-0.40 ==================================== DISCHARGE LABS: ==================================== ___ 07:20AM BLOOD WBC-7.5 RBC-4.67 Hgb-13.2 Hct-40.8 MCV-87 MCH-28.3 MCHC-32.4 RDW-14.2 RDWSD-45.1 Plt ___ ___ 07:20AM BLOOD Glucose-125* UreaN-19 Creat-0.6 Na-143 K-3.7 Cl-98 HCO3-26 AnGap-19* ___ 07:20AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.9 ==================================== IMAGING: ==================================== None ==================================== MICROBIOLOGY: ==================================== None Brief Hospital Course: ======================= BRIEF SUMMARY ======================= ___ is a ___ year old woman with a history of rheumatoid arthritis (on prednisone, formerly on abatacept), diabetes mellitus type II (insulin-dependent, poorly controlled), congestive heart failure (EF 46%, s/p ICD), recently discharged from ___ for hyperglycemia, presenting with a 1 day history of diffuse musculoskeletal pain and uncertain adherence to home prednisone, concerning for an RA flare. She was treated with 10mg oral Prednisone, her pain was well managed with a combination of tramadol and acetaminophen. On admission she was also found to be hypervolemic from her CHF and was diuresed until she back to her estimate dry weight. Her weight on discharge was 204lbs. ======================== PROBLEM-BASED SUMMARY ======================== # Rhematoid artritis # Acute on Chronic Diffuse Muscle and Joint pain Patient presented with significant polyarticular pain (fingers, wrists, knees) in the setting of unclear prednisone use at home, making an RA flare the most likely etiology. She recently had to discontinue taking her abatacept due to insurance coverage and inability to afford it. She is followed as an outpatient by Dr. ___ at ___ (___), diagnostic serologies are not available in the ___ system (prior ___ positive only to 1:40). Unclear history of other DMARD trials. Other relevant labs included: CRP 90, TSH wnl, CK 16 (low). She was treated with her outpatient regimen of Prednisone 10mg PO, and given her appropriate response she was not given a pulse dose of steroids. Her pain was well controlled with Tramadol 50mg q6h PRN (typically required 3 doses/day) and acetaminophen (limited to 2g/day given history of NASH). - Will require re-evaluation of RA management as an outpatient given recent hospitalizations for glycemic control and comorbid CHF # HFrEF s/p ICD: LVEF was 46% in ___ dry weight 204lb. On admission she was found on exam to be volume up and was diuresed with Lasix 20mg IV dialy - TID over the course of her stay. When transitioned to oral form, her Lasix was increased to 30mg PO qd. She was otherwise discharged on her home medication regimen which also includes metoprolol and spironolactone. - Furosemide dose increased to 30mg PO qD - Discharge weight (dry weight): 204 lbs # Urinary retention: On Hospital Day #1 she was found to have 1L of retained urine on bladder scan, likely due to oxycodone administered overnight for pain. She was switched to tramadol for pain control and did not have any further episodes of retention. # Diabetes Mellitus, Type II- Insulin dependent # Hyperglycemia Her last A1C was 12% and she was recently admitted to ___ ___ for steroid-induced hyperglycemia (discharge ___. Her home regimen of glargine 60u qHS and Humalog 20u TID was adjusted while inpatient to glargine 45u + Humalog 15u TID, while receiving steroid therapy. Given her steroid use for her RA and poorly controlled blood glucose at home, she will require closer follow up for her diabetes management. - Discharge insulin regimen: Glargine 45u qHS + Humalog 15u TID with meals. ======================== TRANSITIONAL ISSUES: ======================== DISCHARGE DRY WEIGHT: 204 lb DISCHARGE DIURETIC: 30mg Lasix PO daily - Follow up with Primary Care Physician regarding titration of medications for CHF and management of diabetes (CHF management also being managed with cardiologist). Changes made to medications: 1) Furosemide increased from 20mg PO to 30mg PO 2) Insulin regimen: 15u Humalog TID + 45u glargine qHS (pre-admission regimen 20u Humalog TID + 60u glargine qHS) 3) Would recheck chem 10 on current PO dose of furosemide to ensure no overdiuresis 4) Consider connecting to an outpatient therapist for support in the setting of multiple life stressors, including loss of three family members in the last six months (patient identifies the stress of these events as having an influence on recent ___ medical conditions). 5) Consider sleep study for OSA and exploration of CPAP options to which patient may be more agreeable. 6) Ongoing titration of insulin - Follow up with OP Rheumatologist ___: 1) financial assistance options in order to reinitiate treatment with Orencia. 2) consideration of other long-term steroid-sparing management of RA if unable to get financial assistance for orencia; patient currently being discharged on standing prednisone for control - Follow up with OP cardiologist: 1) Ongoing titration of outpatient furosemide, with consideration of concurrent changes which will be made in steroid dosing for RA management # Code status: Full code (presumed) # Contact: ___ (husband) Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Spironolactone 25 mg PO DAILY 2. PredniSONE 10 mg PO DAILY 3. Nystatin-Triamcinolone Ointment 1 Appl TP BID:PRN To affected area 4. MetFORMIN (Glucophage) 500 mg PO TAKE 2 TABS (1000) IN THE AM AND ONE TAB IN THE ___ 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Citalopram 40 mg PO DAILY 9. Fenofibrate 200 mg PO DAILY 10. Magnesium Oxide 400 mg PO ONCE 11. Levothyroxine Sodium 25 mcg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Glargine 60 Units Bedtime Humalog 20 Units Breakfast Humalog 20 Units Lunch Humalog 20 Units Dinner 14. Furosemide 20 mg PO DAILY 15. LORazepam 0.5 mg PO Q8H:PRN Anxiety Discharge Medications: 1. Acetaminophen 1000 mg PO BID Please do not exceed 2 grams of acetaminophen per day. RX acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours Disp #40 Tablet Refills:0 2. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN RX tramadol 50 mg 1 tablet(s) by mouth every 6 hours as needed Disp #20 Tablet Refills:0 3. Furosemide 30 mg PO DAILY RX furosemide [Lasix] 20 mg 1.5 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Glargine 45 Units Bedtime Humalog 15 Units Breakfast Humalog 15 Units Lunch Humalog 15 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Atorvastatin 80 mg PO QPM 6. Citalopram 40 mg PO DAILY 7. Fenofibrate 200 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Levothyroxine Sodium 25 mcg PO DAILY 10. Lisinopril 10 mg PO DAILY 11. LORazepam 0.5 mg PO Q8H:PRN Anxiety 12. Magnesium Oxide 400 mg PO ONCE 13. MetFORMIN (Glucophage) 500 mg PO TAKE 2 TABS (1000) IN THE AM AND ONE TAB IN THE ___ 14. Metoprolol Succinate XL 100 mg PO DAILY 15. Nystatin-Triamcinolone Ointment 1 Appl TP BID:PRN To affected area 16. PredniSONE 10 mg PO DAILY RX prednisone 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 17. Spironolactone 25 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ================= PRIMARY DIAGNOSIS ================= Rheumatoid Arthritis exacerbation =================== SECONDARY DIAGNOSES =================== Congestive Heart Failure (EF 46%) acute exacerbation Diabetes Mellitus, type II- insulin dependent Urinary retention 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 taking care of you at ___. Please see below for information on your time in the hospital. ================================ WHY WAS I IN THE HOSPITAL? ================================ - You came to the hospital because you were having intense joint pain due to a rheumatoid arthritis flare, and were also found to have some extra retained fluid from you congestive heart failure. ================================ WHAT HAPPENED IN THE HOSPITAL? ================================ - You were given oral steroids (prednisone) and pain medication (tramadol and acetaminophen) to treat your arthritis and to control your pain. - You were given intravenous diuretics to treat your heart failure by removing some of the extra volume and help you breathe easier. ================================ WHAT SHOULD I DO WHEN I GO HOME? ================================ - Take your medications are prescribed. - Please follow up with your Primary Care Doctor, ___, and endocrinologist (appointments listed below) - Please check your weight at the same time each morning, after urinating and before breakfast, and notify your cardiologist if you are greater than 3lbs above or below your dry weight of 205 lbs. - Continue taking your discharge regimen of 15u Humalog three times daily + 45u glargine nightly. If your blood sugars are repeatedly high on measurement (>300), please go back to your pre-admission regimen of 20u Humalog 3x/daily and 60u glargine nightly. We wish you the best! -Your Care Team at ___ Followup Instructions: ___	[ "M0689", "I5023", "I110", "E1165", "Z794", "T380X5A", "Y9289", "F909", "K219", "E860", "E039", "K7581", "E669", "Z6838", "E781", "R330", "T402X5A", "Y92230", "Z95810" ]	Allergies: Aspirin / Meperidine / Gabapentin / Wellbutrin / Nsaids / hydromorphone / ibuprofen / ceftriaxone / atorvastatin / bupropriom Chief Complaint: Diffuse stiffness and musculoskeletal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED], with RA (on intermittent prednisone), IDDM, who presents with diffuse musculoskeletal joint pain x 3 weeks. She reports that her RA is worse than usual. In the past three weeks, she has recently visited [MASKED] to help manage her RA. Her most recent admission to [MASKED] was for [MASKED] days for steroid-induced hyperglycemia. Upon discharge on [MASKED], she was asked to continue taking prednisone however she reports not taking any prednisone since this time. (She was on 10mg prednisone during her hospital stay). She says that she was using tramadol, which has not resolved her pain. She was unable to walk this AM upon wakening. She reports that upon coming to the hospital, she had [MASKED] bodily pain. She clarifies that she has joint pain in her elbows, wrists, knees, and feet. She has left knee swelling that started 2 weeks ago. She describes intermittent swelling of her joints in the past. She describes generalized joint stiffness. She has muscle pain in her arms. She was seen yesterday in the [MASKED] ED for arm injury. She reports diffuse stiffness in her joints. She denies a history of trauma. She reports blurry vision, that resolved with insulin (however, she did not receive any insulin in the ED and per the ED note, her blurry vision resolved with fluids). She reports a headache. She does feel nausea that started yesterday, and did have an episode of emesis before coming to the hospital. She does not currently feel chest pain, shortness of breath. She has no cough. She does not feel chills, but per what was told to her during hospital admissions, she has had low-grade temperatures. Her last BM was yesterday- she has on average, [MASKED] BMs/day. Her last meal was this evening. She has not had any urinary output today (she says she has had an overactive bladder in the past three weeks). She reports being sweaty [MASKED]. She reports that she has had a rash around her neck "forever", and that a component of photosensitivity is involved. She reports that she first noticed the rash on her face a week ago, after putting on a cream. Of note, the patient was somnolent during the HPI, as she had just received morphine in the ED, and it was difficult to elicit reliable history. For example, she describes that she was not prescribed prednisone upon being discharged from [MASKED], but she was prescribed 10 mg prednisone. She has not had taken her home medications prior to admission. In the ED, initial VS were 97.8F, 96 HR, 18 RR, 114/68, 100% sat on RA. Exam notable for left knee swelling. Labs showed FSGS 236. LFTs were notable for AST 57, AP 155 , Alb 3.3. K+ normal @ 4.1. No imaging taken. She received IV morphine sulfate 4mg x2, IV Zofran 4mg, IV NS (500 mL), tramadol 50 mg. Transfer VS were 97.5, 81 HR, 125/78, RR 18, 95% RA. On arrival to the floor, patient reports that her pain is well-controlled and asked for some ginger ale. Past Medical History: Rheumatoid Arthritis HFrEF s/p ICD HTN IDDM Obesity ADHD Depression Dermatitis [MASKED] MTX NASH Hepatitis A Arthralgias of hand R then L [MASKED] Carpal tunnel syndrom [MASKED] HLD Hypertrygliceridemia Social History: [MASKED] Family History: No autoimmune disorders, no RA Mother and brother-DM and CAD Father- CAD, colon cancer Physical Exam: ================================ ADMISSION EXAM: ================================ VS: 97.7 [MASKED] 20 92 Ra General: NAD, laying supine, snoring, obese HEENT: EOMI (grossly intact), pinpoint pupils, anicteric sclera, dry mucous membranes NECK: supple, thick soft neck folds HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB anterior and posteriorly, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses on R, but not left, 2+ pulses radially NEURO: moving all 4 extremities spontaneously MSK: Left knee swelling, nontender, nonerythematous Hands: No ulnar deviation, L [MASKED] digit swan neck deviation. PIP enlarged, tender to palpation. SKIN: warm and well perfused, no excoriations or lesions, erythematous rash over neck/shoulders. nasal sparing malar rash. ================================ DISCHARGE EXAM: ================================ Vitals: 97.9 120 / 72 69 18 93%Ra General: NAD, laying supine HEENT: EOMI grossly intact, dry mucous membranes NECK: supple, JVP 8-9cm HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Good air movement bilaterally, rales at L lung base, none on right. No wheezes or rhonchi. ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding. EXTREMITIES: boggy synovia still noted at MCP's and PIP's bilaterally, contracture of [MASKED] digit on L hand, No ulnar deviation, L [MASKED] digit swan neck deviation. PULSES: 2+ DP pulses on R, but not left, 2+ pulses radially NEURO: moving all 4 extremities spontaneously MSK: Improved left knee swelling with minimal effusion, nontender, nonerythematous SKIN: Erythematous over neck/shoulders. No extensor surface nodules noted. Warm and well perfused, no excoriations or lesions, nasal sparing malar rash. Pertinent Results: ==================================== ADMISSION LABS: ==================================== [MASKED] 03:03PM BLOOD WBC-6.7 RBC-4.72 Hgb-13.1 Hct-41.6 MCV-88 MCH-27.8 MCHC-31.5* RDW-14.0 RDWSD-45.4 Plt [MASKED] [MASKED] 03:03PM BLOOD Neuts-67 Bands-0 [MASKED] Monos-10 Eos-3 Baso-0 [MASKED] Metas-1* Myelos-0 Im [MASKED] AbsNeut-4.49 AbsLymp-1.27 AbsMono-0.67 AbsEos-0.20 AbsBaso-0.00* [MASKED] 03:03PM BLOOD Glucose-235* UreaN-12 Creat-0.5 Na-134 K-7.3* Cl-97 HCO3-23 AnGap-14 [MASKED] 03:03PM BLOOD ALT-29 AST-57* AlkPhos-155* TotBili-0.6 [MASKED] 03:03PM BLOOD Albumin-3.3* ==================================== INTERVAL LABS: ==================================== [MASKED] 06:25AM BLOOD ALT-22 AST-13 LD([MASKED])-201 CK(CPK)-16* AlkPhos-151* TotBili-0.5 [MASKED] 06:25AM BLOOD CRP-99.3* [MASKED] 06:25AM BLOOD TSH-0.40 ==================================== DISCHARGE LABS: ==================================== [MASKED] 07:20AM BLOOD WBC-7.5 RBC-4.67 Hgb-13.2 Hct-40.8 MCV-87 MCH-28.3 MCHC-32.4 RDW-14.2 RDWSD-45.1 Plt [MASKED] [MASKED] 07:20AM BLOOD Glucose-125* UreaN-19 Creat-0.6 Na-143 K-3.7 Cl-98 HCO3-26 AnGap-19* [MASKED] 07:20AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.9 ==================================== IMAGING: ==================================== None ==================================== MICROBIOLOGY: ==================================== None Brief Hospital Course: ======================= BRIEF SUMMARY ======================= [MASKED] is a [MASKED] year old woman with a history of rheumatoid arthritis (on prednisone, formerly on abatacept), diabetes mellitus type II (insulin-dependent, poorly controlled), congestive heart failure (EF 46%, s/p ICD), recently discharged from [MASKED] for hyperglycemia, presenting with a 1 day history of diffuse musculoskeletal pain and uncertain adherence to home prednisone, concerning for an RA flare. She was treated with 10mg oral Prednisone, her pain was well managed with a combination of tramadol and acetaminophen. On admission she was also found to be hypervolemic from her CHF and was diuresed until she back to her estimate dry weight. Her weight on discharge was 204lbs. ======================== PROBLEM-BASED SUMMARY ======================== # Rhematoid artritis # Acute on Chronic Diffuse Muscle and Joint pain Patient presented with significant polyarticular pain (fingers, wrists, knees) in the setting of unclear prednisone use at home, making an RA flare the most likely etiology. She recently had to discontinue taking her abatacept due to insurance coverage and inability to afford it. She is followed as an outpatient by Dr. [MASKED] at [MASKED] ([MASKED]), diagnostic serologies are not available in the [MASKED] system (prior [MASKED] positive only to 1:40). Unclear history of other DMARD trials. Other relevant labs included: CRP 90, TSH wnl, CK 16 (low). She was treated with her outpatient regimen of Prednisone 10mg PO, and given her appropriate response she was not given a pulse dose of steroids. Her pain was well controlled with Tramadol 50mg q6h PRN (typically required 3 doses/day) and acetaminophen (limited to 2g/day given history of NASH). - Will require re-evaluation of RA management as an outpatient given recent hospitalizations for glycemic control and comorbid CHF # HFrEF s/p ICD: LVEF was 46% in [MASKED] dry weight 204lb. On admission she was found on exam to be volume up and was diuresed with Lasix 20mg IV dialy - TID over the course of her stay. When transitioned to oral form, her Lasix was increased to 30mg PO qd. She was otherwise discharged on her home medication regimen which also includes metoprolol and spironolactone. - Furosemide dose increased to 30mg PO qD - Discharge weight (dry weight): 204 lbs # Urinary retention: On Hospital Day #1 she was found to have 1L of retained urine on bladder scan, likely due to oxycodone administered overnight for pain. She was switched to tramadol for pain control and did not have any further episodes of retention. # Diabetes Mellitus, Type II- Insulin dependent # Hyperglycemia Her last A1C was 12% and she was recently admitted to [MASKED] [MASKED] for steroid-induced hyperglycemia (discharge [MASKED]. Her home regimen of glargine 60u qHS and Humalog 20u TID was adjusted while inpatient to glargine 45u + Humalog 15u TID, while receiving steroid therapy. Given her steroid use for her RA and poorly controlled blood glucose at home, she will require closer follow up for her diabetes management. - Discharge insulin regimen: Glargine 45u qHS + Humalog 15u TID with meals. ======================== TRANSITIONAL ISSUES: ======================== DISCHARGE DRY WEIGHT: 204 lb DISCHARGE DIURETIC: 30mg Lasix PO daily - Follow up with Primary Care Physician regarding titration of medications for CHF and management of diabetes (CHF management also being managed with cardiologist). Changes made to medications: 1) Furosemide increased from 20mg PO to 30mg PO 2) Insulin regimen: 15u Humalog TID + 45u glargine qHS (pre-admission regimen 20u Humalog TID + 60u glargine qHS) 3) Would recheck chem 10 on current PO dose of furosemide to ensure no overdiuresis 4) Consider connecting to an outpatient therapist for support in the setting of multiple life stressors, including loss of three family members in the last six months (patient identifies the stress of these events as having an influence on recent [MASKED] medical conditions). 5) Consider sleep study for OSA and exploration of CPAP options to which patient may be more agreeable. 6) Ongoing titration of insulin - Follow up with OP Rheumatologist [MASKED]: 1) financial assistance options in order to reinitiate treatment with Orencia. 2) consideration of other long-term steroid-sparing management of RA if unable to get financial assistance for orencia; patient currently being discharged on standing prednisone for control - Follow up with OP cardiologist: 1) Ongoing titration of outpatient furosemide, with consideration of concurrent changes which will be made in steroid dosing for RA management # Code status: Full code (presumed) # Contact: [MASKED] (husband) Phone: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Spironolactone 25 mg PO DAILY 2. PredniSONE 10 mg PO DAILY 3. Nystatin-Triamcinolone Ointment 1 Appl TP BID:PRN To affected area 4. MetFORMIN (Glucophage) 500 mg PO TAKE 2 TABS (1000) IN THE AM AND ONE TAB IN THE [MASKED] 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Citalopram 40 mg PO DAILY 9. Fenofibrate 200 mg PO DAILY 10. Magnesium Oxide 400 mg PO ONCE 11. Levothyroxine Sodium 25 mcg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Glargine 60 Units Bedtime Humalog 20 Units Breakfast Humalog 20 Units Lunch Humalog 20 Units Dinner 14. Furosemide 20 mg PO DAILY 15. LORazepam 0.5 mg PO Q8H:PRN Anxiety Discharge Medications: 1. Acetaminophen 1000 mg PO BID Please do not exceed 2 grams of acetaminophen per day. RX acetaminophen 500 mg [MASKED] tablet(s) by mouth every 8 hours Disp #40 Tablet Refills:0 2. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN RX tramadol 50 mg 1 tablet(s) by mouth every 6 hours as needed Disp #20 Tablet Refills:0 3. Furosemide 30 mg PO DAILY RX furosemide [Lasix] 20 mg 1.5 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Glargine 45 Units Bedtime Humalog 15 Units Breakfast Humalog 15 Units Lunch Humalog 15 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Atorvastatin 80 mg PO QPM 6. Citalopram 40 mg PO DAILY 7. Fenofibrate 200 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Levothyroxine Sodium 25 mcg PO DAILY 10. Lisinopril 10 mg PO DAILY 11. LORazepam 0.5 mg PO Q8H:PRN Anxiety 12. Magnesium Oxide 400 mg PO ONCE 13. MetFORMIN (Glucophage) 500 mg PO TAKE 2 TABS (1000) IN THE AM AND ONE TAB IN THE [MASKED] 14. Metoprolol Succinate XL 100 mg PO DAILY 15. Nystatin-Triamcinolone Ointment 1 Appl TP BID:PRN To affected area 16. PredniSONE 10 mg PO DAILY RX prednisone 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 17. Spironolactone 25 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: ================= PRIMARY DIAGNOSIS ================= Rheumatoid Arthritis exacerbation =================== SECONDARY DIAGNOSES =================== Congestive Heart Failure (EF 46%) acute exacerbation Diabetes Mellitus, type II- insulin dependent Urinary retention 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 taking care of you at [MASKED]. Please see below for information on your time in the hospital. ================================ WHY WAS I IN THE HOSPITAL? ================================ - You came to the hospital because you were having intense joint pain due to a rheumatoid arthritis flare, and were also found to have some extra retained fluid from you congestive heart failure. ================================ WHAT HAPPENED IN THE HOSPITAL? ================================ - You were given oral steroids (prednisone) and pain medication (tramadol and acetaminophen) to treat your arthritis and to control your pain. - You were given intravenous diuretics to treat your heart failure by removing some of the extra volume and help you breathe easier. ================================ WHAT SHOULD I DO WHEN I GO HOME? ================================ - Take your medications are prescribed. - Please follow up with your Primary Care Doctor, [MASKED], and endocrinologist (appointments listed below) - Please check your weight at the same time each morning, after urinating and before breakfast, and notify your cardiologist if you are greater than 3lbs above or below your dry weight of 205 lbs. - Continue taking your discharge regimen of 15u Humalog three times daily + 45u glargine nightly. If your blood sugars are repeatedly high on measurement (>300), please go back to your pre-admission regimen of 20u Humalog 3x/daily and 60u glargine nightly. We wish you the best! -Your Care Team at [MASKED] Followup Instructions: [MASKED]	[]	[ "I110", "E1165", "Z794", "K219", "E039", "E669", "Y92230" ]	[ "M0689: Other specified rheumatoid arthritis, multiple sites", "I5023: Acute on chronic systolic (congestive) heart failure", "I110: Hypertensive heart disease with heart failure", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z794: Long term (current) use of insulin", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "F909: Attention-deficit hyperactivity disorder, unspecified type", "K219: Gastro-esophageal reflux disease without esophagitis", "E860: Dehydration", "E039: Hypothyroidism, unspecified", "K7581: Nonalcoholic steatohepatitis (NASH)", "E669: Obesity, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "E781: Pure hyperglyceridemia", "R330: Drug induced retention of urine", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z95810: Presence of automatic (implantable) cardiac defibrillator" ]
10,047,172	21,396,386	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: ___ ___ biliary stenting and paracentesis ___ ___ paracentesis History of Present Illness: ___ year old M with metastatic pancreatic cancer (to liver) s/p multiple lines of chemotherapy now on capecitabine and tarceva who earlier today had a biliary stent placed presents with fever.Patient went home and had fever of 102 along with weakness. Presented to ___ where VS were HR 117 and BP 151/57, and febrile to 103. Put on vanc/zosyn, given 500 cc NS, and they touched base with Dr. ___ agreed with transfer to BID ___ and admission. ERCP earlier today was done to remove a metal stent and replace with a plastic biliary stent. During that procedure it was noted that there was likely malignant infiltration into the duodenum given the narrowing seen on scope. ___: labs with WBC 8 Hgb 9.0, Tbili 5.1, AP 525, AST 67 ALT 31. Lipase 5, lactate 4.9 In the ___, initial vitals: 98.8 93. 124/58 18 97% RA Labs significant for WBC of 11, Hgb of 7.8, lactate of 4.0. TBili of 4.6. Tmax in ___ 102.8 Patient given Tylenol and 500cc IVF. Past Medical History: Mr. ___ was diagnosed pancreatic adenocarcinoma metastatic to the liver in ___ when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX ___ which was halted due to rising CA ___ and increased size of liver metastases. In ___, CA ___ elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In ___ he started gemcitabine/Abraxane. Imaging ___ showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Course complicated by right thigh muscle infarct presumed ___ diabetes in ___. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Has required multiple dose and schedule adjustments in order to maximize quality of life, minimize marrow toxicity and maintain control over tumor (primarily assessed by tumor marker). Imaging has showed mixed response in early ___: given discordance with ___, unclear if true progression vs variations due to reduced chemotherapy exposure at various time points for various toxicity and scheduling reasons. In setting of increasing side effects and mixed response by imaging/markers, changed to CapOx on ___ scans show a mixed response to treatment, regimen changed to modified FOLFIRINOX -___: Began modified FOLFIRINOX with dose reduction ___ IVP and Leucovorin held from regimen) (Per OMR, patient previously given this regimine at ___ for 3 cycles ___ ago) -___: CT scan showed progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. -___: Patient started on erlotinib with plan for C1D1 of gemcitabine on ___. -Admitted to ___ on ___ for hyperbilirubinemia, fevers, n/v, and acute urinary retention. OTHER PAST MEDICAL HISTORY : - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture - kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI abd ___ Social History: ___ Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: ADMISSION PHYSICAL EXAM ======================== Vitals: 98.5 88 126/57 12 94%RA GENERAL: lethargic, oriented, no acute distress HEENT: mild icterus, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: distended, tympanitic. soft, nontender. active BS EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rashes NEURO: CN ___ intact. Moves all extremities without issue DISCHARGE PHYSICAL EXAM ======================== Patient appeared still and at rest. Carotid pulses were not visible. Heart sounds not audible. No chest rise was appreciated. Corneal reflexes were absent. Time of death is 7PM ___. Pertinent Results: IMAGING ======== # ERCP (___): The duodenal mucosa appeared erythematous, friable with edematous folds in the first and second portion of the duodenum resulting in luminal narrowing. Findings concerning for malignant tumor infiltration. The CBD was successfully cannulated with the CleverCut 3V sphincterotome preloaded with a 0.025in guidewire. The guidewire was advanced alongside the FCMS into the intrahepatic biliary tree. Contrast injection revealed a partial distal migration of the FCMS and mildly dilated intrahepatic ducts. A 8.5mm X 7cm ___ Biliary stent was successfully placed across the papilla alongside the metal stent. There was excellent spontaneous drainage of bile and contrast at the end of the procedure. # L PICC Line placement (___) # MRCP (___): 1. Increased tumor burden as evidenced by interval increase in size in the multiple liver metastases. Although difficult to accurately measure given the absence of IV contrast, the pancreatic mass also appears overall increased in size. 2. Similar appearance of mild diffuse intrahepatic biliary ductal dilatation secondary to obstructing mass in the pancreatic head. Pneumobilia is re-identified, with new air noted in the gallbladder, that is likely related to recent procedure and patency of the CBD stent. Absence of IV contrast limits the evaluation of possible superimposed acute cholangitis. 3. Increased large volume ascites. 4. New wedged-shaped splenic lesions likely represent infarcts. # PTBD (___): Successful placement of left hepatic duct biliary stent which drains the left duct into the patent covered CBD stent. A decision was made intraoperatively to not stent the right bile ducts due to the paucity of right biliary dilation on ultrasound and the known subsegmental obstructions on MRCP. Drainage of 3.1 L paracentesis # U/S guided Paracentesis (___): 3 L of reddish fluid was removed (LLQ).. Fluid WBC 85 RBC 7750 P25 L27 Mon2 NRBC1 Meso6 Macro40 TP 1.0 Gluc 75 LDH 87 Tbili 0.___ y/o M with PMHx of DM2, HTN, HLD, as well as metastatic pancreatic CA with recent ERCP with stent placement on ___, who returned to the ___ with fever. He was treated for cholangitis, but ultimately had progressive terminal illness in the setting of his cancer and was placed in impatient hospice, passing away on CMO status. # Sepsis / Cholangitis Likely source of fevers is biliary, given known malignancy with liver mets as well as recent ERCP. MRCP showing increase in size of liver mets, with stable diffuse intrahepatic biliary ductal dilatation. He was admitted to the MICU and remained stable there. He was treated with vancomycin, cefepime, flagyl initally. Vanc was subsequently ___ as it was felt to be unnecessary for biliary coverage. Pt underwent left hepatic duct stenting by ___ without any complications. While on cefepime/flagyl, the patient remained afebrile and without any localizing symptoms but developed worsening leukocytosis. Repeat cultures and diagnostic paracentesis were unrevealing of additional infectious etiology. Per discussion with his outpatient oncologist, his worsening leukocytosis may be ___ disease progression of his malignancy. # Metastatic Pancreatic CA: On palliative chemo with gemcitabine/tarceva. MCRP showed progression of known liver mets as above. Pt has required repeat paracenteses, most recently ___, for re-accumulating ascites. Unfortunately repeat CEA 215.0; CA ___ was markedly elevated at 200,000. Initially the family expressed interest in an aggressive approach, but over time, it became clearer that he was rapidly deteriorating. He had persistent leukocytosis, low albumin despite TPN, acute kidney insufficiency, developed encephalopathy, and had rapid accumulation of ascites despite 2 therapeutic paracentesis. ___ ultimate decision was to focus on his comfort measures only. The TPN, antibiotics, and oral medications were discontinued. Palliative care and his primary oncologist were also involved of his care during this stay. He ultimately passed away in an inpatient hospice setting. ** OTHER ISSUE ******* # Splenic Infarcts: Seen on MRCP. Per radiology, there was no need for further imaging as MRCP was definitive. The patient was asymptomatic and treated supportively. # T2DM: Metformin on hold, on HISS. FSBS remain elevated; however, pt has not been getting his long acting insulin. # HTN: Restarted home amlodipine and lisinopril with improvement in BP. Patient continued on home Lasix. # Severe Malnutrition / Coagulopathy: On TPN at home, will continue in house. INR elevated despite not being anticoagulated, likely due to poor nutrition and liver dysfunction from metastatic disease. Improved after vitamin K given. # Anemia: Chronic, baseline hgb is ___. He received 1u pRBC transfusion on ___. # BPH: Continued home tamsulosin. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon ___ CAP PO TID W/MEALS 2. DULoxetine 30 mg PO DAILY 3. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 4. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 5. MethylPHENIDATE (Ritalin) 20 mg PO QAM 6. Nystatin Oral Suspension 5 mL PO QID 7. Pyridoxine 50 mg PO DAILY 8. Tamsulosin 0.4 mg PO BID 9. Furosemide 40 mg PO DAILY 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Metastatic pancreatic cancer Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: ___	[ "A419", "R6521", "E43", "N179", "G9340", "K830", "C250", "D688", "K831", "C787", "C784", "R188", "Z9221", "Z66", "G908", "T451X5A", "Y92019", "E119", "Z794", "E785", "Z96642", "N281", "I10", "D72829", "D735", "Z6824", "D630", "N400" ]	Allergies: sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate Chief Complaint: fever Major Surgical or Invasive Procedure: [MASKED] [MASKED] biliary stenting and paracentesis [MASKED] [MASKED] paracentesis History of Present Illness: [MASKED] year old M with metastatic pancreatic cancer (to liver) s/p multiple lines of chemotherapy now on capecitabine and tarceva who earlier today had a biliary stent placed presents with fever.Patient went home and had fever of 102 along with weakness. Presented to [MASKED] where VS were HR 117 and BP 151/57, and febrile to 103. Put on vanc/zosyn, given 500 cc NS, and they touched base with Dr. [MASKED] agreed with transfer to BID [MASKED] and admission. ERCP earlier today was done to remove a metal stent and replace with a plastic biliary stent. During that procedure it was noted that there was likely malignant infiltration into the duodenum given the narrowing seen on scope. [MASKED]: labs with WBC 8 Hgb 9.0, Tbili 5.1, AP 525, AST 67 ALT 31. Lipase 5, lactate 4.9 In the [MASKED], initial vitals: 98.8 93. 124/58 18 97% RA Labs significant for WBC of 11, Hgb of 7.8, lactate of 4.0. TBili of 4.6. Tmax in [MASKED] 102.8 Patient given Tylenol and 500cc IVF. Past Medical History: Mr. [MASKED] was diagnosed pancreatic adenocarcinoma metastatic to the liver in [MASKED] when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX [MASKED] which was halted due to rising CA [MASKED] and increased size of liver metastases. In [MASKED], CA [MASKED] elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In [MASKED] he started gemcitabine/Abraxane. Imaging [MASKED] showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Course complicated by right thigh muscle infarct presumed [MASKED] diabetes in [MASKED]. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Has required multiple dose and schedule adjustments in order to maximize quality of life, minimize marrow toxicity and maintain control over tumor (primarily assessed by tumor marker). Imaging has showed mixed response in early [MASKED]: given discordance with [MASKED], unclear if true progression vs variations due to reduced chemotherapy exposure at various time points for various toxicity and scheduling reasons. In setting of increasing side effects and mixed response by imaging/markers, changed to CapOx on [MASKED] scans show a mixed response to treatment, regimen changed to modified FOLFIRINOX -[MASKED]: Began modified FOLFIRINOX with dose reduction [MASKED] IVP and Leucovorin held from regimen) (Per OMR, patient previously given this regimine at [MASKED] for 3 cycles [MASKED] ago) -[MASKED]: CT scan showed progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. -[MASKED]: Patient started on erlotinib with plan for C1D1 of gemcitabine on [MASKED]. -Admitted to [MASKED] on [MASKED] for hyperbilirubinemia, fevers, n/v, and acute urinary retention. OTHER PAST MEDICAL HISTORY : - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture - kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI abd [MASKED] Social History: [MASKED] Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: ADMISSION PHYSICAL EXAM ======================== Vitals: 98.5 88 126/57 12 94%RA GENERAL: lethargic, oriented, no acute distress HEENT: mild icterus, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: distended, tympanitic. soft, nontender. active BS EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rashes NEURO: CN [MASKED] intact. Moves all extremities without issue DISCHARGE PHYSICAL EXAM ======================== Patient appeared still and at rest. Carotid pulses were not visible. Heart sounds not audible. No chest rise was appreciated. Corneal reflexes were absent. Time of death is 7PM [MASKED]. Pertinent Results: IMAGING ======== # ERCP ([MASKED]): The duodenal mucosa appeared erythematous, friable with edematous folds in the first and second portion of the duodenum resulting in luminal narrowing. Findings concerning for malignant tumor infiltration. The CBD was successfully cannulated with the CleverCut 3V sphincterotome preloaded with a 0.025in guidewire. The guidewire was advanced alongside the FCMS into the intrahepatic biliary tree. Contrast injection revealed a partial distal migration of the FCMS and mildly dilated intrahepatic ducts. A 8.5mm X 7cm [MASKED] Biliary stent was successfully placed across the papilla alongside the metal stent. There was excellent spontaneous drainage of bile and contrast at the end of the procedure. # L PICC Line placement ([MASKED]) # MRCP ([MASKED]): 1. Increased tumor burden as evidenced by interval increase in size in the multiple liver metastases. Although difficult to accurately measure given the absence of IV contrast, the pancreatic mass also appears overall increased in size. 2. Similar appearance of mild diffuse intrahepatic biliary ductal dilatation secondary to obstructing mass in the pancreatic head. Pneumobilia is re-identified, with new air noted in the gallbladder, that is likely related to recent procedure and patency of the CBD stent. Absence of IV contrast limits the evaluation of possible superimposed acute cholangitis. 3. Increased large volume ascites. 4. New wedged-shaped splenic lesions likely represent infarcts. # PTBD ([MASKED]): Successful placement of left hepatic duct biliary stent which drains the left duct into the patent covered CBD stent. A decision was made intraoperatively to not stent the right bile ducts due to the paucity of right biliary dilation on ultrasound and the known subsegmental obstructions on MRCP. Drainage of 3.1 L paracentesis # U/S guided Paracentesis ([MASKED]): 3 L of reddish fluid was removed (LLQ).. Fluid WBC 85 RBC 7750 P25 L27 Mon2 NRBC1 Meso6 Macro40 TP 1.0 Gluc 75 LDH 87 Tbili 0.[MASKED] y/o M with PMHx of DM2, HTN, HLD, as well as metastatic pancreatic CA with recent ERCP with stent placement on [MASKED], who returned to the [MASKED] with fever. He was treated for cholangitis, but ultimately had progressive terminal illness in the setting of his cancer and was placed in impatient hospice, passing away on CMO status. # Sepsis / Cholangitis Likely source of fevers is biliary, given known malignancy with liver mets as well as recent ERCP. MRCP showing increase in size of liver mets, with stable diffuse intrahepatic biliary ductal dilatation. He was admitted to the MICU and remained stable there. He was treated with vancomycin, cefepime, flagyl initally. Vanc was subsequently [MASKED] as it was felt to be unnecessary for biliary coverage. Pt underwent left hepatic duct stenting by [MASKED] without any complications. While on cefepime/flagyl, the patient remained afebrile and without any localizing symptoms but developed worsening leukocytosis. Repeat cultures and diagnostic paracentesis were unrevealing of additional infectious etiology. Per discussion with his outpatient oncologist, his worsening leukocytosis may be [MASKED] disease progression of his malignancy. # Metastatic Pancreatic CA: On palliative chemo with gemcitabine/tarceva. MCRP showed progression of known liver mets as above. Pt has required repeat paracenteses, most recently [MASKED], for re-accumulating ascites. Unfortunately repeat CEA 215.0; CA [MASKED] was markedly elevated at 200,000. Initially the family expressed interest in an aggressive approach, but over time, it became clearer that he was rapidly deteriorating. He had persistent leukocytosis, low albumin despite TPN, acute kidney insufficiency, developed encephalopathy, and had rapid accumulation of ascites despite 2 therapeutic paracentesis. [MASKED] ultimate decision was to focus on his comfort measures only. The TPN, antibiotics, and oral medications were discontinued. Palliative care and his primary oncologist were also involved of his care during this stay. He ultimately passed away in an inpatient hospice setting. ** OTHER ISSUE ******* # Splenic Infarcts: Seen on MRCP. Per radiology, there was no need for further imaging as MRCP was definitive. The patient was asymptomatic and treated supportively. # T2DM: Metformin on hold, on HISS. FSBS remain elevated; however, pt has not been getting his long acting insulin. # HTN: Restarted home amlodipine and lisinopril with improvement in BP. Patient continued on home Lasix. # Severe Malnutrition / Coagulopathy: On TPN at home, will continue in house. INR elevated despite not being anticoagulated, likely due to poor nutrition and liver dysfunction from metastatic disease. Improved after vitamin K given. # Anemia: Chronic, baseline hgb is [MASKED]. He received 1u pRBC transfusion on [MASKED]. # BPH: Continued home tamsulosin. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon [MASKED] CAP PO TID W/MEALS 2. DULoxetine 30 mg PO DAILY 3. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 4. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 5. MethylPHENIDATE (Ritalin) 20 mg PO QAM 6. Nystatin Oral Suspension 5 mL PO QID 7. Pyridoxine 50 mg PO DAILY 8. Tamsulosin 0.4 mg PO BID 9. Furosemide 40 mg PO DAILY 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Metastatic pancreatic cancer Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: [MASKED]	[]	[ "N179", "Z66", "E119", "Z794", "E785", "I10", "N400" ]	[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "E43: Unspecified severe protein-calorie malnutrition", "N179: Acute kidney failure, unspecified", "G9340: Encephalopathy, unspecified", "K830: Cholangitis", "C250: Malignant neoplasm of head of pancreas", "D688: Other specified coagulation defects", "K831: Obstruction of bile duct", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C784: Secondary malignant neoplasm of small intestine", "R188: Other ascites", "Z9221: Personal history of antineoplastic chemotherapy", "Z66: Do not resuscitate", "G908: Other disorders of autonomic nervous system", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "Z96642: Presence of left artificial hip joint", "N281: Cyst of kidney, acquired", "I10: Essential (primary) hypertension", "D72829: Elevated white blood cell count, unspecified", "D735: Infarction of spleen", "Z6824: Body mass index [BMI] 24.0-24.9, adult", "D630: Anemia in neoplastic disease", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms" ]
10,047,172	24,433,031	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: ERCP ___ with plastic stent pull and balloon sweeps, difficult ERCP History of Present Illness: Mr. ___ is a ___ man with pancreatic cancer metastatic to the liver (dx ___, MS stable, KRAS mutation) with progression on modified FOLFIRINOX, admitted from ___ clinic on ___ for fevers up to 102.2 F, nonbilious emesis x 1, and acute urinary retention. He had been on bridge chemotherapy with erlotinib (since ___ and was scheduled for C1D1 of gemcitabine on ___, but this was held in the setting of his new symptoms. The patient said he had been feeling well until about two weeks ago, when he began developing increased bloating and poor appetite. Then about ___ days PTA, he started to have low grade temperatures around ___ F and felt intermittently nauseous. During the clinic visit on ___, he had an episode of voluminous vomiting of partially undigested food from breakfast at least three hours prior. Stated that he felt very fatigued and out of sorts. No abdominal pain, fevers, chills or night sweats. In clinic, his vital signs were: BP 161/55, T 99.4 (up to 102.2) with HR ___, RR 16, and SaO2 100% on RA. His exam was notable for oropharyngeal thrush, trace edema of the lower extremities, and skin desquamation on the bottom of his feet without any evidence of skin breakdown. His labs in clinic were significant for WBC 12.2, H/H 9.8/12.2, Na 126, ALT/AST ___ with tbili 1.6 alk phos 855. He had an elevated lactate of 3.7. Notably, his CEA was 47.4 (up from prior) and ___ ___ ___ (up from ___ on ___. He was given 1L IVF, zofran, nystatin, and tylenol, and blood and urine cultures were obtained. Dr. ___ spoke with Dr. ___ with plan for MRCP with consideration of further endoscopic intervention with percutaneous drainage to relieve possible gastric outlet obstruction. In clinic, patient was also found to have poor UOP with only 60cc voided post-IVF resuscitation and bladder scan revealing > 500cc retained urine. Post void bladder scan showed 458cc in the bladder with plan for further management of his hyperbilirubinemia, fevers, n/v, and acute urinary retention on OMED. Overnight, patient was started on IV cefepime/flagyl and received 1L IVF and zofran for nausea. Additional blood cultures were obtained and a CXR showed no evidence of any acute intrapulmonary process and KUB was negative for SBO. Labs were notable for a Na 125, BUN/Cr ___, HCO3 21, lactate 3.7, ALT/AST 53/88, AP 762, Tbili 1.9, Dbili 1.4, WBC 11.5, and H/H 9.3/27.8. He became hypoglycemic with FSBG 56 at 0200 and was given 12.5 gm D50 IV x 1 and started on D5LR @ 125 cc/hr. On recheck, his FSBG was 132. A RUQ ultrasound was ordered and pending at the time of evaluation. Past Medical History: ONCOLOGIC HISTORY: Mr. ___ was diagnosed pancreatic adenocarcinoma metastatic to the liver in ___ when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX ___ which was halted due to rising CA ___ and increased size of liver metastases. In ___, CA ___ elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In ___ he started gemcitabine/Abraxane. Imaging ___ showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Course complicated by right thigh muscle infarct presumed ___ diabetes in ___. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Has required multiple dose and schedule adjustments in order to maximize quality of life, minimize marrow toxicity and maintain control over tumor (primarily assessed by tumor marker). Imaging has showed mixed response in early ___: given discordance with ___, unclear if true progression vs variations due to reduced chemotherapy exposure at various time points for various toxicity and scheduling reasons. In setting of increasing side effects and mixed response by imaging/markers, changed to CapOx on ___ scans show a mixed response to treatment, regimen changed to modified FOLFIRINOX -___: Began modified FOLFIRINOX with dose reduction ___ IVP and Leucovorin held from regimen) (Per OMR, patient previously given this regimine at ___ for 3 cycles ___ ago) -___: CT scan showed progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. -___: Patient started on erlotinib with plan for C1D1 of gemcitabine on ___. -Admitted to ___ on ___ for hyperbilirubinemia, fevers, n/v, and acute urinary retention. OTHER PAST MEDICAL HISTORY (per OMR): - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture - kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI ___ Social History: ___ Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: ON ADMISSION: VS: Tmax 101.7 (___) Tc 97.4 BP 140/70 HR 67 RR 16 SaO2 99% on RA GEN: Cachectic, mildly jaundiced-appearing elderly man, in NAD. HEENT: Oropharynx with mild thrush. Sclerae anicteric, conjunctivae pink. CHEST: CTAB. No wheezes, rales or rhonchi. CARDIAC: RRR, nl S1/S2, III/VI apical SEM. Port site looks c/d/i. ABD: Soft, distended, nontender, BS+. No rebound or guarding. EXT: WWP, trace edema, no cyanosis or erythema. SKIN: Desquamation on the plantar aspect of his feet bilaterally. DISCHARGE PHYSICAL EXAM: VS: 97.8 154-170/66-70 66-70 ___ GEN: A&Ox3, NAD. Pleasant, lying comfortably in bed. HEENT: MMM, clear oropharynx CHEST: CTAB. No wheezes, rales or rhonchi. CARDIAC: RRR, nl S1/S2, III/VI apical SEM. ABD: Soft, distended, nontender, BS+, tympanic. No rebound or guarding. EXT: WWP, no edema, no cyanosis or erythema. SKIN: Port site c/d/i. Pertinent Results: ADMISSION LABS ___ 08:37PM BLOOD WBC-11.5* RBC-3.07* Hgb-9.3* Hct-27.8* MCV-91 MCH-30.3 MCHC-33.5 RDW-16.3* RDWSD-54.3* Plt ___ ___ 12:30PM BLOOD WBC-12.2# RBC-3.21 Hgb-9.8* Hct-29.4* MCV-92 MCH-30.5 MCHC-33.3 RDW-16.2* RDWSD-54.8* Plt ___ ___ 12:30PM BLOOD Neuts-86.9* Lymphs-4.0* Monos-8.2 Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.62# AbsLymp-0.49 AbsMono-0.99* AbsEos-0.00* AbsBaso-0.02 ___ 08:37PM BLOOD Plt ___ ___ 08:37PM BLOOD ___ PTT-35.3 ___ ___ 12:30PM BLOOD Plt ___ ___ 08:37PM BLOOD Glucose-126* UreaN-27* Creat-1.3* Na-125* K-4.4 Cl-90* HCO3-21* AnGap-18 ___ 12:30PM BLOOD UreaN-31* Creat-1.2 Na-126* K-5.0 Cl-89* ___ 08:37PM BLOOD ALT-53* AST-88* LD(LDH)-203 AlkPhos-762* TotBili-1.9* DirBili-1.4* IndBili-0.5 ___ 12:30PM BLOOD ALT-55* AST-91* AlkPhos-855* TotBili-1.6* ___ 08:37PM BLOOD Calcium-8.6 Phos-2.5* Mg-1.5* ___ 12:30PM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.9 Mg-1.5* DISCHARGE LABS ___ 05:27AM BLOOD WBC-8.2 RBC-2.67* Hgb-8.0* Hct-24.1* MCV-90 MCH-30.0 MCHC-33.2 RDW-18.5* RDWSD-58.5* Plt ___ ___ 05:27AM BLOOD Plt ___ ___ 05:27AM BLOOD Plt ___ ___ 05:27AM BLOOD ___ PTT-32.3 ___ ___ 05:27AM BLOOD Glucose-114* UreaN-23* Creat-1.3* Na-131* K-3.9 Cl-99 HCO3-24 AnGap-12 ___ 05:27AM BLOOD ALT-41* AST-93* LD(LDH)-240 AlkPhos-768* TotBili-3.1* ___ 05:27AM BLOOD Albumin-2.7* Calcium-8.1* Phos-3.8 Mg-1.9 MICRO: ___ 3:05 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): 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-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Reported to and read back by ___, ___ @ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS GALLINARUM \| AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- 1 S VANCOMYCIN------------ 4 S ERCP ___: Major Papilla: A previously placed metal stent and plastic stents were found in the major papilla. There was evidence of distal migration, though the majority of the stent remained within the CBD. There was evidence of significant debris surrounding and within the lumen of the stent. Cannulation: Given significant duodenal narrowing and distortion we were unable to get the therapeutic duodenoscope into an appropriate position. Thus, we switched to a diagnostic duodenoscope and cannulated the bile duct in a long position. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Small amount of contrast medium was injected resulting in complete opacification. The procedure was moderately difficult Biliary Tree: The common bile duct, was filled with contrast and well visualized. There was no evidence of obvious filling defects within the level of the stent and above it. I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good Procedures: A plastic stent was removed from the main duct. The sphincterotome was exchanged for an extraction balloon catheter. Balloon sweeps were perfromed and yielded small amount of sludge. Further sweeps were performed until no debris was noted. Impression: A previously placed metal stent and plastic stents were found in the major papilla. There was evidence of distal migration, though the majority of the stent remained within the CBD. There was evidence of significant debris surrounding and within the lumen of the stent. Given significant duodenal narrowing and distortion we were unable to get the therapeutic duodenoscope into an appropriate position. Thus, we switched to a diagnostic duodenoscope and cannulated the bile duct in a long positition. A plastic stent was removed from the main duct. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Small amount of contrast medium was injected resulting in complete opacification. The procedure was moderately difficult The common bile duct, was filled with contrast and well visualized. There was no evidence of obvious filling defects within the level of the stent and above it. The sphincterotome was exchanged for an extraction balloon catheter. Balloon sweeps were perfromed and yielded small amount of sludge. Further sweeps were performed until no debris was noted. RUQ ultrasound ___: 1. Mild peripheral biliary ductal dilation, most predominantly seen in the left hepatic dome. No significant central biliary ductal dilation. 2. Numerous hepatic metastasis, please refer to recent MRI for more detailed description. 3. Mild splenomegaly. 4. Redemonstration of a pancreatic neoplasm measuring 1.7 x 3.9 cm, again for more detailed description please correlate with recent MRI. KUB ___: No evidence of small-bowel obstruction. CXR ___: Comparison to ___. No relevant change is noted. Signs of mild overinflation. No evidence of pneumonia. No pulmonary edema, no pleural effusions. No pneumothorax. Normal size of the heart. The right pectoral Port-A-Cath is in stable correct position. MRI Liver ___: Progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. Additionally, the primary pancreatic cancer in the pancreatic head is very minimally increased in size. CT CHEST w/ CON ___: New irregular nodule in the right upper lobe and interval increase of the right lower lobe nodules concerning for progressive metastatic disease. ERCP ___: 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. Mass: A 3.5 cm X 4 cm ill-defined mass was noted in the head of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. The mass is involving the confluence, especially the SMV with narrowing of vessel diameter. FNB was performed. Color doppler was used to determine an avascular path for needle aspiration. A 22-gauge needle with a stylet was used to perform biopsy. Six needle passes were made into the mass. Biopsies were sent for pathology. Scan of the left hepatic lobe reveled multiple hypoechoic lesions measured between 0.5-2cm, highly suspected for metastatic disease, FNB was performed from 3 different hepatic lesions Otherwise normal upper eus to third part of the duodenum Brief Hospital Course: ___ with metastatic pancreatic cancer admitted for acute biliary obstruction and bacteremia likely secondary to a biliary source. # Polymicrobial Bacteremia/biliary sepsis: Secondary to biliary obstruction and now s/p CBD stent repositioning and debris removal on ___, repeat ERCP on ___ with replacement of stent. Blood cx growing klebsiella and enterococcus. - discontinued vancomycin/cefepime/flagyl, D1 = ___ - started on zosyn 4.5 g IV Q8H per speciation and sensitivities for GNR and GPC as above; will need 14-day course of abx END DATE ___ - home IV abx TID with end date ___ for completion of 14 day course, ___ services - prior 10x60 fully covered biliary WallFlex stent from ___ was replaced with new stent ___ via ERCP - trended LFTs; Tbili 3.0->3.1 on day of discharge. Will have follow up labs on ___ to trend LFTs, Cr # Malignant biliary obstruction: Upward trending LFTs since ___. s/p ERCP on ___ with repositioning of distally migrated metal stent in CBD, removal of plastic stent from the main duct, cannulation of the bile duct via diagnostic duodenoscope. Overall hyperbilirubinemia/elevated LFTs slightly improving s/p ERCP decompression. - Home with antibiotics as above - Repeated ERCP ___ as above - continue to trend LFTs on outpatient basis # Hypertension: SBPs up to 190s on ___ in the setting of held home antihypertensives since admission. SBP 150s-170s, restarted home lisinopril after discussion with outpatient nephrologist - Continued home amlodipine - started on lisinopril 5mg daily (___) for HTN; Cr bumped with 10mg PO lisinopril, returned pt to 5mg daily dose - f/u creatinine on ___ # Anemia: Normocytic, likely ACD. NTD # Acute Kidney Injury: Improved with treatment and improvement of sepsis, secondary to pre-renal injury. # Urinary retention: Resolved. Intermittent, likely secondary to BPH. Resolved. Currently urinating without issue # DM2: Had an episode of hypoglycemia on admission while NPO, now normoglycemic on home diet. - held home metformin while inpatient - HISS, started home lantus 15U QAM ___ # Metastatic pancreatic cancer: Dx ___ with mets to liver, progressed on modified FOLFIRINOX. Bridge chemotherapy to clinical trial with erlotinib/gemcitabine held. Evidence of progression on MRI on ___ while on modified FOLFIRINOX. Upward trending CEA and CA ___. - Plan to resume bridge chemotherapy to clinical trial pending clinical status - Continued Ritalin and Ativan prn, creon with meals TRANSITIONAL ISSUES: ==================== -Patient to finish 2 week zosyn abx course through ___ with ___ following -Please recheck electrolytes, and LFTs on ___ and send to PCP and Dr. ___ was temporarily started on lisinopril 10 mg daily for BP control; discussed with Dr. ___ (patient's nephrologist) and Dr. ___ - patient had creatinine bump from 1.0->1.2, so dose was decreased to 5mg daily. Renal function should be closely monitored, and may need to be stopped if resuming chemo that would cause renal vasoconstriction (ie: oxaliplatin). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 3. Tamsulosin 0.4 mg PO BID 4. DULoxetine 30 mg PO DAILY 5. Creon ___ CAP PO TID W/MEALS 6. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 7. MethylPHENIDATE (Ritalin) 20 mg PO QAM 8. Nystatin Oral Suspension 5 mL PO QID 9. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 10. Pyridoxine 50 mg PO DAILY 11. Glargine 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Creon ___ CAP PO TID W/MEALS 3. DULoxetine 30 mg PO DAILY 4. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 6. Pyridoxine 50 mg PO DAILY 7. Tamsulosin 0.4 mg PO BID 8. Piperacillin-Tazobactam 4.5 g IV Q8H RX piperacillin-tazobactam 4.5 gram 4.5 g IV every 8 hours Disp #30 Vial Refills:0 9. MethylPHENIDATE (Ritalin) 20 mg PO QAM 10. Nystatin Oral Suspension 5 mL PO QID 11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 12. Glargine 15 Units Breakfast 13. Lisinopril 5 mg PO DAILY RX lisinopril 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 14. Outpatient Lab Work LABS FOR ___ ICD-9-CM Diagnosis Code ___.2 Biliary Obstruction CBC, Chem 10, ALT, AST, AP, LDH, TBili, Albumin Send to ATTN: Dr. ___ ___ and ATTN: Dr. ___ ___ ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: biliary obstruction pancreatic cancer Klebsiella and enterococcal septicemia Acute kidney injury SECONDARY DIAGNOSIS: Type 2 diabetes mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for fever and elevated liver tests. You were found to have an obstruction in your biliary system and underwent a procedure called ERCP where a stent was placed. As your liver tests continued to trend up, you underwent a second ERCP where your previous stent which appeared to have migrated was replaced. Your blood cultures grew two different organisms (Klebsiella and enterococcus) and you are being discharged on an antibiotic called zosyn which will continue through ___ for a total two week course. Please follow up with your oncologist Dr. ___. You will also have follow up lab draws to continue to monitor your liver tests. It was a pleasure caring for you - we wish you all the best! Sincerely, Your ___ Oncology Team Followup Instructions: ___	[ "A4159", "K831", "N179", "D688", "C250", "E872", "K315", "C787", "B370", "E871", "R188", "B961", "A4181", "Z1611", "D381", "Z9221", "N401", "R338", "E860", "E8342", "D6481", "E806", "D483", "Z934", "R630", "Z6820", "R112", "E119", "I10", "E785", "Z96642", "N281" ]	Allergies: sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate Chief Complaint: Fever Major Surgical or Invasive Procedure: ERCP [MASKED] with plastic stent pull and balloon sweeps, difficult ERCP History of Present Illness: Mr. [MASKED] is a [MASKED] man with pancreatic cancer metastatic to the liver (dx [MASKED], MS stable, KRAS mutation) with progression on modified FOLFIRINOX, admitted from [MASKED] clinic on [MASKED] for fevers up to 102.2 F, nonbilious emesis x 1, and acute urinary retention. He had been on bridge chemotherapy with erlotinib (since [MASKED] and was scheduled for C1D1 of gemcitabine on [MASKED], but this was held in the setting of his new symptoms. The patient said he had been feeling well until about two weeks ago, when he began developing increased bloating and poor appetite. Then about [MASKED] days PTA, he started to have low grade temperatures around [MASKED] F and felt intermittently nauseous. During the clinic visit on [MASKED], he had an episode of voluminous vomiting of partially undigested food from breakfast at least three hours prior. Stated that he felt very fatigued and out of sorts. No abdominal pain, fevers, chills or night sweats. In clinic, his vital signs were: BP 161/55, T 99.4 (up to 102.2) with HR [MASKED], RR 16, and SaO2 100% on RA. His exam was notable for oropharyngeal thrush, trace edema of the lower extremities, and skin desquamation on the bottom of his feet without any evidence of skin breakdown. His labs in clinic were significant for WBC 12.2, H/H 9.8/12.2, Na 126, ALT/AST [MASKED] with tbili 1.6 alk phos 855. He had an elevated lactate of 3.7. Notably, his CEA was 47.4 (up from prior) and [MASKED] [MASKED] [MASKED] (up from [MASKED] on [MASKED]. He was given 1L IVF, zofran, nystatin, and tylenol, and blood and urine cultures were obtained. Dr. [MASKED] spoke with Dr. [MASKED] with plan for MRCP with consideration of further endoscopic intervention with percutaneous drainage to relieve possible gastric outlet obstruction. In clinic, patient was also found to have poor UOP with only 60cc voided post-IVF resuscitation and bladder scan revealing > 500cc retained urine. Post void bladder scan showed 458cc in the bladder with plan for further management of his hyperbilirubinemia, fevers, n/v, and acute urinary retention on OMED. Overnight, patient was started on IV cefepime/flagyl and received 1L IVF and zofran for nausea. Additional blood cultures were obtained and a CXR showed no evidence of any acute intrapulmonary process and KUB was negative for SBO. Labs were notable for a Na 125, BUN/Cr [MASKED], HCO3 21, lactate 3.7, ALT/AST 53/88, AP 762, Tbili 1.9, Dbili 1.4, WBC 11.5, and H/H 9.3/27.8. He became hypoglycemic with FSBG 56 at 0200 and was given 12.5 gm D50 IV x 1 and started on D5LR @ 125 cc/hr. On recheck, his FSBG was 132. A RUQ ultrasound was ordered and pending at the time of evaluation. Past Medical History: ONCOLOGIC HISTORY: Mr. [MASKED] was diagnosed pancreatic adenocarcinoma metastatic to the liver in [MASKED] when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX [MASKED] which was halted due to rising CA [MASKED] and increased size of liver metastases. In [MASKED], CA [MASKED] elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In [MASKED] he started gemcitabine/Abraxane. Imaging [MASKED] showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Course complicated by right thigh muscle infarct presumed [MASKED] diabetes in [MASKED]. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Has required multiple dose and schedule adjustments in order to maximize quality of life, minimize marrow toxicity and maintain control over tumor (primarily assessed by tumor marker). Imaging has showed mixed response in early [MASKED]: given discordance with [MASKED], unclear if true progression vs variations due to reduced chemotherapy exposure at various time points for various toxicity and scheduling reasons. In setting of increasing side effects and mixed response by imaging/markers, changed to CapOx on [MASKED] scans show a mixed response to treatment, regimen changed to modified FOLFIRINOX -[MASKED]: Began modified FOLFIRINOX with dose reduction [MASKED] IVP and Leucovorin held from regimen) (Per OMR, patient previously given this regimine at [MASKED] for 3 cycles [MASKED] ago) -[MASKED]: CT scan showed progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. -[MASKED]: Patient started on erlotinib with plan for C1D1 of gemcitabine on [MASKED]. -Admitted to [MASKED] on [MASKED] for hyperbilirubinemia, fevers, n/v, and acute urinary retention. OTHER PAST MEDICAL HISTORY (per OMR): - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture - kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI [MASKED] Social History: [MASKED] Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: ON ADMISSION: VS: Tmax 101.7 ([MASKED]) Tc 97.4 BP 140/70 HR 67 RR 16 SaO2 99% on RA GEN: Cachectic, mildly jaundiced-appearing elderly man, in NAD. HEENT: Oropharynx with mild thrush. Sclerae anicteric, conjunctivae pink. CHEST: CTAB. No wheezes, rales or rhonchi. CARDIAC: RRR, nl S1/S2, III/VI apical SEM. Port site looks c/d/i. ABD: Soft, distended, nontender, BS+. No rebound or guarding. EXT: WWP, trace edema, no cyanosis or erythema. SKIN: Desquamation on the plantar aspect of his feet bilaterally. DISCHARGE PHYSICAL EXAM: VS: 97.8 154-170/66-70 66-70 [MASKED] GEN: A&Ox3, NAD. Pleasant, lying comfortably in bed. HEENT: MMM, clear oropharynx CHEST: CTAB. No wheezes, rales or rhonchi. CARDIAC: RRR, nl S1/S2, III/VI apical SEM. ABD: Soft, distended, nontender, BS+, tympanic. No rebound or guarding. EXT: WWP, no edema, no cyanosis or erythema. SKIN: Port site c/d/i. Pertinent Results: ADMISSION LABS [MASKED] 08:37PM BLOOD WBC-11.5* RBC-3.07* Hgb-9.3* Hct-27.8* MCV-91 MCH-30.3 MCHC-33.5 RDW-16.3* RDWSD-54.3* Plt [MASKED] [MASKED] 12:30PM BLOOD WBC-12.2# RBC-3.21 Hgb-9.8* Hct-29.4* MCV-92 MCH-30.5 MCHC-33.3 RDW-16.2* RDWSD-54.8* Plt [MASKED] [MASKED] 12:30PM BLOOD Neuts-86.9* Lymphs-4.0* Monos-8.2 Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-10.62# AbsLymp-0.49 AbsMono-0.99* AbsEos-0.00* AbsBaso-0.02 [MASKED] 08:37PM BLOOD Plt [MASKED] [MASKED] 08:37PM BLOOD [MASKED] PTT-35.3 [MASKED] [MASKED] 12:30PM BLOOD Plt [MASKED] [MASKED] 08:37PM BLOOD Glucose-126* UreaN-27* Creat-1.3* Na-125* K-4.4 Cl-90* HCO3-21* AnGap-18 [MASKED] 12:30PM BLOOD UreaN-31* Creat-1.2 Na-126* K-5.0 Cl-89* [MASKED] 08:37PM BLOOD ALT-53* AST-88* LD(LDH)-203 AlkPhos-762* TotBili-1.9* DirBili-1.4* IndBili-0.5 [MASKED] 12:30PM BLOOD ALT-55* AST-91* AlkPhos-855* TotBili-1.6* [MASKED] 08:37PM BLOOD Calcium-8.6 Phos-2.5* Mg-1.5* [MASKED] 12:30PM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.9 Mg-1.5* DISCHARGE LABS [MASKED] 05:27AM BLOOD WBC-8.2 RBC-2.67* Hgb-8.0* Hct-24.1* MCV-90 MCH-30.0 MCHC-33.2 RDW-18.5* RDWSD-58.5* Plt [MASKED] [MASKED] 05:27AM BLOOD Plt [MASKED] [MASKED] 05:27AM BLOOD Plt [MASKED] [MASKED] 05:27AM BLOOD [MASKED] PTT-32.3 [MASKED] [MASKED] 05:27AM BLOOD Glucose-114* UreaN-23* Creat-1.3* Na-131* K-3.9 Cl-99 HCO3-24 AnGap-12 [MASKED] 05:27AM BLOOD ALT-41* AST-93* LD(LDH)-240 AlkPhos-768* TotBili-3.1* [MASKED] 05:27AM BLOOD Albumin-2.7* Calcium-8.1* Phos-3.8 Mg-1.9 MICRO: [MASKED] 3:05 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): 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-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [MASKED]: GRAM NEGATIVE ROD(S). Reported to and read back by [MASKED], [MASKED] @ [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS GALLINARUM \| AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- 1 S VANCOMYCIN------------ 4 S ERCP [MASKED]: Major Papilla: A previously placed metal stent and plastic stents were found in the major papilla. There was evidence of distal migration, though the majority of the stent remained within the CBD. There was evidence of significant debris surrounding and within the lumen of the stent. Cannulation: Given significant duodenal narrowing and distortion we were unable to get the therapeutic duodenoscope into an appropriate position. Thus, we switched to a diagnostic duodenoscope and cannulated the bile duct in a long position. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Small amount of contrast medium was injected resulting in complete opacification. The procedure was moderately difficult Biliary Tree: The common bile duct, was filled with contrast and well visualized. There was no evidence of obvious filling defects within the level of the stent and above it. I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good Procedures: A plastic stent was removed from the main duct. The sphincterotome was exchanged for an extraction balloon catheter. Balloon sweeps were perfromed and yielded small amount of sludge. Further sweeps were performed until no debris was noted. Impression: A previously placed metal stent and plastic stents were found in the major papilla. There was evidence of distal migration, though the majority of the stent remained within the CBD. There was evidence of significant debris surrounding and within the lumen of the stent. Given significant duodenal narrowing and distortion we were unable to get the therapeutic duodenoscope into an appropriate position. Thus, we switched to a diagnostic duodenoscope and cannulated the bile duct in a long positition. A plastic stent was removed from the main duct. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Small amount of contrast medium was injected resulting in complete opacification. The procedure was moderately difficult The common bile duct, was filled with contrast and well visualized. There was no evidence of obvious filling defects within the level of the stent and above it. The sphincterotome was exchanged for an extraction balloon catheter. Balloon sweeps were perfromed and yielded small amount of sludge. Further sweeps were performed until no debris was noted. RUQ ultrasound [MASKED]: 1. Mild peripheral biliary ductal dilation, most predominantly seen in the left hepatic dome. No significant central biliary ductal dilation. 2. Numerous hepatic metastasis, please refer to recent MRI for more detailed description. 3. Mild splenomegaly. 4. Redemonstration of a pancreatic neoplasm measuring 1.7 x 3.9 cm, again for more detailed description please correlate with recent MRI. KUB [MASKED]: No evidence of small-bowel obstruction. CXR [MASKED]: Comparison to [MASKED]. No relevant change is noted. Signs of mild overinflation. No evidence of pneumonia. No pulmonary edema, no pleural effusions. No pneumothorax. Normal size of the heart. The right pectoral Port-A-Cath is in stable correct position. MRI Liver [MASKED]: Progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. Additionally, the primary pancreatic cancer in the pancreatic head is very minimally increased in size. CT CHEST w/ CON [MASKED]: New irregular nodule in the right upper lobe and interval increase of the right lower lobe nodules concerning for progressive metastatic disease. ERCP [MASKED]: 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. Mass: A 3.5 cm X 4 cm ill-defined mass was noted in the head of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. The mass is involving the confluence, especially the SMV with narrowing of vessel diameter. FNB was performed. Color doppler was used to determine an avascular path for needle aspiration. A 22-gauge needle with a stylet was used to perform biopsy. Six needle passes were made into the mass. Biopsies were sent for pathology. Scan of the left hepatic lobe reveled multiple hypoechoic lesions measured between 0.5-2cm, highly suspected for metastatic disease, FNB was performed from 3 different hepatic lesions Otherwise normal upper eus to third part of the duodenum Brief Hospital Course: [MASKED] with metastatic pancreatic cancer admitted for acute biliary obstruction and bacteremia likely secondary to a biliary source. # Polymicrobial Bacteremia/biliary sepsis: Secondary to biliary obstruction and now s/p CBD stent repositioning and debris removal on [MASKED], repeat ERCP on [MASKED] with replacement of stent. Blood cx growing klebsiella and enterococcus. - discontinued vancomycin/cefepime/flagyl, D1 = [MASKED] - started on zosyn 4.5 g IV Q8H per speciation and sensitivities for GNR and GPC as above; will need 14-day course of abx END DATE [MASKED] - home IV abx TID with end date [MASKED] for completion of 14 day course, [MASKED] services - prior 10x60 fully covered biliary WallFlex stent from [MASKED] was replaced with new stent [MASKED] via ERCP - trended LFTs; Tbili 3.0->3.1 on day of discharge. Will have follow up labs on [MASKED] to trend LFTs, Cr # Malignant biliary obstruction: Upward trending LFTs since [MASKED]. s/p ERCP on [MASKED] with repositioning of distally migrated metal stent in CBD, removal of plastic stent from the main duct, cannulation of the bile duct via diagnostic duodenoscope. Overall hyperbilirubinemia/elevated LFTs slightly improving s/p ERCP decompression. - Home with antibiotics as above - Repeated ERCP [MASKED] as above - continue to trend LFTs on outpatient basis # Hypertension: SBPs up to 190s on [MASKED] in the setting of held home antihypertensives since admission. SBP 150s-170s, restarted home lisinopril after discussion with outpatient nephrologist - Continued home amlodipine - started on lisinopril 5mg daily ([MASKED]) for HTN; Cr bumped with 10mg PO lisinopril, returned pt to 5mg daily dose - f/u creatinine on [MASKED] # Anemia: Normocytic, likely ACD. NTD # Acute Kidney Injury: Improved with treatment and improvement of sepsis, secondary to pre-renal injury. # Urinary retention: Resolved. Intermittent, likely secondary to BPH. Resolved. Currently urinating without issue # DM2: Had an episode of hypoglycemia on admission while NPO, now normoglycemic on home diet. - held home metformin while inpatient - HISS, started home lantus 15U QAM [MASKED] # Metastatic pancreatic cancer: Dx [MASKED] with mets to liver, progressed on modified FOLFIRINOX. Bridge chemotherapy to clinical trial with erlotinib/gemcitabine held. Evidence of progression on MRI on [MASKED] while on modified FOLFIRINOX. Upward trending CEA and CA [MASKED]. - Plan to resume bridge chemotherapy to clinical trial pending clinical status - Continued Ritalin and Ativan prn, creon with meals TRANSITIONAL ISSUES: ==================== -Patient to finish 2 week zosyn abx course through [MASKED] with [MASKED] following -Please recheck electrolytes, and LFTs on [MASKED] and send to PCP and Dr. [MASKED] was temporarily started on lisinopril 10 mg daily for BP control; discussed with Dr. [MASKED] (patient's nephrologist) and Dr. [MASKED] - patient had creatinine bump from 1.0->1.2, so dose was decreased to 5mg daily. Renal function should be closely monitored, and may need to be stopped if resuming chemo that would cause renal vasoconstriction (ie: oxaliplatin). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 3. Tamsulosin 0.4 mg PO BID 4. DULoxetine 30 mg PO DAILY 5. Creon [MASKED] CAP PO TID W/MEALS 6. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 7. MethylPHENIDATE (Ritalin) 20 mg PO QAM 8. Nystatin Oral Suspension 5 mL PO QID 9. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 10. Pyridoxine 50 mg PO DAILY 11. Glargine 15 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Creon [MASKED] CAP PO TID W/MEALS 3. DULoxetine 30 mg PO DAILY 4. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 6. Pyridoxine 50 mg PO DAILY 7. Tamsulosin 0.4 mg PO BID 8. Piperacillin-Tazobactam 4.5 g IV Q8H RX piperacillin-tazobactam 4.5 gram 4.5 g IV every 8 hours Disp #30 Vial Refills:0 9. MethylPHENIDATE (Ritalin) 20 mg PO QAM 10. Nystatin Oral Suspension 5 mL PO QID 11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 12. Glargine 15 Units Breakfast 13. Lisinopril 5 mg PO DAILY RX lisinopril 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 14. Outpatient Lab Work LABS FOR [MASKED] ICD-9-CM Diagnosis Code [MASKED].2 Biliary Obstruction CBC, Chem 10, ALT, AST, AP, LDH, TBili, Albumin Send to ATTN: Dr. [MASKED] [MASKED] and ATTN: Dr. [MASKED] [MASKED] [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: biliary obstruction pancreatic cancer Klebsiella and enterococcal septicemia Acute kidney injury SECONDARY DIAGNOSIS: Type 2 diabetes mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted for fever and elevated liver tests. You were found to have an obstruction in your biliary system and underwent a procedure called ERCP where a stent was placed. As your liver tests continued to trend up, you underwent a second ERCP where your previous stent which appeared to have migrated was replaced. Your blood cultures grew two different organisms (Klebsiella and enterococcus) and you are being discharged on an antibiotic called zosyn which will continue through [MASKED] for a total two week course. Please follow up with your oncologist Dr. [MASKED]. You will also have follow up lab draws to continue to monitor your liver tests. It was a pleasure caring for you - we wish you all the best! Sincerely, Your [MASKED] Oncology Team Followup Instructions: [MASKED]	[]	[ "N179", "E872", "E871", "E119", "I10", "E785" ]	[ "A4159: Other Gram-negative sepsis", "K831: Obstruction of bile duct", "N179: Acute kidney failure, unspecified", "D688: Other specified coagulation defects", "C250: Malignant neoplasm of head of pancreas", "E872: Acidosis", "K315: Obstruction of duodenum", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "B370: Candidal stomatitis", "E871: Hypo-osmolality and hyponatremia", "R188: Other ascites", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "A4181: Sepsis due to Enterococcus", "Z1611: Resistance to penicillins", "D381: Neoplasm of uncertain behavior of trachea, bronchus and lung", "Z9221: Personal history of antineoplastic chemotherapy", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "E860: Dehydration", "E8342: Hypomagnesemia", "D6481: Anemia due to antineoplastic chemotherapy", "E806: Other disorders of bilirubin metabolism", "D483: Neoplasm of uncertain behavior of retroperitoneum", "Z934: Other artificial openings of gastrointestinal tract status", "R630: Anorexia", "Z6820: Body mass index [BMI] 20.0-20.9, adult", "R112: Nausea with vomiting, unspecified", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z96642: Presence of left artificial hip joint", "N281: Cyst of kidney, acquired" ]
10,047,172	24,794,546	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate / heparin Attending: ___ Chief Complaint: ___ Major Surgical or Invasive Procedure: EGD s/p PICC placement ___ History of Present Illness: ___ yo male with a history of pancreatic cancer who is admitted with melena. The patient states this morning when he went to the bathroom he noticed black stool. He had this one previous time a couple of weeks ago the day after an ERCP but has not had it since. He denies any abdominal pain or nausea. He otherwise feels ok but does have fatigue and a poor appetite. He denies any recent fever, shortness of breath, rashes, or dysuria. Of note he was recently admitted from ___ with bacteremia and a biliary obstruction and had an CBD stent replacement. He completed a course of antibiotics with zosyn yesterday. REVIEW OF SYSTEMS: - All reviewed and negative except as noted in the HPI. Past Medical History: ONCOLOGIC HISTORY: Mr. ___ was diagnosed pancreatic adenocarcinoma metastatic to the liver in ___ when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX ___ which was halted due to rising CA ___ and increased size of liver metastases. In ___, CA ___ elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In ___ he started gemcitabine/Abraxane. Imaging ___ showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Course complicated by right thigh muscle infarct presumed ___ diabetes in ___. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Has required multiple dose and schedule adjustments in order to maximize quality of life, minimize marrow toxicity and maintain control over tumor (primarily assessed by tumor marker). Imaging has showed mixed response in early ___: given discordance with ___, unclear if true progression vs variations due to reduced chemotherapy exposure at various time points for various toxicity and scheduling reasons. In setting of increasing side effects and mixed response by imaging/markers, changed to CapOx on ___ scans show a mixed response to treatment, regimen changed to modified FOLFIRINOX -___: Began modified FOLFIRINOX with dose reduction ___ IVP and Leucovorin held from regimen) (Per OMR, patient previously given this regimine at ___ for 3 cycles ___ ago) -___: CT scan showed progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. -___: Patient started on erlotinib with plan for C1D1 of gemcitabine on ___. -Admitted to ___ on ___ for hyperbilirubinemia, fevers, n/v, and acute urinary retention. OTHER PAST MEDICAL HISTORY : - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture - kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI ___ Social History: ___ Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: PHYSICAL EXAM: General: NAD VITAL SIGNS: T 98.3 BP 156/72 HR 86 O2 100%RA HEENT: MMM, no OP lesions CV: RR PULM: CTAB ABD: Soft, NT, distended. LIMBS: No edema, clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown NEURO: Alert and oriented, no focal deficits. Discharge Exam: VS 98.2 160/80 88 18 97%RA Gen: thin, alert and conversant, more energetic than prior HEENT: MMM, OP clear Cardiovasc: RRR, old systolic murmur, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, NT, ND, BS+, protuberant, bulging flanks, + fluid wave Ext: no edema, warm, dry, no cyanosis or clubbing Skin: anasarca appears to be improving. Neuro: AAOx3. No facial droop. Nonfocal Psych: full range of affect GU: No foley, otherwise deferred Pertinent Results: Admission Labs: ___ 11:30AM BLOOD WBC-7.7 RBC-2.65* Hgb-8.0* Hct-24.9* MCV-94 MCH-30.2 MCHC-32.1 RDW-22.0* RDWSD-74.4* Plt ___ ___ 11:30AM BLOOD ___ PTT-27.6 ___ ___ 11:30AM BLOOD Glucose-214* UreaN-22* Creat-1.3* Na-132* K-4.9 Cl-99 HCO3-19* AnGap-19 ___ 11:30AM BLOOD ALT-36 AST-73* AlkPhos-683* TotBili-1.8* ___ 11:30AM BLOOD Lipase-9 ___ 11:30AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.8 RUQ US: 1. Moderate ascites. 2. Innumerable hepatic lesions, better demonstrated on prior MRI. 3. Known pneumobilia, suggestive of CBD stent patency. 4. Gallbladder sludge, without sonographic evidence of acute cholecystitis. ___ EGD: Findings: Esophagus: Mucosa: Evidence of a widely patent Schatzki's ring. Normal mucosa was otherwise noted. Stomach: Contents: Note was made of solid food within the stomach. There was no evidence of fresh or old blood Duodenum: Contents: The duodenal bulb was noted to contain a large quantity of solid food. There was no evidence of fresh or old blood. Impression: Evidence of a widely patent Schatzki's ring. Normal esophageal mucosa was otherwise noted. Note was made of solid food within the stomach. There was no evidence of fresh or old blood. The duodenal bulb was noted to contain a large quantity of solid food. There was no evidence of fresh or old blood within the duodenum. Discharge Labs: ___ 05:13AM BLOOD WBC-9.4 RBC-2.65* Hgb-8.3* Hct-25.2* MCV-95# MCH-31.3# MCHC-32.9# RDW-21.2* RDWSD-70.7* Plt ___ ___ 05:13AM BLOOD Glucose-49* UreaN-31* Creat-0.9 Na-137 K-3.9 Cl-101 HCO3-24 AnGap-16 ___ 06:20AM BLOOD ALT-47* AST-95* AlkPhos-849* TotBili-1.4 ___ 05:13AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.0 ___ 06:15AM BLOOD HEPARIN DEPENDENT ANTIBODIES-PND Brief Hospital Course: Mr. ___ is a ___ man with pancreatic ca s/p recent ERCP w CBD stent placement, DM type 2, recent biliary sepsis s/p stent/completed abx course (last dose zosyn ___ who presented with intermittent melena. Repeat ERCP found retained food in stomach and duodenal bulb (?due to mass compressing on duodenum), could not see source of bleeding. Responded well to 1u PRBC for anemia and GI bleeding appears to have stopped on his own. He has generally had poor po intake over several weeks in the setting of a known duodenal obstruction relating to his cancer and he was started on TPN (___) via ___. Hospital course complicated by hyperglycemia (controlled by the addition of insulin to the TPN) and thrombocytopenia (most likely relating to his known liver involvement and splenomegaly but heparin-dependent antibody was sent), improving upon discharge. On day of discharge plts >100 tomorrow and he received a dose of gemcitabine/erlotinib (per Dr. ___. Tolerating cycled TPN well, decreased insulin in TPN prior to discharge due to hypoglycemia overnight during cycle, patient awoke with symptoms. Rest of hospital course/plan as outlined below by issue: # Gastric/Duodenal outlet obstruction with protein calorie malnutrition: Initially with nausea/vomiting, poor PO intake which improved overall however not to the point to sustain his nutrition on a full liquid diet alone. He declined NJ tube placement. The issue of a J tube placement was raised however he was determined to be too high risk (given worsening ascites and liver mets). Discussed with surgery, who felt that presence of ascites and liver mets put him at very high risk for ascetic superinfection and poor wound healing. Given patient's aversion to NJT, discussed nutritional options again with ERCP team including revisiting attempting duodenal stent but not a candidate for a duodenal stent (given high likelihood of migration). The decision was made with Mr. ___ and his wife to pursue initiation of TPN. - TPN started ___ per nutrition recs, tolerating cycled TPN upon discharge. # Anasarca due to protein calorie malnutrition: Felt some improvement with lasix 20mg PO, so started on daily dosing x 7 days with counseling for daily weights and expected inadequate diuresis until protein levels improved. - lasix 20 mg PO daily - repeat lytes in follow up # Melena, upper GI bleed, Acute blood loss anemia on anemia of chronic inflammation: CBC stable after 1u PRBC ___. Suspect residual blood in current stools, but most likely this was tumor bleeding. # Metastatic pancreatic cancer: Diagnosed ___ stage 4, progressed on modified FOLFIRINOX, C1 Gemzar ___ received erlotinib. SW consult placed but patient declined. Inpatient chemo was delayed due to thrombocytopenia, which improved prior to discharge, and he received dose of gemcitabine/erlotinib on day of discharge due to improvement in platelets. - continued home Ritalin, ativan, Creon with liquids as tolerated # Thrombocytopenia: feel most likely due to liver disease with multiple mets (splenomegaly noted on MRI from ___) however progressive nature concerning for HIT, HIT-antibody was sent. Note that he had not been receiving sc heparin while inpatient due to concern for GI bleeding but had been receiving heparin flushes for his port. Thombocytopenia improved prior to discharge. - changed heparin flushes to citrate - follow up CBC as outpatient # HTN: continued home amlodipine, lisinopril # Acute Kidney Injury: Improved with IVF, likely prerenal. # Hyponatremia: Mild, likely hypovolemic and improved with IVF overnight. History of SIADH, known lingular mass unlikely playing a role during this admission. # Recent Klebsiella bacteremia: completed treatment course with Zosyn on ___, no evidence of infection throughout this admission. # DMII: HISS, hyperglycemic after PO intake improved. Restarted lantus 10U qAM (home dose previously 15U qAM) + ISS + insulin contained in his TPN which was titrated. # Abnormal LFTs: likely due to numerous liver mets, relatively stable # GOC: Wife and patient are very well-educated about his condition, want every aggressive treatment. Full code # Transitional Issues: -continue full liquids (although per ERCP, should not advance any further) -f/u with Dr. ___ ongoing chemotherapy -follow up with Dr. ___ with outpatient dietician ___ ___ for ongoing management of TPN. You need outpatient labs drawn to follow your TPN -heparin dependent antibodies will need to be followed up by Dr. ___ with her over the phone, aware of test sent) # ACCESS on discharge: PORT, PICC placed ___ > 30 minutes spent on discharge day planning, counseling, and coordination care. Discussed with patient and primary oncologist close follow up. Medically stable for discharge home with services. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Creon ___ CAP PO TID W/MEALS 3. DULoxetine 30 mg PO DAILY 4. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 6. Pyridoxine 50 mg PO DAILY 7. Tamsulosin 0.4 mg PO BID 8. MethylPHENIDATE (Ritalin) 20 mg PO QAM 9. Nystatin Oral Suspension 5 mL PO QID 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 11. Lisinopril 5 mg PO DAILY 12. Glargine 15 Units Breakfast Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Creon ___ CAP PO TID W/MEALS 3. DULoxetine 30 mg PO DAILY 4. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Lisinopril 5 mg PO DAILY 6. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 7. MethylPHENIDATE (Ritalin) 20 mg PO QAM 8. Pyridoxine 50 mg PO DAILY 9. Simethicone 80 mg PO TID:PRN gas 10. Sodium CITRATE 4% 3 mL DWELL PRN instead of heparin lock 11. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 13. Nystatin Oral Suspension 5 mL PO QID 14. Tamsulosin 0.4 mg PO BID 15. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: malnutrition, metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for bleeding from the GI tract relating to your underlying pancreatic cancer. You had an ERCP which showed retained food in your stomach but no source of bleeding. You had poor nutrition relating to obstruction by the cancer on your duodenum so a PICC line was placed and you were started on total parenteral nutrition (TPN) which was adjusted over the weekend. Please make sure to have some juice when TPN finishes in the morning. Your home long acting lantus insulin dose was decreased to 10units. You should not advance your diet beyond liquids due to the risk of obstruction in your intestine. Your platelets were low which is likely due to tumor involvement in your liver, but they were improving prior to discharge, and you were able to get your chemotherapy on ___. Follow up with Dr. ___ as an outpatient for ongoing chemotherapy. You should follow up with Dr. ___ with outpatient dietician ___ for ongoing management of your TPN. You need outpatient labs drawn to follow your TPN which will be followed up by this provider. Please make sure you weigh yourself daily, and call your doctor if your weight increases by more than ___ in 24 hours. Please take Lasix daily to help with your swelling for the next week. If you start to feel dizzy or dehydrated, DO NOT take your Lasix and call your doctor right away. We wish you all the best. Followup Instructions: ___	[ "K315", "C787", "N179", "E46", "E1165", "R188", "C250", "E871", "D62", "K921", "D6959", "K222", "I10", "E785", "K3189", "Z6821" ]	Allergies: sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate / heparin Chief Complaint: [MASKED] Major Surgical or Invasive Procedure: EGD s/p PICC placement [MASKED] History of Present Illness: [MASKED] yo male with a history of pancreatic cancer who is admitted with melena. The patient states this morning when he went to the bathroom he noticed black stool. He had this one previous time a couple of weeks ago the day after an ERCP but has not had it since. He denies any abdominal pain or nausea. He otherwise feels ok but does have fatigue and a poor appetite. He denies any recent fever, shortness of breath, rashes, or dysuria. Of note he was recently admitted from [MASKED] with bacteremia and a biliary obstruction and had an CBD stent replacement. He completed a course of antibiotics with zosyn yesterday. REVIEW OF SYSTEMS: - All reviewed and negative except as noted in the HPI. Past Medical History: ONCOLOGIC HISTORY: Mr. [MASKED] was diagnosed pancreatic adenocarcinoma metastatic to the liver in [MASKED] when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX [MASKED] which was halted due to rising CA [MASKED] and increased size of liver metastases. In [MASKED], CA [MASKED] elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In [MASKED] he started gemcitabine/Abraxane. Imaging [MASKED] showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Course complicated by right thigh muscle infarct presumed [MASKED] diabetes in [MASKED]. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Has required multiple dose and schedule adjustments in order to maximize quality of life, minimize marrow toxicity and maintain control over tumor (primarily assessed by tumor marker). Imaging has showed mixed response in early [MASKED]: given discordance with [MASKED], unclear if true progression vs variations due to reduced chemotherapy exposure at various time points for various toxicity and scheduling reasons. In setting of increasing side effects and mixed response by imaging/markers, changed to CapOx on [MASKED] scans show a mixed response to treatment, regimen changed to modified FOLFIRINOX -[MASKED]: Began modified FOLFIRINOX with dose reduction [MASKED] IVP and Leucovorin held from regimen) (Per OMR, patient previously given this regimine at [MASKED] for 3 cycles [MASKED] ago) -[MASKED]: CT scan showed progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. -[MASKED]: Patient started on erlotinib with plan for C1D1 of gemcitabine on [MASKED]. -Admitted to [MASKED] on [MASKED] for hyperbilirubinemia, fevers, n/v, and acute urinary retention. OTHER PAST MEDICAL HISTORY : - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture - kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI [MASKED] Social History: [MASKED] Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: PHYSICAL EXAM: General: NAD VITAL SIGNS: T 98.3 BP 156/72 HR 86 O2 100%RA HEENT: MMM, no OP lesions CV: RR PULM: CTAB ABD: Soft, NT, distended. LIMBS: No edema, clubbing, tremors, or asterixis SKIN: No rashes or skin breakdown NEURO: Alert and oriented, no focal deficits. Discharge Exam: VS 98.2 160/80 88 18 97%RA Gen: thin, alert and conversant, more energetic than prior HEENT: MMM, OP clear Cardiovasc: RRR, old systolic murmur, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA [MASKED]. GI: soft, NT, ND, BS+, protuberant, bulging flanks, + fluid wave Ext: no edema, warm, dry, no cyanosis or clubbing Skin: anasarca appears to be improving. Neuro: AAOx3. No facial droop. Nonfocal Psych: full range of affect GU: No foley, otherwise deferred Pertinent Results: Admission Labs: [MASKED] 11:30AM BLOOD WBC-7.7 RBC-2.65* Hgb-8.0* Hct-24.9* MCV-94 MCH-30.2 MCHC-32.1 RDW-22.0* RDWSD-74.4* Plt [MASKED] [MASKED] 11:30AM BLOOD [MASKED] PTT-27.6 [MASKED] [MASKED] 11:30AM BLOOD Glucose-214* UreaN-22* Creat-1.3* Na-132* K-4.9 Cl-99 HCO3-19* AnGap-19 [MASKED] 11:30AM BLOOD ALT-36 AST-73* AlkPhos-683* TotBili-1.8* [MASKED] 11:30AM BLOOD Lipase-9 [MASKED] 11:30AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.8 RUQ US: 1. Moderate ascites. 2. Innumerable hepatic lesions, better demonstrated on prior MRI. 3. Known pneumobilia, suggestive of CBD stent patency. 4. Gallbladder sludge, without sonographic evidence of acute cholecystitis. [MASKED] EGD: Findings: Esophagus: Mucosa: Evidence of a widely patent Schatzki's ring. Normal mucosa was otherwise noted. Stomach: Contents: Note was made of solid food within the stomach. There was no evidence of fresh or old blood Duodenum: Contents: The duodenal bulb was noted to contain a large quantity of solid food. There was no evidence of fresh or old blood. Impression: Evidence of a widely patent Schatzki's ring. Normal esophageal mucosa was otherwise noted. Note was made of solid food within the stomach. There was no evidence of fresh or old blood. The duodenal bulb was noted to contain a large quantity of solid food. There was no evidence of fresh or old blood within the duodenum. Discharge Labs: [MASKED] 05:13AM BLOOD WBC-9.4 RBC-2.65* Hgb-8.3* Hct-25.2* MCV-95# MCH-31.3# MCHC-32.9# RDW-21.2* RDWSD-70.7* Plt [MASKED] [MASKED] 05:13AM BLOOD Glucose-49* UreaN-31* Creat-0.9 Na-137 K-3.9 Cl-101 HCO3-24 AnGap-16 [MASKED] 06:20AM BLOOD ALT-47* AST-95* AlkPhos-849* TotBili-1.4 [MASKED] 05:13AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.0 [MASKED] 06:15AM BLOOD HEPARIN DEPENDENT ANTIBODIES-PND Brief Hospital Course: Mr. [MASKED] is a [MASKED] man with pancreatic ca s/p recent ERCP w CBD stent placement, DM type 2, recent biliary sepsis s/p stent/completed abx course (last dose zosyn [MASKED] who presented with intermittent melena. Repeat ERCP found retained food in stomach and duodenal bulb (?due to mass compressing on duodenum), could not see source of bleeding. Responded well to 1u PRBC for anemia and GI bleeding appears to have stopped on his own. He has generally had poor po intake over several weeks in the setting of a known duodenal obstruction relating to his cancer and he was started on TPN ([MASKED]) via [MASKED]. Hospital course complicated by hyperglycemia (controlled by the addition of insulin to the TPN) and thrombocytopenia (most likely relating to his known liver involvement and splenomegaly but heparin-dependent antibody was sent), improving upon discharge. On day of discharge plts >100 tomorrow and he received a dose of gemcitabine/erlotinib (per Dr. [MASKED]. Tolerating cycled TPN well, decreased insulin in TPN prior to discharge due to hypoglycemia overnight during cycle, patient awoke with symptoms. Rest of hospital course/plan as outlined below by issue: # Gastric/Duodenal outlet obstruction with protein calorie malnutrition: Initially with nausea/vomiting, poor PO intake which improved overall however not to the point to sustain his nutrition on a full liquid diet alone. He declined NJ tube placement. The issue of a J tube placement was raised however he was determined to be too high risk (given worsening ascites and liver mets). Discussed with surgery, who felt that presence of ascites and liver mets put him at very high risk for ascetic superinfection and poor wound healing. Given patient's aversion to NJT, discussed nutritional options again with ERCP team including revisiting attempting duodenal stent but not a candidate for a duodenal stent (given high likelihood of migration). The decision was made with Mr. [MASKED] and his wife to pursue initiation of TPN. - TPN started [MASKED] per nutrition recs, tolerating cycled TPN upon discharge. # Anasarca due to protein calorie malnutrition: Felt some improvement with lasix 20mg PO, so started on daily dosing x 7 days with counseling for daily weights and expected inadequate diuresis until protein levels improved. - lasix 20 mg PO daily - repeat lytes in follow up # Melena, upper GI bleed, Acute blood loss anemia on anemia of chronic inflammation: CBC stable after 1u PRBC [MASKED]. Suspect residual blood in current stools, but most likely this was tumor bleeding. # Metastatic pancreatic cancer: Diagnosed [MASKED] stage 4, progressed on modified FOLFIRINOX, C1 Gemzar [MASKED] received erlotinib. SW consult placed but patient declined. Inpatient chemo was delayed due to thrombocytopenia, which improved prior to discharge, and he received dose of gemcitabine/erlotinib on day of discharge due to improvement in platelets. - continued home Ritalin, ativan, Creon with liquids as tolerated # Thrombocytopenia: feel most likely due to liver disease with multiple mets (splenomegaly noted on MRI from [MASKED]) however progressive nature concerning for HIT, HIT-antibody was sent. Note that he had not been receiving sc heparin while inpatient due to concern for GI bleeding but had been receiving heparin flushes for his port. Thombocytopenia improved prior to discharge. - changed heparin flushes to citrate - follow up CBC as outpatient # HTN: continued home amlodipine, lisinopril # Acute Kidney Injury: Improved with IVF, likely prerenal. # Hyponatremia: Mild, likely hypovolemic and improved with IVF overnight. History of SIADH, known lingular mass unlikely playing a role during this admission. # Recent Klebsiella bacteremia: completed treatment course with Zosyn on [MASKED], no evidence of infection throughout this admission. # DMII: HISS, hyperglycemic after PO intake improved. Restarted lantus 10U qAM (home dose previously 15U qAM) + ISS + insulin contained in his TPN which was titrated. # Abnormal LFTs: likely due to numerous liver mets, relatively stable # GOC: Wife and patient are very well-educated about his condition, want every aggressive treatment. Full code # Transitional Issues: -continue full liquids (although per ERCP, should not advance any further) -f/u with Dr. [MASKED] ongoing chemotherapy -follow up with Dr. [MASKED] with outpatient dietician [MASKED] [MASKED] for ongoing management of TPN. You need outpatient labs drawn to follow your TPN -heparin dependent antibodies will need to be followed up by Dr. [MASKED] with her over the phone, aware of test sent) # ACCESS on discharge: PORT, PICC placed [MASKED] > 30 minutes spent on discharge day planning, counseling, and coordination care. Discussed with patient and primary oncologist close follow up. Medically stable for discharge home with services. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Creon [MASKED] CAP PO TID W/MEALS 3. DULoxetine 30 mg PO DAILY 4. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 6. Pyridoxine 50 mg PO DAILY 7. Tamsulosin 0.4 mg PO BID 8. MethylPHENIDATE (Ritalin) 20 mg PO QAM 9. Nystatin Oral Suspension 5 mL PO QID 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 11. Lisinopril 5 mg PO DAILY 12. Glargine 15 Units Breakfast Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Creon [MASKED] CAP PO TID W/MEALS 3. DULoxetine 30 mg PO DAILY 4. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Lisinopril 5 mg PO DAILY 6. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 7. MethylPHENIDATE (Ritalin) 20 mg PO QAM 8. Pyridoxine 50 mg PO DAILY 9. Simethicone 80 mg PO TID:PRN gas 10. Sodium CITRATE 4% 3 mL DWELL PRN instead of heparin lock 11. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 13. Nystatin Oral Suspension 5 mL PO QID 14. Tamsulosin 0.4 mg PO BID 15. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: malnutrition, metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted for bleeding from the GI tract relating to your underlying pancreatic cancer. You had an ERCP which showed retained food in your stomach but no source of bleeding. You had poor nutrition relating to obstruction by the cancer on your duodenum so a PICC line was placed and you were started on total parenteral nutrition (TPN) which was adjusted over the weekend. Please make sure to have some juice when TPN finishes in the morning. Your home long acting lantus insulin dose was decreased to 10units. You should not advance your diet beyond liquids due to the risk of obstruction in your intestine. Your platelets were low which is likely due to tumor involvement in your liver, but they were improving prior to discharge, and you were able to get your chemotherapy on [MASKED]. Follow up with Dr. [MASKED] as an outpatient for ongoing chemotherapy. You should follow up with Dr. [MASKED] with outpatient dietician [MASKED] for ongoing management of your TPN. You need outpatient labs drawn to follow your TPN which will be followed up by this provider. Please make sure you weigh yourself daily, and call your doctor if your weight increases by more than [MASKED] in 24 hours. Please take Lasix daily to help with your swelling for the next week. If you start to feel dizzy or dehydrated, DO NOT take your Lasix and call your doctor right away. We wish you all the best. Followup Instructions: [MASKED]	[]	[ "N179", "E1165", "E871", "D62", "I10", "E785" ]	[ "K315: Obstruction of duodenum", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "N179: Acute kidney failure, unspecified", "E46: Unspecified protein-calorie malnutrition", "E1165: Type 2 diabetes mellitus with hyperglycemia", "R188: Other ascites", "C250: Malignant neoplasm of head of pancreas", "E871: Hypo-osmolality and hyponatremia", "D62: Acute posthemorrhagic anemia", "K921: Melena", "D6959: Other secondary thrombocytopenia", "K222: Esophageal obstruction", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K3189: Other diseases of stomach and duodenum", "Z6821: Body mass index [BMI] 21.0-21.9, adult" ]
10,047,172	28,178,907	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate Attending: ___. Chief Complaint: anasarca Major Surgical or Invasive Procedure: therapeutic paracentesis with ___ History of Present Illness: Professor ___ is a pleasant ___ w/ T2DM, HTN, DL and pancreatic cancer metastatic to the liver (biopsy proven), dx ___, currently on C1D10 Gemcitabine and erlotinib, who p/w leaking paracentesis site on his LLQ, increased abdominal distention, increased b/l ___. His last paracentesis was ___, and 3L removed. He denied any F/CP/SOB but found to have new small b/l pleural effusions Past Medical History: ONCOLOGIC HISTORY: Mr. ___ was diagnosed pancreatic adenocarcinoma metastatic to the liver in ___ when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX ___ which was halted due to rising CA ___ and increased size of liver metastases. In ___, CA ___ elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In ___ he started gemcitabine/Abraxane. Imaging ___ showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Course complicated by right thigh muscle infarct presumed ___ diabetes in ___. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Has required multiple dose and schedule adjustments in order to maximize quality of life, minimize marrow toxicity and maintain control over tumor (primarily assessed by tumor marker). Imaging has showed mixed response in early ___: given discordance with ___, unclear if true progression vs variations due to reduced chemotherapy exposure at various time points for various toxicity and scheduling reasons. In setting of increasing side effects and mixed response by imaging/markers, changed to CapOx on ___ scans show a mixed response to treatment, regimen changed to modified FOLFIRINOX -___: Began modified FOLFIRINOX with dose reduction ___ IVP and Leucovorin held from regimen) (Per OMR, patient previously given this regimine at ___ for 3 cycles ___ ago) -___: CT scan showed progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. -___: Patient started on erlotinib with plan for C1D1 of gemcitabine on ___. -Admitted to ___ on ___ for hyperbilirubinemia, fevers, n/v, and acute urinary retention. OTHER PAST MEDICAL HISTORY : - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture - kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI ___ Social History: ___ Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 97.8F 156/72 91 18 97% 158 lbs General: NAD, Resting in bed comfortably, well nourished HEENT: MM dry, + mild thrush along the mandible folds CV: RR, NL S1S2 no ___ apical SEM PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, distended, dressing over LLQ saturated LIMBS: WWP, 2+ pitting ___, no tremors SKIN: No rashes on the extremities, port site looks well, skin overlying left picc intact NEURO: Grossly normal DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 97.5 Axillary 140 / 70 92 19 95 RA General: NAD, Resting in bed comfortably, evidence of wasting though with distended abdomen HEENT: MM dry, + mild thrush along the mandible folds CV: RR, NL S1S2 no ___ apical SEM PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, notably distended, LLQ suture in place LIMBS: WWP, 2+ pitting ___, no tremors SKIN: No rashes on the extremities, port site looks well, skin overlying left picc intact NEURO: Grossly normal Pertinent Results: ADMISSION LABS ___ 12:08PM BLOOD WBC-2.4# RBC-2.47 Hgb-8.0* Hct-23.6* MCV-96 MCH-32.4* MCHC-33.9 RDW-19.1* RDWSD-65.4* Plt ___ ___ 12:08PM BLOOD AbsNeut-1.57# ___ 12:08PM BLOOD Plt ___ ___ 09:35PM BLOOD Glucose-172 UreaN-35* Creat-1.1 Na-137 K-4.1 Cl-102 HCO3-23 AnGap-16 ___ 09:35PM BLOOD ALT-38 AST-76* LD(LDH)-321* AlkPhos-949* TotBili-1.4 ___ 09:35PM BLOOD TotProt-6.1* Albumin-2.6* Globuln-3.5 ___ 09:45PM BLOOD Lactate-2.7* DISCHARGE LABS ___ 05:44AM BLOOD WBC-4.8 RBC-2.95* Hgb-9.2* Hct-27.7* MCV-94 MCH-31.2 MCHC-33.2 RDW-19.1* RDWSD-62.6* Plt ___ ___ 09:35PM BLOOD Neuts-63 Bands-1 ___ Monos-10 Eos-0 Baso-0 ___ Myelos-0 Hyperse-3* AbsNeut-3.42 AbsLymp-1.17* AbsMono-0.51 AbsEos-0.00* AbsBaso-0.00* ___ 09:35PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 05:44AM BLOOD Plt ___ ___ 05:44AM BLOOD ___ ___ 05:44AM BLOOD Glucose-156* UreaN-32* Creat-1.0 Na-136 K-4.1 Cl-102 HCO3-23 AnGap-15 ___ 05:44AM BLOOD ALT-36 AST-74* LD(LDH)-305* AlkPhos-933* TotBili-1.5 ___ 05:44AM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.1 Mg-1.9 IMAGING: MRI Liver ___ Progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. Additionally, the primary pancreatic cancer in the pancreatic head is very minimally increased in size. CT CHEST w/ CON ___ New irregular nodule in the right upper lobe and interval increase of the right lower lobe nodules concerning for progressive metastatic disease. ERCP ___ 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 [partially] were imaged from the gastric body and fundus. Mass: A 3.5 cm X 4 cm ill-defined mass was noted in the head of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. The mass is involving the confluence, especially the SMV with narrowing of vessel diameter. FNB was performed. Color doppler was used to determine an avascular path for needle aspiration. A 22-gauge needle with a stylet was used to perform biopsy. Six needle passes were made into the mass. Biopsies were sent for pathology. Scan of the left hepatic lobe reveled multiple hypoechoic lesions measured between 0.5-2cm, highly suspected for metastatic disease, FNB was performed from 3 different hepatic lesions Otherwise normal upper eus to third part of the duodenum CXR ___ 1. Left PICC tip in the low SVC. No pneumothorax. 2. Small bilateral pleural effusions, new in the interval, with bibasilar atelectasis. Brief Hospital Course: ___ w/ T2DM, HTN, DL and pancreatic cancer metastatic to the liver (biopsy proven), dx ___, currently on C1D10 Gemcitabine and erlotinib, recent biliary sepsis s/p stent/completed abx course for klebsiella bacteremia (last dose zosyn ___ who p/w leaking paracentesis site on his LLQ and increased anasarca with ___ edema and new asymptomatic ___ pleural effusions, patient is now s/p therapeutic paracentesis ___. He was seen by his primary oncologist and will follow up with her on ___ and will continue with 1000 mg xeloda bid X 14 days, 7 days off and tarceva continuously once home delivery complete. # Increased Anasarca # Ascites # Leaking Paracentesis site Since ___, pt has gained 24 lbs. Likely multifactorial, but will discuss w/ onc whether this maybe due to capillary leak syndrome from gemcitabine. Other causes include pancreatic ca, pseudocirrohsis from liver mets, protein calorie malnutrition, iatrogenic fluid overload from TPN. INR and LFTs largely stable w/o evidence of hepatic decompensation. He was started on lasix on most recent admission. - home amlodipine, lisinopril held while patient was admitted so that diuretic regimen could be increased. started on 50mg daily and 20mg Lasix daily. TPN was held for contribution to fluid overload. Patient underwent ___ guided therapeutic para ___ # Pancreatic Ca Diagnosed ___ stage 4, progressed on modified FOLFIRINOX, C1 Gemzar ___ received erlotinib. Dr ___ followed through inpatient admission. Did not administer Gemcitabine while inpatient. pt will follow up as outpatient for Gemcitabine, dosing schedule per Dr. ___. ___ consider every other week dosing given significant fatigue, weigh benefits and AEs of chemo. Continued Ritalin and Ativan prn, continued creon 2 caps w/ break, 2 w/ lunch, 1 w/ dinner, 0 w/ snacks # Gastric/Duodenal outlet obstruction # Protein Calorie Malnutrition. Per recent discharge note, he is not a candidate for duodenal stent given high likelihood of migration. He was started on TPN. SHould continue to evaluate contribution of TPN to fluid overload. TPN held during hospitalization for diuresis. # Thrombocytopenia This is most likely due to his hepatic disease and splenomegaly, as well as chemo. However there was c/f HIT on recent admission but ruled out. avoided hsq for now until further clarified w/ Dr ___. continued TEDS # Normocytic Anemia: due to inflammatory block from neoplasm and antineoplastic therapy # Recent Klebsiella bacteremia: completed treatment course with Zosyn on ___. # T2DM: At home takes metformin w/ Glargine 10U w/ breakfast and ISS. Here will hold and keep only on ISS. Of note, he also has insulin in his TPN. # HTN: held amlodipine (which can cause ___ and lisinopril in favor of lasix and aldactone # Heart murmur: chronic x ___ years per his report # BPH: cont tamsulosin bid. TRANSITIONAL ISSUES ================================== -home amlodipine 10 mg and lisinopril 5 mg daily held for BP room as patient started on spironolactone 50 mg for increased diuresis -Please F/U BP, Cr and next apt; d/c weight 158 lbs; presumed dry weight 136 lbs, d/c creatinine 1.0 -Patient advised to call PCP and oncologist regarding extreme weight changes -Left message for ___ TPN center to try to concentrate home TPN to help reduce fluid overload Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amlodipine 10 mg PO DAILY 2. Creon ___ CAP PO TID W/MEALS 3. DULoxetine 30 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 6. MethylPHENIDATE (Ritalin) 20 mg PO QAM 7. Pyridoxine 50 mg PO DAILY 8. Simethicone 80 mg PO TID:PRN gas 9. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 11. Nystatin Oral Suspension 5 mL PO QID 12. Tamsulosin 0.4 mg PO BID 13. Furosemide 20 mg PO DAILY Discharge Medications: 1. Creon ___ CAP PO TID W/MEALS 2. DULoxetine 30 mg PO DAILY 3. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 4. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 5. MethylPHENIDATE (Ritalin) 20 mg PO QAM 6. Nystatin Oral Suspension 5 mL PO QID 7. Pyridoxine 50 mg PO DAILY 8. Simethicone 80 mg PO TID:PRN gas 9. Tamsulosin 0.4 mg PO BID 10. Spironolactone 50 mg PO DAILY RX spironolactone [Aldactone] 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 11. Furosemide 20 mg PO DAILY 12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 13. Erlotinib ___ mg PO DAILY dosing per outpatient oncologist 14. Capecitabine 1000 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: pancreatic cancer malignant ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital for continued leakage after undergoing paracentesis. You had stitches placed to good effect to stop the leaking. While in the hospital, you underwent paracentesis with the interventional radiology team and your diuretics were increased to add spironolactone 50mg daily on top of your furosemide 20 mg daily to prevent fluid from accumulating. You are now safe for discharge home with close follow up. We left a message with out TPN team to adjust and concentrate your home TPN. You should also follow up with Dr. ___ in ___. You will continue your chemotherapy at home as planned until you get home delivery of xeldoa (1000 mg twice a day for two weeks on, then one week off) and Tarceva. It was a pleasure caring for you - we wish you well! Sincerely, Your ___ Oncology Team Followup Instructions: ___	[ "R180", "C250", "C787", "K315", "E46", "D696", "D6481", "E119", "I10", "N400" ]	Allergies: sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase Inhibitors / saxagliptin / pioglitazone / canagliflozin / fenofibrate Chief Complaint: anasarca Major Surgical or Invasive Procedure: therapeutic paracentesis with [MASKED] History of Present Illness: Professor [MASKED] is a pleasant [MASKED] w/ T2DM, HTN, DL and pancreatic cancer metastatic to the liver (biopsy proven), dx [MASKED], currently on C1D10 Gemcitabine and erlotinib, who p/w leaking paracentesis site on his LLQ, increased abdominal distention, increased b/l [MASKED]. His last paracentesis was [MASKED], and 3L removed. He denied any F/CP/SOB but found to have new small b/l pleural effusions Past Medical History: ONCOLOGIC HISTORY: Mr. [MASKED] was diagnosed pancreatic adenocarcinoma metastatic to the liver in [MASKED] when he was admitted for painless jaundice. CT showed 3.3cm pancreatic head mass and MRI showed a 1.8cm left kidney lesion concerning for RCC as well as 2 sub-cm liver masses. FNA of pancreas showed 'suspicious' cells. His pancreatic mass was deemed unresectable due to abutting the SMV and portal vein. He was treated with three cycles of FOLFIRINOX [MASKED] which was halted due to rising CA [MASKED] and increased size of liver metastases. In [MASKED], CA [MASKED] elevated to 23K and considered potentially related to left finger infection in setting of diabetes. Imaging shows increased size of liver metastases. In [MASKED] he started gemcitabine/Abraxane. Imaging [MASKED] showing slight decrease in the size of the liver metastases with stable disease at the pancreas. Course complicated by right thigh muscle infarct presumed [MASKED] diabetes in [MASKED]. Primary chemotherapy side effect has been neuropathy on the bottoms of b/l feet without impairment of ADLs. Has required multiple dose and schedule adjustments in order to maximize quality of life, minimize marrow toxicity and maintain control over tumor (primarily assessed by tumor marker). Imaging has showed mixed response in early [MASKED]: given discordance with [MASKED], unclear if true progression vs variations due to reduced chemotherapy exposure at various time points for various toxicity and scheduling reasons. In setting of increasing side effects and mixed response by imaging/markers, changed to CapOx on [MASKED] scans show a mixed response to treatment, regimen changed to modified FOLFIRINOX -[MASKED]: Began modified FOLFIRINOX with dose reduction [MASKED] IVP and Leucovorin held from regimen) (Per OMR, patient previously given this regimine at [MASKED] for 3 cycles [MASKED] ago) -[MASKED]: CT scan showed progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. -[MASKED]: Patient started on erlotinib with plan for C1D1 of gemcitabine on [MASKED]. -Admitted to [MASKED] on [MASKED] for hyperbilirubinemia, fevers, n/v, and acute urinary retention. OTHER PAST MEDICAL HISTORY : - T2DM - Hypertension - Hyperlipidemia - s/p L hip replacement - heart murmur - s/p nose fracture - kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI [MASKED] Social History: [MASKED] Family History: Mother: dementia Father: bladder cancer at older age Cancers in the family: paternal cousin with primary liver cancer Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 97.8F 156/72 91 18 97% 158 lbs General: NAD, Resting in bed comfortably, well nourished HEENT: MM dry, + mild thrush along the mandible folds CV: RR, NL S1S2 no [MASKED] apical SEM PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, distended, dressing over LLQ saturated LIMBS: WWP, 2+ pitting [MASKED], no tremors SKIN: No rashes on the extremities, port site looks well, skin overlying left picc intact NEURO: Grossly normal DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 97.5 Axillary 140 / 70 92 19 95 RA General: NAD, Resting in bed comfortably, evidence of wasting though with distended abdomen HEENT: MM dry, + mild thrush along the mandible folds CV: RR, NL S1S2 no [MASKED] apical SEM PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, notably distended, LLQ suture in place LIMBS: WWP, 2+ pitting [MASKED], no tremors SKIN: No rashes on the extremities, port site looks well, skin overlying left picc intact NEURO: Grossly normal Pertinent Results: ADMISSION LABS [MASKED] 12:08PM BLOOD WBC-2.4# RBC-2.47 Hgb-8.0* Hct-23.6* MCV-96 MCH-32.4* MCHC-33.9 RDW-19.1* RDWSD-65.4* Plt [MASKED] [MASKED] 12:08PM BLOOD AbsNeut-1.57# [MASKED] 12:08PM BLOOD Plt [MASKED] [MASKED] 09:35PM BLOOD Glucose-172 UreaN-35* Creat-1.1 Na-137 K-4.1 Cl-102 HCO3-23 AnGap-16 [MASKED] 09:35PM BLOOD ALT-38 AST-76* LD(LDH)-321* AlkPhos-949* TotBili-1.4 [MASKED] 09:35PM BLOOD TotProt-6.1* Albumin-2.6* Globuln-3.5 [MASKED] 09:45PM BLOOD Lactate-2.7* DISCHARGE LABS [MASKED] 05:44AM BLOOD WBC-4.8 RBC-2.95* Hgb-9.2* Hct-27.7* MCV-94 MCH-31.2 MCHC-33.2 RDW-19.1* RDWSD-62.6* Plt [MASKED] [MASKED] 09:35PM BLOOD Neuts-63 Bands-1 [MASKED] Monos-10 Eos-0 Baso-0 [MASKED] Myelos-0 Hyperse-3* AbsNeut-3.42 AbsLymp-1.17* AbsMono-0.51 AbsEos-0.00* AbsBaso-0.00* [MASKED] 09:35PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [MASKED] 05:44AM BLOOD Plt [MASKED] [MASKED] 05:44AM BLOOD [MASKED] [MASKED] 05:44AM BLOOD Glucose-156* UreaN-32* Creat-1.0 Na-136 K-4.1 Cl-102 HCO3-23 AnGap-15 [MASKED] 05:44AM BLOOD ALT-36 AST-74* LD(LDH)-305* AlkPhos-933* TotBili-1.5 [MASKED] 05:44AM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.1 Mg-1.9 IMAGING: MRI Liver [MASKED] Progression of disease with an interval increase in size of the innumerable hepatic masses, increased abnormal soft tissue in the retroperitoneum, and increasing ascites. Additionally, the primary pancreatic cancer in the pancreatic head is very minimally increased in size. CT CHEST w/ CON [MASKED] New irregular nodule in the right upper lobe and interval increase of the right lower lobe nodules concerning for progressive metastatic disease. ERCP [MASKED] 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 [partially] were imaged from the gastric body and fundus. Mass: A 3.5 cm X 4 cm ill-defined mass was noted in the head of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. The mass is involving the confluence, especially the SMV with narrowing of vessel diameter. FNB was performed. Color doppler was used to determine an avascular path for needle aspiration. A 22-gauge needle with a stylet was used to perform biopsy. Six needle passes were made into the mass. Biopsies were sent for pathology. Scan of the left hepatic lobe reveled multiple hypoechoic lesions measured between 0.5-2cm, highly suspected for metastatic disease, FNB was performed from 3 different hepatic lesions Otherwise normal upper eus to third part of the duodenum CXR [MASKED] 1. Left PICC tip in the low SVC. No pneumothorax. 2. Small bilateral pleural effusions, new in the interval, with bibasilar atelectasis. Brief Hospital Course: [MASKED] w/ T2DM, HTN, DL and pancreatic cancer metastatic to the liver (biopsy proven), dx [MASKED], currently on C1D10 Gemcitabine and erlotinib, recent biliary sepsis s/p stent/completed abx course for klebsiella bacteremia (last dose zosyn [MASKED] who p/w leaking paracentesis site on his LLQ and increased anasarca with [MASKED] edema and new asymptomatic [MASKED] pleural effusions, patient is now s/p therapeutic paracentesis [MASKED]. He was seen by his primary oncologist and will follow up with her on [MASKED] and will continue with 1000 mg xeloda bid X 14 days, 7 days off and tarceva continuously once home delivery complete. # Increased Anasarca # Ascites # Leaking Paracentesis site Since [MASKED], pt has gained 24 lbs. Likely multifactorial, but will discuss w/ onc whether this maybe due to capillary leak syndrome from gemcitabine. Other causes include pancreatic ca, pseudocirrohsis from liver mets, protein calorie malnutrition, iatrogenic fluid overload from TPN. INR and LFTs largely stable w/o evidence of hepatic decompensation. He was started on lasix on most recent admission. - home amlodipine, lisinopril held while patient was admitted so that diuretic regimen could be increased. started on 50mg daily and 20mg Lasix daily. TPN was held for contribution to fluid overload. Patient underwent [MASKED] guided therapeutic para [MASKED] # Pancreatic Ca Diagnosed [MASKED] stage 4, progressed on modified FOLFIRINOX, C1 Gemzar [MASKED] received erlotinib. Dr [MASKED] followed through inpatient admission. Did not administer Gemcitabine while inpatient. pt will follow up as outpatient for Gemcitabine, dosing schedule per Dr. [MASKED]. [MASKED] consider every other week dosing given significant fatigue, weigh benefits and AEs of chemo. Continued Ritalin and Ativan prn, continued creon 2 caps w/ break, 2 w/ lunch, 1 w/ dinner, 0 w/ snacks # Gastric/Duodenal outlet obstruction # Protein Calorie Malnutrition. Per recent discharge note, he is not a candidate for duodenal stent given high likelihood of migration. He was started on TPN. SHould continue to evaluate contribution of TPN to fluid overload. TPN held during hospitalization for diuresis. # Thrombocytopenia This is most likely due to his hepatic disease and splenomegaly, as well as chemo. However there was c/f HIT on recent admission but ruled out. avoided hsq for now until further clarified w/ Dr [MASKED]. continued TEDS # Normocytic Anemia: due to inflammatory block from neoplasm and antineoplastic therapy # Recent Klebsiella bacteremia: completed treatment course with Zosyn on [MASKED]. # T2DM: At home takes metformin w/ Glargine 10U w/ breakfast and ISS. Here will hold and keep only on ISS. Of note, he also has insulin in his TPN. # HTN: held amlodipine (which can cause [MASKED] and lisinopril in favor of lasix and aldactone # Heart murmur: chronic x [MASKED] years per his report # BPH: cont tamsulosin bid. TRANSITIONAL ISSUES ================================== -home amlodipine 10 mg and lisinopril 5 mg daily held for BP room as patient started on spironolactone 50 mg for increased diuresis -Please F/U BP, Cr and next apt; d/c weight 158 lbs; presumed dry weight 136 lbs, d/c creatinine 1.0 -Patient advised to call PCP and oncologist regarding extreme weight changes -Left message for [MASKED] TPN center to try to concentrate home TPN to help reduce fluid overload Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amlodipine 10 mg PO DAILY 2. Creon [MASKED] CAP PO TID W/MEALS 3. DULoxetine 30 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 6. MethylPHENIDATE (Ritalin) 20 mg PO QAM 7. Pyridoxine 50 mg PO DAILY 8. Simethicone 80 mg PO TID:PRN gas 9. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 11. Nystatin Oral Suspension 5 mL PO QID 12. Tamsulosin 0.4 mg PO BID 13. Furosemide 20 mg PO DAILY Discharge Medications: 1. Creon [MASKED] CAP PO TID W/MEALS 2. DULoxetine 30 mg PO DAILY 3. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep 4. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue, decreased concentration 5. MethylPHENIDATE (Ritalin) 20 mg PO QAM 6. Nystatin Oral Suspension 5 mL PO QID 7. Pyridoxine 50 mg PO DAILY 8. Simethicone 80 mg PO TID:PRN gas 9. Tamsulosin 0.4 mg PO BID 10. Spironolactone 50 mg PO DAILY RX spironolactone [Aldactone] 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 11. Furosemide 20 mg PO DAILY 12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 13. Erlotinib [MASKED] mg PO DAILY dosing per outpatient oncologist 14. Capecitabine 1000 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: pancreatic cancer malignant ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital for continued leakage after undergoing paracentesis. You had stitches placed to good effect to stop the leaking. While in the hospital, you underwent paracentesis with the interventional radiology team and your diuretics were increased to add spironolactone 50mg daily on top of your furosemide 20 mg daily to prevent fluid from accumulating. You are now safe for discharge home with close follow up. We left a message with out TPN team to adjust and concentrate your home TPN. You should also follow up with Dr. [MASKED] in [MASKED]. You will continue your chemotherapy at home as planned until you get home delivery of xeldoa (1000 mg twice a day for two weeks on, then one week off) and Tarceva. It was a pleasure caring for you - we wish you well! Sincerely, Your [MASKED] Oncology Team Followup Instructions: [MASKED]	[]	[ "D696", "E119", "I10", "N400" ]	[ "R180: Malignant ascites", "C250: Malignant neoplasm of head of pancreas", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "K315: Obstruction of duodenum", "E46: Unspecified protein-calorie malnutrition", "D696: Thrombocytopenia, unspecified", "D6481: Anemia due to antineoplastic chemotherapy", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms" ]
10,047,297	28,528,068	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim DS / Purinethol / simvastatin / lovastatin / Pravastatin / Fosamax / Niaspan Extended-Release / Cholest Off / colestipol / citalopram Attending: ___. Chief Complaint: weakness, AMS Major Surgical or Invasive Procedure: None History of Present Illness: CC: weakness, ams HPI(4): ___ female with moderate to severe dementia, on treatment for C. difficile, ulcerative colitis presents with presyncope, altered mental status. Per ED, patient had recurrence of diarrhea yesterday. Today she was increasingly weak and fatigued, not acting as her normal self. The family believes that she was sufficiently weak that they believe that she was close to passing out. They report that her mental status is improved at the time of evaluation. The patient denies any active pain. Denies any fevers. Family denies any history of cough, fevers, report of abdominal pain, vomiting. Per ED she is currently being treated for C Diff. Per ED has PNA and UTI will treat with rocephin and azithro Per nursing, patient presents after experiencing a near syncopal episode earlier today. Patient is actively being treated for cdiff with PO vanco. Per family, patient became drowsy and "talking slow" and denies LOC. Denies hitting head/injury. Denies complaints. Reports decreased PO intake. I reviewed VS, labs, orders, imaging, old records. VSS, HR 90 on arrival, BP was 98/55, improved w/ IVF, RR 23 at max, satting well. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: PROTHOMBIN GENE MUTATION ARTHRITIS SCIATICA TOTAL ABDOMINAL HYSTERECTOMY HEART MURMUR IMPAIRED FASTING GLUCOSE INSOMNIA HYPERCHOLESTEROLEMIA ALLERGIC RHINITIS GASTROESOPHAGEAL REFLUX HEART MURMUR HYPERCHOLESTEROLEMIA IMPAIRED FASTING GLUCOSE OSTEOPENIA PROTHOMBIN GENE MUTATION ULCERATIVE COLITIS OBESITY DEMENTIA Social History: ___ Family History: FAMILY HISTORY: Relative Status Age Problem Onset Comments Mother ___ DEMENTIA Father ___ LUNG CANCER smoker Sister ___ LEUKEMIA Brother Living ___ Brother Living ___ Son Living ___ PROTHROMBIN GENE Son Living ___ DEEP VENOUS THROMBOPHLEBITIS PROTHROMBIN GENE Physical Exam: Admission Exam =================================== EXAM(8) VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: soft, diffusely tender abdomen GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge Exam ======================================== Pertinent Results: ADMISSION LABS ========================= ___ 11:35PM BLOOD WBC-15.1* RBC-4.80 Hgb-12.9 Hct-40.2 MCV-84 MCH-26.9 MCHC-32.1 RDW-15.6* RDWSD-46.8* Plt ___ ___ 11:35PM BLOOD Neuts-73.5* Lymphs-14.2* Monos-6.8 Eos-2.7 Baso-0.8 Im ___ AbsNeut-11.06# AbsLymp-2.14 AbsMono-1.02 AbsEos-0.41 AbsBaso-0.12* ___ 11:35PM BLOOD Plt ___ ___ 11:35PM BLOOD Glucose-84 UreaN-15 Creat-0.7 Na-143 K-3.3 Cl-103 HCO3-21* AnGap-19* ___ 11:35PM BLOOD ALT-16 AST-21 AlkPhos-77 TotBili-0.2 ___ 10:20PM BLOOD Calcium-8.4 Phos-3.4 Mg-1.8 ___ 05:55AM BLOOD calTIBC-216* Ferritn-204* TRF-166* ___ 10:43PM BLOOD ___ pO2-108* pCO2-34* pH-7.47* calTCO2-25 Base XS-1 ___ 09:28AM BLOOD Lactate-1.6 DISCHARGE LABS: ========================= MICRO ========================= UCx (___): ___ yeast Stool Cx (___): negative UCx (___): mixed flora BCx (___): pending STUDIES: ========================= EKG (___) NSR at 61 bpm, LAD, PR 116, QRS 88, QTC 458, TWI III (similar to ___ EKG (___): NSR at 72 bpm, borderline LAD, PR 147, QRS 97, QTC 461, TWI III/V3 (QTC increased from 433 in ___ CXR (___): The patient is rotated, limiting evaluation however persisting opacities in the right lower lung are likely not significantly changed. NCHCT (___): Exam is limited by motion despite multiple attempted repeats. Within this limitation, there is no acute intracranial process. CXR (___): Probable right lower lobe pneumonia. Brief Hospital Course: ___ w/ dementia, UC (on prednisone/mesalamine), C. diff (on PO vanco since ___ p/w diarrhea and presyncopal episode. # Pre-syncopal episode: # AMS: # Possible UTI: # Possible CAP: The patient presented with confusion and a near syncopal episode, likely in the setting of increased diarrhea and hypovolemia secondary to undertreated C.diff (patient reportedly non-adherent to PO Vancomycin). WBC initially 15.1, electrolytes and lactate WNL. UA positive, although patient without clear urinary symptoms and UCx with mixed flora (likely contaminated, repeat with yeast). CXR with possible RLL pneumonia, but no clear respiratory symptoms. NCHCT negative for intracerebral hemorrhage. S/S evaluation showed no e/o aspiration. Legionella Ag negative, Strep pneumo pending at discharge. BCx NGTD at discharge. Received IVFs and was started on CTX/azithromycin with resolution of leukocytosis and rapid return to baseline mental status. On the night of ___ the patient was noted to be difficult to arouse after receiving seroquel and ramelteon for insomnia. Labs and VBG were reassuring, and the episode was attributed to medication effect. She was again at baseline mental status the following morning. Although suspicion for infection was relatively low, given her initial leukocytosis and rapid improvement on antibiotics (or perhaps despite antibiotics), she was narrowed to cefpodoxime (PCN allergy and prolonged QTC) and discharged to complete a 10d course (___). She is being discharged to rehab for ___ and additional support in the setting and acute infections. # Diarrhea: # C diff: # Ulcerative colitis: Patient presented with diarrhea in setting of recently diagnosed C.diff and concern for PO Vancomycin non-adherence (husband was reportedly not giving her the medication 4x/d). The GI service was consulted and thought a UC flare less likely. Vancomycin was re-initiated, with improvement in her diarrhea (only ___ loose stools documented daily). Given likely non-adherence, her start date for vancomycin should be considered ___ (not ___ when originally prescribed), with duration of course to be determined by outpatient GI (Dr. ___ but likely 2 weeks after completion of antibiotics (through ___. The patient's home prednisone was changed from 6mg alternating with 6.5mg to 6.5mg daily for ease of administration per GI. Of note, the patient was often unwilling to take mesalamine (didn't appear to have difficulty swallowing capsules but would spit them out). This medication was continued on discharge, but the patient's outpatient gastroenterologist, Dr. ___, was notified that medication adjustment may be necessary in the outpatient setting. # Leukocytosis: WBC 15.1 on admission. Improved with fluids, resumption of PO Vancomycin, and antibiotics for possible PNA vs UTI. On ___ slightly uptrended to 12.4, without clear evidence of new infection. ___ be secondary to known C.diff, for which she is being treated. WBC 10.5 on discharge. # Dementia: # Sundowning: Severe, likely fronto-temporal dementia at baseline (AOx1, pleasant, conversant but largely nonsensical, dependent in most ADLs). Per son, ___., patient is now back to baseline. Home memantine was continued (although limited data in fronto-temporal dementia). She frequently tried to get up without nursing assistance and sundowned in the evenings. Seroquel was trialed initially; in combination with ramelteon it caused hypersomnolence. Given borderline prolonged QTC (450s-460s), trazodone 25mg was trialed without effect. All efforts should be made to minimize pharmacologic treatments if possible. Should pharmacologic options be necessary, QTC should be monitored closely. QTC at discharge was 480. # Microcytic/normocytic anemia: Hct 40.2 on admission, downtrended to 33 and 34.8 on discharge. Ferritin 204, TIBC 216. No e/o active bleeding. Further w/u was deferred to outpatient providers. # Hypernatremia: # Hypophosphatemia: Intermittently mildly hypernatremia and hypophosphatemic, likely due to poor PO intake. Phos was repleted and PO intake encouraged (often required prompting to eat), with resolution of both. # Concern for inadequate home support: The patient's dementia is significant enough that she needs 24 hour help, including with most ADLs. There was concern that her husband (and primary caregiver) may suffer from some dementia himself and is partly unwilling and partly unable to provide necessary around-the-clock care. After a family meeting on ___, the family agree to rehab placement and is considering completion of a ___ application to have long-term care as an option afterwards, which she will likely need. The patient's husband is opposed to this plan but is not the HCP and cannot care for her at home. The patient's HCP confirms that she remains FULL CODE for now as they discuss as a family. TRANSITIONAL [ ] f/u BCx (pending at discharge) [ ] f/u Strep pneumo Ag (pending at discharge) [ ] check electrolytes, including Na, K, Phos on ______ [ ] monitor QTC if QTC prolonging medications resumed [ ] cefpodoxime course ___ [ ] outpatient gastroenterologist (Dr. ___ to consider alternatives to mesalamine if patient unwilling to take Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ketoconazole 2% 1 Appl TP BID:PRN rash 2. Memantine 10 mg PO BID 3. Mesalamine 800 mg PO 2 IN AM 3 AT NIGHT 4. PredniSONE 6.5 alternating with 6 mg PO DAILY 5. QUEtiapine Fumarate 50 mg PO QHS:PRN agitation 6. Sertraline 50 mg PO DAILY 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 8. Vancomycin Oral Liquid ___ mg PO Q6H Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:*0 2. PredniSONE 6.5 mg PO DAILY 3. TraZODone 25 mg PO QHS:PRN insomnia 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 5. Ketoconazole 2% 1 Appl TP BID:PRN rash 6. Memantine 10 mg PO BID 7. Mesalamine 800 mg PO 2 IN AM 3 AT NIGHT 8. Sertraline 50 mg PO DAILY 9. Vancomycin Oral Liquid ___ mg PO Q6H 10. HELD- QUEtiapine Fumarate 50 mg PO QHS:PRN agitation This medication was held. Do not restart QUEtiapine Fumarate until told to do so by your primary care doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pre-syncope Clostridium difficile Possible UTI Possible CAP Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with confusion and a near fainting episode, likely secondary to dehydration in the setting of diarrhea. Infection was thought unlikely, but given some evidence for a urinary tract infection you were started on antibiotics, continued at discharge (cefpodoxime through ___. Given the status of your heart, Seroquel is likely not the ___ medication for sleep. Please follow up with your primary care doctor to consider alternatives, recognizing that there are no good options available unfortunately. You are being discharged to a rehab facility, where you will have additional assistance with your medications and self care while you recover your strength. With ___ wishes, ___ Medicine Followup Instructions: ___	[ "A0472", "J189", "G9341", "E870", "E872", "K5190", "E860", "E8339", "N390", "T368X6A", "G3109", "F0280", "E785", "M5430", "E861", "Z87891", "Z7952", "D509", "K219", "Z91128", "Y92009" ]	Allergies: Penicillins / Bactrim DS / Purinethol / simvastatin / lovastatin / Pravastatin / Fosamax / Niaspan Extended-Release / Cholest Off / colestipol / citalopram Chief Complaint: weakness, AMS Major Surgical or Invasive Procedure: None History of Present Illness: CC: weakness, ams HPI(4): [MASKED] female with moderate to severe dementia, on treatment for C. difficile, ulcerative colitis presents with presyncope, altered mental status. Per ED, patient had recurrence of diarrhea yesterday. Today she was increasingly weak and fatigued, not acting as her normal self. The family believes that she was sufficiently weak that they believe that she was close to passing out. They report that her mental status is improved at the time of evaluation. The patient denies any active pain. Denies any fevers. Family denies any history of cough, fevers, report of abdominal pain, vomiting. Per ED she is currently being treated for C Diff. Per ED has PNA and UTI will treat with rocephin and azithro Per nursing, patient presents after experiencing a near syncopal episode earlier today. Patient is actively being treated for cdiff with PO vanco. Per family, patient became drowsy and "talking slow" and denies LOC. Denies hitting head/injury. Denies complaints. Reports decreased PO intake. I reviewed VS, labs, orders, imaging, old records. VSS, HR 90 on arrival, BP was 98/55, improved w/ IVF, RR 23 at max, satting well. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: PROTHOMBIN GENE MUTATION ARTHRITIS SCIATICA TOTAL ABDOMINAL HYSTERECTOMY HEART MURMUR IMPAIRED FASTING GLUCOSE INSOMNIA HYPERCHOLESTEROLEMIA ALLERGIC RHINITIS GASTROESOPHAGEAL REFLUX HEART MURMUR HYPERCHOLESTEROLEMIA IMPAIRED FASTING GLUCOSE OSTEOPENIA PROTHOMBIN GENE MUTATION ULCERATIVE COLITIS OBESITY DEMENTIA Social History: [MASKED] Family History: FAMILY HISTORY: Relative Status Age Problem Onset Comments Mother [MASKED] DEMENTIA Father [MASKED] LUNG CANCER smoker Sister [MASKED] LEUKEMIA Brother Living [MASKED] Brother Living [MASKED] Son Living [MASKED] PROTHROMBIN GENE Son Living [MASKED] DEEP VENOUS THROMBOPHLEBITIS PROTHROMBIN GENE Physical Exam: Admission Exam =================================== EXAM(8) VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: soft, diffusely tender abdomen GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Discharge Exam ======================================== Pertinent Results: ADMISSION LABS ========================= [MASKED] 11:35PM BLOOD WBC-15.1* RBC-4.80 Hgb-12.9 Hct-40.2 MCV-84 MCH-26.9 MCHC-32.1 RDW-15.6* RDWSD-46.8* Plt [MASKED] [MASKED] 11:35PM BLOOD Neuts-73.5* Lymphs-14.2* Monos-6.8 Eos-2.7 Baso-0.8 Im [MASKED] AbsNeut-11.06# AbsLymp-2.14 AbsMono-1.02 AbsEos-0.41 AbsBaso-0.12* [MASKED] 11:35PM BLOOD Plt [MASKED] [MASKED] 11:35PM BLOOD Glucose-84 UreaN-15 Creat-0.7 Na-143 K-3.3 Cl-103 HCO3-21* AnGap-19* [MASKED] 11:35PM BLOOD ALT-16 AST-21 AlkPhos-77 TotBili-0.2 [MASKED] 10:20PM BLOOD Calcium-8.4 Phos-3.4 Mg-1.8 [MASKED] 05:55AM BLOOD calTIBC-216* Ferritn-204* TRF-166* [MASKED] 10:43PM BLOOD [MASKED] pO2-108* pCO2-34* pH-7.47* calTCO2-25 Base XS-1 [MASKED] 09:28AM BLOOD Lactate-1.6 DISCHARGE LABS: ========================= MICRO ========================= UCx ([MASKED]): [MASKED] yeast Stool Cx ([MASKED]): negative UCx ([MASKED]): mixed flora BCx ([MASKED]): pending STUDIES: ========================= EKG ([MASKED]) NSR at 61 bpm, LAD, PR 116, QRS 88, QTC 458, TWI III (similar to [MASKED] EKG ([MASKED]): NSR at 72 bpm, borderline LAD, PR 147, QRS 97, QTC 461, TWI III/V3 (QTC increased from 433 in [MASKED] CXR ([MASKED]): The patient is rotated, limiting evaluation however persisting opacities in the right lower lung are likely not significantly changed. NCHCT ([MASKED]): Exam is limited by motion despite multiple attempted repeats. Within this limitation, there is no acute intracranial process. CXR ([MASKED]): Probable right lower lobe pneumonia. Brief Hospital Course: [MASKED] w/ dementia, UC (on prednisone/mesalamine), C. diff (on PO vanco since [MASKED] p/w diarrhea and presyncopal episode. # Pre-syncopal episode: # AMS: # Possible UTI: # Possible CAP: The patient presented with confusion and a near syncopal episode, likely in the setting of increased diarrhea and hypovolemia secondary to undertreated C.diff (patient reportedly non-adherent to PO Vancomycin). WBC initially 15.1, electrolytes and lactate WNL. UA positive, although patient without clear urinary symptoms and UCx with mixed flora (likely contaminated, repeat with yeast). CXR with possible RLL pneumonia, but no clear respiratory symptoms. NCHCT negative for intracerebral hemorrhage. S/S evaluation showed no e/o aspiration. Legionella Ag negative, Strep pneumo pending at discharge. BCx NGTD at discharge. Received IVFs and was started on CTX/azithromycin with resolution of leukocytosis and rapid return to baseline mental status. On the night of [MASKED] the patient was noted to be difficult to arouse after receiving seroquel and ramelteon for insomnia. Labs and VBG were reassuring, and the episode was attributed to medication effect. She was again at baseline mental status the following morning. Although suspicion for infection was relatively low, given her initial leukocytosis and rapid improvement on antibiotics (or perhaps despite antibiotics), she was narrowed to cefpodoxime (PCN allergy and prolonged QTC) and discharged to complete a 10d course ([MASKED]). She is being discharged to rehab for [MASKED] and additional support in the setting and acute infections. # Diarrhea: # C diff: # Ulcerative colitis: Patient presented with diarrhea in setting of recently diagnosed C.diff and concern for PO Vancomycin non-adherence (husband was reportedly not giving her the medication 4x/d). The GI service was consulted and thought a UC flare less likely. Vancomycin was re-initiated, with improvement in her diarrhea (only [MASKED] loose stools documented daily). Given likely non-adherence, her start date for vancomycin should be considered [MASKED] (not [MASKED] when originally prescribed), with duration of course to be determined by outpatient GI (Dr. [MASKED] but likely 2 weeks after completion of antibiotics (through [MASKED]. The patient's home prednisone was changed from 6mg alternating with 6.5mg to 6.5mg daily for ease of administration per GI. Of note, the patient was often unwilling to take mesalamine (didn't appear to have difficulty swallowing capsules but would spit them out). This medication was continued on discharge, but the patient's outpatient gastroenterologist, Dr. [MASKED], was notified that medication adjustment may be necessary in the outpatient setting. # Leukocytosis: WBC 15.1 on admission. Improved with fluids, resumption of PO Vancomycin, and antibiotics for possible PNA vs UTI. On [MASKED] slightly uptrended to 12.4, without clear evidence of new infection. [MASKED] be secondary to known C.diff, for which she is being treated. WBC 10.5 on discharge. # Dementia: # Sundowning: Severe, likely fronto-temporal dementia at baseline (AOx1, pleasant, conversant but largely nonsensical, dependent in most ADLs). Per son, [MASKED]., patient is now back to baseline. Home memantine was continued (although limited data in fronto-temporal dementia). She frequently tried to get up without nursing assistance and sundowned in the evenings. Seroquel was trialed initially; in combination with ramelteon it caused hypersomnolence. Given borderline prolonged QTC (450s-460s), trazodone 25mg was trialed without effect. All efforts should be made to minimize pharmacologic treatments if possible. Should pharmacologic options be necessary, QTC should be monitored closely. QTC at discharge was 480. # Microcytic/normocytic anemia: Hct 40.2 on admission, downtrended to 33 and 34.8 on discharge. Ferritin 204, TIBC 216. No e/o active bleeding. Further w/u was deferred to outpatient providers. # Hypernatremia: # Hypophosphatemia: Intermittently mildly hypernatremia and hypophosphatemic, likely due to poor PO intake. Phos was repleted and PO intake encouraged (often required prompting to eat), with resolution of both. # Concern for inadequate home support: The patient's dementia is significant enough that she needs 24 hour help, including with most ADLs. There was concern that her husband (and primary caregiver) may suffer from some dementia himself and is partly unwilling and partly unable to provide necessary around-the-clock care. After a family meeting on [MASKED], the family agree to rehab placement and is considering completion of a [MASKED] application to have long-term care as an option afterwards, which she will likely need. The patient's husband is opposed to this plan but is not the HCP and cannot care for her at home. The patient's HCP confirms that she remains FULL CODE for now as they discuss as a family. TRANSITIONAL [ ] f/u BCx (pending at discharge) [ ] f/u Strep pneumo Ag (pending at discharge) [ ] check electrolytes, including Na, K, Phos on [MASKED] [ ] monitor QTC if QTC prolonging medications resumed [ ] cefpodoxime course [MASKED] [ ] outpatient gastroenterologist (Dr. [MASKED] to consider alternatives to mesalamine if patient unwilling to take Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ketoconazole 2% 1 Appl TP BID:PRN rash 2. Memantine 10 mg PO BID 3. Mesalamine 800 mg PO 2 IN AM 3 AT NIGHT 4. PredniSONE 6.5 alternating with 6 mg PO DAILY 5. QUEtiapine Fumarate 50 mg PO QHS:PRN agitation 6. Sertraline 50 mg PO DAILY 7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 8. Vancomycin Oral Liquid [MASKED] mg PO Q6H Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:*0 2. PredniSONE 6.5 mg PO DAILY 3. TraZODone 25 mg PO QHS:PRN insomnia 4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 5. Ketoconazole 2% 1 Appl TP BID:PRN rash 6. Memantine 10 mg PO BID 7. Mesalamine 800 mg PO 2 IN AM 3 AT NIGHT 8. Sertraline 50 mg PO DAILY 9. Vancomycin Oral Liquid [MASKED] mg PO Q6H 10. HELD- QUEtiapine Fumarate 50 mg PO QHS:PRN agitation This medication was held. Do not restart QUEtiapine Fumarate until told to do so by your primary care doctor Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Pre-syncope Clostridium difficile Possible UTI Possible CAP Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital with confusion and a near fainting episode, likely secondary to dehydration in the setting of diarrhea. Infection was thought unlikely, but given some evidence for a urinary tract infection you were started on antibiotics, continued at discharge (cefpodoxime through [MASKED]. Given the status of your heart, Seroquel is likely not the [MASKED] medication for sleep. Please follow up with your primary care doctor to consider alternatives, recognizing that there are no good options available unfortunately. You are being discharged to a rehab facility, where you will have additional assistance with your medications and self care while you recover your strength. With [MASKED] wishes, [MASKED] Medicine Followup Instructions: [MASKED]	[]	[ "E872", "N390", "E785", "Z87891", "D509", "K219" ]	[ "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "J189: Pneumonia, unspecified organism", "G9341: Metabolic encephalopathy", "E870: Hyperosmolality and hypernatremia", "E872: Acidosis", "K5190: Ulcerative colitis, unspecified, without complications", "E860: Dehydration", "E8339: Other disorders of phosphorus metabolism", "N390: Urinary tract infection, site not specified", "T368X6A: Underdosing of other systemic antibiotics, initial encounter", "G3109: Other frontotemporal dementia", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "E785: Hyperlipidemia, unspecified", "M5430: Sciatica, unspecified side", "E861: Hypovolemia", "Z87891: Personal history of nicotine dependence", "Z7952: Long term (current) use of systemic steroids", "D509: Iron deficiency anemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z91128: Patient's intentional underdosing of medication regimen for other reason", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,047,299	24,558,017	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Renal mass Major Surgical or Invasive Procedure: ___ left partial nephrectomy History of Present Illness: ___ h/o L renal mass NOW s/p robotic L partial (really hemi) nephrectomy Past Medical History: Malignant brain tumor as above. Colonoscopy for rectal bleeding ___, positive for hemorrhoids. Social History: ___ Family History: Maternal GM with goiter. Physical Exam: WdWn, NAD, AVSS Interactive, cooperative Abdomen soft, appropriately tender along incisions Incisions otherwise c/d/i Extremities w/out edema or pitting and there is no reported calf pain to deep palpation Pertinent Results: ___ 08:05AM BLOOD WBC-11.0* RBC-4.33* Hgb-12.4* Hct-37.5* MCV-87 MCH-28.6 MCHC-33.1 RDW-12.0 RDWSD-38.9 Plt ___ ___ 08:05AM BLOOD Glucose-93 UreaN-11 Creat-2.0* Na-136 K-4.4 Cl-98 HCO3-29 AnGap-13 ___ 08:05AM BLOOD Mg-2.___rief Hospital Course - PARTIAL NEPHRECTOMY Patient was admitted to Urology after undergoing robotic left partial nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, and provided with pneumoboots and incentive spirometry for prophylaxis. On POD1, the patient ambulated, restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. He remained mildly tachycardic in the setting of persistent pain; he was 120s post op and 100s on POD1, confirmed multiple times and sinus tachycardia on EKG. On POD2, urethral Foley catheter were removed without difficulty and diet was advanced as tolerated. HR remained in 100s and was down to ___. On POD3, the JP output had remained low and was removed. HR remained in the ___ and he felt well, ease of ambulation, voiding, pain controlled. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic in approximately four weeks time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Acetaminophen 1000 mg PO Q6H 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Renal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please also refer to the provided handout that details instructions and expectations for your post-operative phase as made available by Dr. ___ office. -Resume your pre-admission/home medications except as noted. ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -___ reduce the strain/pressure on your abdomen and incision sites; remember to log roll onto your side and then use your hands to push yourself upright while taking advantage of the momentum of putting your legs/feet to the ground. --There may be bandage strips called steristrips which have been applied to reinforce wound closure. Allow these bandage strips to fall off on their own over time but PLEASE REMOVE ANY REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may get the steristrips wet. -Please AVOID aspirin or aspirin containing products and supplements that may have blood-thinning effects (like Fish Oil, Vitamin E, etc.) unless you have otherwise been advised. This will be noted in your medication reconciliation. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Call your Urologist's office to schedule/confirm your follow-up appointment in 4 weeks AND if you have any questions. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised. Light household chores/activity and leisurely walking/activity is OK and should be continued. Do NOT be a couch potato -Tylenol should be your first-line pain medication. A narcotic pain medication has been prescribed for breakthrough pain ___. REPLACE the Tylenol with this narcotic pain medication if additional pain control is needed.. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up ___ as directed in the handout -You may shower normally but do NOT immerse your incisions or bathe -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: ___	[ "C642", "E890", "Z85841", "H532", "Z85850", "R000" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Renal mass Major Surgical or Invasive Procedure: [MASKED] left partial nephrectomy History of Present Illness: [MASKED] h/o L renal mass NOW s/p robotic L partial (really hemi) nephrectomy Past Medical History: Malignant brain tumor as above. Colonoscopy for rectal bleeding [MASKED], positive for hemorrhoids. Social History: [MASKED] Family History: Maternal GM with goiter. Physical Exam: WdWn, NAD, AVSS Interactive, cooperative Abdomen soft, appropriately tender along incisions Incisions otherwise c/d/i Extremities w/out edema or pitting and there is no reported calf pain to deep palpation Pertinent Results: [MASKED] 08:05AM BLOOD WBC-11.0* RBC-4.33* Hgb-12.4* Hct-37.5* MCV-87 MCH-28.6 MCHC-33.1 RDW-12.0 RDWSD-38.9 Plt [MASKED] [MASKED] 08:05AM BLOOD Glucose-93 UreaN-11 Creat-2.0* Na-136 K-4.4 Cl-98 HCO3-29 AnGap-13 [MASKED] 08:05AM BLOOD Mg-2. rief Hospital Course - PARTIAL NEPHRECTOMY Patient was admitted to Urology after undergoing robotic left partial nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, and provided with pneumoboots and incentive spirometry for prophylaxis. On POD1, the patient ambulated, restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. He remained mildly tachycardic in the setting of persistent pain; he was 120s post op and 100s on POD1, confirmed multiple times and sinus tachycardia on EKG. On POD2, urethral Foley catheter were removed without difficulty and diet was advanced as tolerated. HR remained in 100s and was down to [MASKED]. On POD3, the JP output had remained low and was removed. HR remained in the [MASKED] and he felt well, ease of ambulation, voiding, pain controlled. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic in approximately four weeks time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 50 mcg PO DAILY 2. Acetaminophen 1000 mg PO Q6H 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 4. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Renal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please also refer to the provided handout that details instructions and expectations for your post-operative phase as made available by Dr. [MASKED] office. -Resume your pre-admission/home medications except as noted. ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -[MASKED] reduce the strain/pressure on your abdomen and incision sites; remember to log roll onto your side and then use your hands to push yourself upright while taking advantage of the momentum of putting your legs/feet to the ground. --There may be bandage strips called steristrips which have been applied to reinforce wound closure. Allow these bandage strips to fall off on their own over time but PLEASE REMOVE ANY REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may get the steristrips wet. -Please AVOID aspirin or aspirin containing products and supplements that may have blood-thinning effects (like Fish Oil, Vitamin E, etc.) unless you have otherwise been advised. This will be noted in your medication reconciliation. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Call your Urologist's office to schedule/confirm your follow-up appointment in 4 weeks AND if you have any questions. -Do not eat constipating foods for [MASKED] weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised. Light household chores/activity and leisurely walking/activity is OK and should be continued. Do NOT be a couch potato -Tylenol should be your first-line pain medication. A narcotic pain medication has been prescribed for breakthrough pain [MASKED]. REPLACE the Tylenol with this narcotic pain medication if additional pain control is needed.. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up [MASKED] as directed in the handout -You may shower normally but do NOT immerse your incisions or bathe -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: [MASKED]	[]	[]	[ "C642: Malignant neoplasm of left kidney, except renal pelvis", "E890: Postprocedural hypothyroidism", "Z85841: Personal history of malignant neoplasm of brain", "H532: Diplopia", "Z85850: Personal history of malignant neoplasm of thyroid", "R000: Tachycardia, unspecified" ]
10,047,484	29,910,256	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Demerol / Iodinated Contrast- Oral and IV Dye Attending: ___. Major Surgical or Invasive Procedure: NGT placement ___ EGD ___ no interventions NGT placement ___ attach Pertinent Results: ADMISSION LABS: =============== ___ 04:15PM BLOOD WBC-11.4* RBC-5.01 Hgb-15.5 Hct-45.6 MCV-91 MCH-30.9 MCHC-34.0 RDW-13.2 RDWSD-43.2 Plt ___ ___ 01:34AM BLOOD ___ PTT-22.8* ___ ___ 04:15PM BLOOD Glucose-136* UreaN-14 Creat-0.9 Na-135 K-5.9* Cl-97 HCO3-19* AnGap-19* ___ 04:15PM BLOOD ALT-46* AST-60* AlkPhos-114 TotBili-0.5 ___ 04:15PM BLOOD Albumin-4.5 ___ 04:45AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9 ___ 04:40PM BLOOD Lactate-3.2* K-4.1 IMAGING: =============== RUQ Ultrasound ___: 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. See recommendations below. ___ Ultrasound ___: "IMPRESSION: Acute deep venous thrombosis of the left common femoral, femoral, popliteal and posterior tibial veins. Minimal flow in the common femoral vein, but there is complete occlusion of the remaining veins. No right lower extremity deep venous thrombosis." CXR ___: "IMPRESSION: No acute cardiopulmonary abnormality." CT Abdomen without contrast ___: "IMPRESSION: 1. Multiple, partially imaged small bowel loops, fluid-filled and dilated to approximately 3.2 cm, with a relatively decompressed terminal ileum. These findings can be seen in the setting of a gastroenteritis, particularly given the presence of fluid within the colon, but an ileus or partial small-bowel obstruction is not definitely excluded. Further assessment with CT imaging of the pelvis may be helpful for further evaluation. 2. Mild pneumobilia within the left hepatic lobe, which could reflect prior sphincterotomy and correlation with any history of endoscopy recommended." CXR ___: "IMPRESSION: The enteric tube extends below the level of diaphragm, with the tip projecting over the stomach." CTA Chest ___: IMPRESSION: 1. Acute, nonocclusive thrombus within the left pulmonary artery that extends distally to involve the left upper and lower lobe arteries and several of their proximal segmental branches. Several nonocclusive thrombi are also seen within the segmental branches of the right pulmonary artery. 2. No evidence of interventricular septal bowing to suggest right heart strain. 3. No evidence of parenchymal opacification to suggest pulmonary infarct. 4. Mildly ectatic ascending thoracic aorta, measuring up to 4.1 cm in diameter. 5. Moderate coronary atherosclerotic disease." KUB for Colonic Transport ___: "IMPRESSION: Persistent small bowel obstruction." KUB Portable ___: "IMPRESSION: 1. Persistent partial small bowel obstruction as evidence by progression of the oral contrast into the colon. 2. Suggest advancing nasogastric tube 5 cm into the stomach." TTE ___: "IMPRESSION: Suboptimal image quality. Mild right ventricular cavity dilation but with preserved free wall motion. Mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function. Mild aortic root dilation. Unable to quantify pulmonary artery systolic pressure. CLINICAL IMPLICATIONS: Based on the echocardiographic findings and ___ ACC/AHA recommendations, antibiotic prophylaxis is NOT recommended." EGD ___: "Normal mucosa in the whole esophagus. Normal mucosa in the whole stomach. Normal mucosa in the whole examined duodenum. Normal major papilla." KUB ___: IMPRESSION: No evidence of obstruction. CXR - line placement ___: "IMPRESSION: 2 sequential images demonstrate advancement of an enteric tube which ultimately projects over the stomach." CT A/P ___ IMPRESSION: 1. Uncomplicated mild acute diverticulitis involving a diverticula along the markedly redundant sigmoid colon in the right upper quadrant, corresponding to site of tenderness. 2. No evidence of bowel obstruction. 3. Mild left hepatic lobe pneumobilia, slightly increased since previous examination. Status post cholecystectomy. KUB ___ 1. Small stool burden within the colon. 2. No dilated loops of small or large bowel. DISCHARGE LABS: ================= ___ 05:55AM BLOOD WBC-6.7 RBC-4.39* Hgb-13.4* Hct-40.8 MCV-93 MCH-30.5 MCHC-32.8 RDW-13.4 RDWSD-45.2 Plt ___ ___ 05:55AM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-142 K-4.0 Cl-107 HCO3-21* AnGap-14 DISCHARGE PHYSICAL EXAM: ==================== 24 HR Data (last updated ___ @ 631) Temp: 97.7 (Tm 98.5), BP: 120/77 (119-148/73-84), HR: 72 (64-87), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: Ra GENERAL: resting comfortably, NAD HEENT: NCAT, PERRLA. R eye with medial conjunctival injection and watery tearing/discharge. No purulence. + rosacea CARDIAC: RRR, normal S1 and S2. No m/r/g LUNGS: CTAB, no w/r/r. No increased work of breathing. ABDOMEN: + BS, distended, tympanic to percussion. No epigastric tenderness to deep palpation EXTREMITIES: 1+ LLE non-pitting edema, L>R. Mild pedal edema bilaterally. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. NEUROLOGIC: awake, alert and interactive. Moving all extremities with purpose Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [] Medications STARTED: amox-clav 875mg PO Q8H, warfarin [] Medications STOPPED: furosemide 40mg [] GI - Consider capsule study to evaluate potential etiology of pSBO [] PCP: - ___ dose warfarin as needed with a goal INR of ___, repeat INR on ___. Patient discharged with 10 days of lovenox as well as warfarin. Discharge INR 1.5 and warfarin dose on day of discharge 6.5mg. - Please follow-up resolution of abdominal pain from diverticulitis with completion of 10 days amox-clav (last day ___ - Please refer to GI for follow-up with capsule study for UGIB - Noted to have pneumobilia on imaging, EGD consistent with prior sphincterotomy. If he develops RUQ pain, would have low threshold to image to ensure pneumobilia is not source of the pain - Found to have echogenic liver consistent with steatosis, consider fibroscan/MRE in the outpatient setting to r/o cirrhosis/fibrosis - Recommend outpatient therapy for rosacea # CONTACT: Health care proxy: ___ Relationship: Husband Phone number: ___ Cell phone: ___ BRIEF HOSPITAL COURSE: ======================= Mr. ___ is a ___ yo M with hx of bipolar disorder and HTN who presented with bilateral leg swelling, dyspnea on exertion, abdominal pain, nausea and coffee ground emesis found to have acute PE, extensive LLE DVT and pSBO. He was bridged initially with heparin, but transitioned to lovenox while starting warfarin, which will be continued on discharge. In regards to his pSBO, NGT was placed, which put out coffee ground emesis. He was managed conservatively and improved with bowel rest and transitioned to a regular diet. GI was consulted for concern of UGIB and the patient underwent an EGD on ___, which did not find a source of the upper GI bleed. He subsequently developed recurrent abdominal distention with concern for SBO, but CT demonstrated mild diverticulitis, which was treated with amox-clav, which was continued on discharge. He was discharged home and his PCP ___ manage his warfarin moving forward. ACUTE ISSUES: ============== # Acute PE # Extensive LLE DVT Patient presented with dyspnea on exertion and worsening leg swelling over the past ___ weeks, found to have acute nonocclusive thrombus within left PA extending distally to involve the left upper and lower lobe arteries and several of their proximal segmental branches. Several nonocclusive thromi were also seen within segmental branches of right pulmonary artery. Also found to have acute DVT of left common femoral, popliteal, and posterior tibial veins with minimal flow in common femoral vein but complete occlusion of remaining veins. No clear provoking factor but patient does report more sedentary lifestyle since his husband has been ill. He was treated with a heparin gtt initially before starting a lovenox bridge to warfarin. Of note, DOACs were not started due to ineraction with his antipsychotic medications. His primary care physician ___ manage his anticoagulation in the outpatient setting. He is being discharged with Lovenox bridge and warfarin 6.5mg daily with script to have INR checked on ___. # partial Small bowel obstruction: resolved Presented with nausea and emesis found to have multiple, partially imaged dilated, fluid filled small bowel loops to 3.2 cm with decompressed terminal ileum. Seen by ACS in ED who placed an NGT. He was managed conservatively and SBO was persistent on gastrograffin study but then resolved with KUB at later point. He was maintained on mIVF while NPO. The partial SBO resolved with bowel rest and he improved with time. He was able to tolerate a regular diet prior to discharge, was passing flatus, and having bowel movements. The etiology of the pSBO was though to be from local inflammation in the setting of diverticulitis as noted below. # Mild diverticulitis: In setting of recurrent abdominal distension and abdominal discomfort there was initial concern for SBO recurrence. NG tube was placed and ACS was reconsulted. Due to decreased NGT output, CT was obtained and demonstrated acute, mild diverituclitis without evidence of complications. He was started on amox-clav due to ciprofloxacin interactions with his warfarin. His diet was slowly advanced until he was tolerating a regular PO diet. Prior to discharge he had a normal bowel movement. He is discharged with total 10 day course of amoxicillin-clav with last day ___. # Coffee ground emesis: resolved # Concern for UGIB Patient with hx of GERD and ___ esophagus and noted increasing abdominal discomfort over the last week. He reported episode of black emesis and noted to have coffee ground emesis from NGT in ED and ICU. was treated with IV PPI BID and his hemoglobin remained stable. GI was consulted and the patient underwent an EGD on ___ that did not find the source of the bleeding. He should follow-up with GI as an outpatient to consider capsule study. # Acute hypoxemic respiratory failure - resolved Patient with low level O2 requirement in ICU and transition to floor which resolved with use of incentive spirometer. This was likely secondary to PE vs. atelectasis from sedentary lifestyle. # Pneumobilia: noted to have pneumobilia on CT imaging as an inpatient and during EGD, per GI, he was noted to have a history of spinchterotomy in the past, which can help to explain the persistent pneumobilia. There was no further intervention indicated. # Irritant conjunctivitis: He was noted to have conjunctival injection/conjunctivitis, likely irritant in setting of eyelash given that patient notes history of prior episodes. He had no purulent drainage, visual changes, eye pain or headaches, and his irritant conjunctivitis improved prior to discharge. # Rosacea: Noted to have progression of his rosacea while inpatient. He would benefit from additional outpatient therapy. CHRONIC/STABLE ISSUES: ====================== # Hypothyroidism: Continued levothyroxine 88mcg daily # Bipolar disorder: continued risperidone 1mg qhs, carbamazepine 100mg qAM, 200mg qPM, clonazepam 0.25mg BID, buspirone 30mg BID # HTN: restarted home amlodipine # Insomnia: continued melatonin Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 88 mcg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Benzonatate 200 mg PO TID:PRN cough 4. Pantoprazole 40 mg PO Q12H 5. RisperiDONE 1 mg PO QHS 6. CarBAMazepine 100 mg PO QAM 7. CarBAMazepine 200 mg PO QPM 8. ClonazePAM 0.5 mg PO BID 9. BusPIRone 30 mg PO BID 10. Cyanocobalamin 1000 mcg PO DAILY 11. amLODIPine 5 mg PO DAILY 12. melatonin 10 mg oral QHS 13. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q8H RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every eight (8) hours Disp #13 Tablet Refills:0 2. Enoxaparin (Treatment) 120 mg SC Q12H RX enoxaparin 120 mg/0.8 mL 120 mg IM twice a day Disp #20 Syringe Refills:0 3. Warfarin 6.5 mg PO DAILY16 Take daily until instructed to change dose by a doctor 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. BusPIRone 30 mg PO BID 7. CarBAMazepine 100 mg PO QAM 8. CarBAMazepine 200 mg PO QPM 9. ClonazePAM 0.5 mg PO BID 10. Cyanocobalamin 1000 mcg PO DAILY 11. Furosemide 40 mg PO DAILY 12. Levothyroxine Sodium 88 mcg PO DAILY 13. melatonin 10 mg oral QHS 14. Pantoprazole 40 mg PO Q12H 15. RisperiDONE 1 mg PO QHS 16.Outpatient Lab Work ICD-9: 415.1 Please draw ___ on ___ Fax results to Dr. ___. FAX: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ==================== Acute pulmonary embolism Acute deep venous thrombosis Diverticulitis SECONDARY DIAGNOSIS: ==================== partial small bowel obstruction Acute hypoxemic respiratory failure Concern for upper GI bleed, coffee ground emesis Hypothyroidism Bipolar disorder Hypertension Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for trouble breathing, abdominal pain, and bloody vomit. What was done for me while I was in the hospital? - We found a blood clot in your leg and lungs. - You were started on medications (warfarin and lovenox) to help prevent further blood clots - You underwent an endoscope to evaluate the cause of your bloody vomit and you were started on a medication to help prevent any more episodes of bloody vomiting. - You had a tube placed in your nose to help relieve the obstruction in your bowels - You were started on antibiotics to help treat diverticulitis, an infection of the bowel What should I do when I leave the hospital? -Please take all of your medications as prescribed. Please go to all of your follow up appointments as scheduled. -Please have blood work drawn on ___ at the ___ lab (___) so your PCP can help adjust your dose of blood thinner medication (warfarin). -If you find you are not having a daily bowel movement, you may try taking Miralax (polyethylene gycol) which is available over the counter. Sincerely, Your ___ Care Team Followup Instructions: ___	[ "K5793", "I2699", "J9601", "I82412", "I82432", "I824Z2", "E872", "E039", "F319", "I10", "G4700", "E8889", "K219", "K838", "L719", "H1089", "G4733", "E6601", "R197" ]	Allergies: Demerol / Iodinated Contrast- Oral and IV Dye Major Surgical or Invasive Procedure: NGT placement [MASKED] EGD [MASKED] no interventions NGT placement [MASKED] attach Pertinent Results: ADMISSION LABS: =============== [MASKED] 04:15PM BLOOD WBC-11.4* RBC-5.01 Hgb-15.5 Hct-45.6 MCV-91 MCH-30.9 MCHC-34.0 RDW-13.2 RDWSD-43.2 Plt [MASKED] [MASKED] 01:34AM BLOOD [MASKED] PTT-22.8* [MASKED] [MASKED] 04:15PM BLOOD Glucose-136* UreaN-14 Creat-0.9 Na-135 K-5.9* Cl-97 HCO3-19* AnGap-19* [MASKED] 04:15PM BLOOD ALT-46* AST-60* AlkPhos-114 TotBili-0.5 [MASKED] 04:15PM BLOOD Albumin-4.5 [MASKED] 04:45AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9 [MASKED] 04:40PM BLOOD Lactate-3.2* K-4.1 IMAGING: =============== RUQ Ultrasound [MASKED]: 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. See recommendations below. [MASKED] Ultrasound [MASKED]: "IMPRESSION: Acute deep venous thrombosis of the left common femoral, femoral, popliteal and posterior tibial veins. Minimal flow in the common femoral vein, but there is complete occlusion of the remaining veins. No right lower extremity deep venous thrombosis." CXR [MASKED]: "IMPRESSION: No acute cardiopulmonary abnormality." CT Abdomen without contrast [MASKED]: "IMPRESSION: 1. Multiple, partially imaged small bowel loops, fluid-filled and dilated to approximately 3.2 cm, with a relatively decompressed terminal ileum. These findings can be seen in the setting of a gastroenteritis, particularly given the presence of fluid within the colon, but an ileus or partial small-bowel obstruction is not definitely excluded. Further assessment with CT imaging of the pelvis may be helpful for further evaluation. 2. Mild pneumobilia within the left hepatic lobe, which could reflect prior sphincterotomy and correlation with any history of endoscopy recommended." CXR [MASKED]: "IMPRESSION: The enteric tube extends below the level of diaphragm, with the tip projecting over the stomach." CTA Chest [MASKED]: IMPRESSION: 1. Acute, nonocclusive thrombus within the left pulmonary artery that extends distally to involve the left upper and lower lobe arteries and several of their proximal segmental branches. Several nonocclusive thrombi are also seen within the segmental branches of the right pulmonary artery. 2. No evidence of interventricular septal bowing to suggest right heart strain. 3. No evidence of parenchymal opacification to suggest pulmonary infarct. 4. Mildly ectatic ascending thoracic aorta, measuring up to 4.1 cm in diameter. 5. Moderate coronary atherosclerotic disease." KUB for Colonic Transport [MASKED]: "IMPRESSION: Persistent small bowel obstruction." KUB Portable [MASKED]: "IMPRESSION: 1. Persistent partial small bowel obstruction as evidence by progression of the oral contrast into the colon. 2. Suggest advancing nasogastric tube 5 cm into the stomach." TTE [MASKED]: "IMPRESSION: Suboptimal image quality. Mild right ventricular cavity dilation but with preserved free wall motion. Mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function. Mild aortic root dilation. Unable to quantify pulmonary artery systolic pressure. CLINICAL IMPLICATIONS: Based on the echocardiographic findings and [MASKED] ACC/AHA recommendations, antibiotic prophylaxis is NOT recommended." EGD [MASKED]: "Normal mucosa in the whole esophagus. Normal mucosa in the whole stomach. Normal mucosa in the whole examined duodenum. Normal major papilla." KUB [MASKED]: IMPRESSION: No evidence of obstruction. CXR - line placement [MASKED]: "IMPRESSION: 2 sequential images demonstrate advancement of an enteric tube which ultimately projects over the stomach." CT A/P [MASKED] IMPRESSION: 1. Uncomplicated mild acute diverticulitis involving a diverticula along the markedly redundant sigmoid colon in the right upper quadrant, corresponding to site of tenderness. 2. No evidence of bowel obstruction. 3. Mild left hepatic lobe pneumobilia, slightly increased since previous examination. Status post cholecystectomy. KUB [MASKED] 1. Small stool burden within the colon. 2. No dilated loops of small or large bowel. DISCHARGE LABS: ================= [MASKED] 05:55AM BLOOD WBC-6.7 RBC-4.39* Hgb-13.4* Hct-40.8 MCV-93 MCH-30.5 MCHC-32.8 RDW-13.4 RDWSD-45.2 Plt [MASKED] [MASKED] 05:55AM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-142 K-4.0 Cl-107 HCO3-21* AnGap-14 DISCHARGE PHYSICAL EXAM: ==================== 24 HR Data (last updated [MASKED] @ 631) Temp: 97.7 (Tm 98.5), BP: 120/77 (119-148/73-84), HR: 72 (64-87), RR: 18 ([MASKED]), O2 sat: 94% (94-98), O2 delivery: Ra GENERAL: resting comfortably, NAD HEENT: NCAT, PERRLA. R eye with medial conjunctival injection and watery tearing/discharge. No purulence. + rosacea CARDIAC: RRR, normal S1 and S2. No m/r/g LUNGS: CTAB, no w/r/r. No increased work of breathing. ABDOMEN: + BS, distended, tympanic to percussion. No epigastric tenderness to deep palpation EXTREMITIES: 1+ LLE non-pitting edema, L>R. Mild pedal edema bilaterally. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. NEUROLOGIC: awake, alert and interactive. Moving all extremities with purpose Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [] Medications STARTED: amox-clav 875mg PO Q8H, warfarin [] Medications STOPPED: furosemide 40mg [] GI - Consider capsule study to evaluate potential etiology of pSBO [] PCP: - [MASKED] dose warfarin as needed with a goal INR of [MASKED], repeat INR on [MASKED]. Patient discharged with 10 days of lovenox as well as warfarin. Discharge INR 1.5 and warfarin dose on day of discharge 6.5mg. - Please follow-up resolution of abdominal pain from diverticulitis with completion of 10 days amox-clav (last day [MASKED] - Please refer to GI for follow-up with capsule study for UGIB - Noted to have pneumobilia on imaging, EGD consistent with prior sphincterotomy. If he develops RUQ pain, would have low threshold to image to ensure pneumobilia is not source of the pain - Found to have echogenic liver consistent with steatosis, consider fibroscan/MRE in the outpatient setting to r/o cirrhosis/fibrosis - Recommend outpatient therapy for rosacea # CONTACT: Health care proxy: [MASKED] Relationship: Husband Phone number: [MASKED] Cell phone: [MASKED] BRIEF HOSPITAL COURSE: ======================= Mr. [MASKED] is a [MASKED] yo M with hx of bipolar disorder and HTN who presented with bilateral leg swelling, dyspnea on exertion, abdominal pain, nausea and coffee ground emesis found to have acute PE, extensive LLE DVT and pSBO. He was bridged initially with heparin, but transitioned to lovenox while starting warfarin, which will be continued on discharge. In regards to his pSBO, NGT was placed, which put out coffee ground emesis. He was managed conservatively and improved with bowel rest and transitioned to a regular diet. GI was consulted for concern of UGIB and the patient underwent an EGD on [MASKED], which did not find a source of the upper GI bleed. He subsequently developed recurrent abdominal distention with concern for SBO, but CT demonstrated mild diverticulitis, which was treated with amox-clav, which was continued on discharge. He was discharged home and his PCP [MASKED] manage his warfarin moving forward. ACUTE ISSUES: ============== # Acute PE # Extensive LLE DVT Patient presented with dyspnea on exertion and worsening leg swelling over the past [MASKED] weeks, found to have acute nonocclusive thrombus within left PA extending distally to involve the left upper and lower lobe arteries and several of their proximal segmental branches. Several nonocclusive thromi were also seen within segmental branches of right pulmonary artery. Also found to have acute DVT of left common femoral, popliteal, and posterior tibial veins with minimal flow in common femoral vein but complete occlusion of remaining veins. No clear provoking factor but patient does report more sedentary lifestyle since his husband has been ill. He was treated with a heparin gtt initially before starting a lovenox bridge to warfarin. Of note, DOACs were not started due to ineraction with his antipsychotic medications. His primary care physician [MASKED] manage his anticoagulation in the outpatient setting. He is being discharged with Lovenox bridge and warfarin 6.5mg daily with script to have INR checked on [MASKED]. # partial Small bowel obstruction: resolved Presented with nausea and emesis found to have multiple, partially imaged dilated, fluid filled small bowel loops to 3.2 cm with decompressed terminal ileum. Seen by ACS in ED who placed an NGT. He was managed conservatively and SBO was persistent on gastrograffin study but then resolved with KUB at later point. He was maintained on mIVF while NPO. The partial SBO resolved with bowel rest and he improved with time. He was able to tolerate a regular diet prior to discharge, was passing flatus, and having bowel movements. The etiology of the pSBO was though to be from local inflammation in the setting of diverticulitis as noted below. # Mild diverticulitis: In setting of recurrent abdominal distension and abdominal discomfort there was initial concern for SBO recurrence. NG tube was placed and ACS was reconsulted. Due to decreased NGT output, CT was obtained and demonstrated acute, mild diverituclitis without evidence of complications. He was started on amox-clav due to ciprofloxacin interactions with his warfarin. His diet was slowly advanced until he was tolerating a regular PO diet. Prior to discharge he had a normal bowel movement. He is discharged with total 10 day course of amoxicillin-clav with last day [MASKED]. # Coffee ground emesis: resolved # Concern for UGIB Patient with hx of GERD and [MASKED] esophagus and noted increasing abdominal discomfort over the last week. He reported episode of black emesis and noted to have coffee ground emesis from NGT in ED and ICU. was treated with IV PPI BID and his hemoglobin remained stable. GI was consulted and the patient underwent an EGD on [MASKED] that did not find the source of the bleeding. He should follow-up with GI as an outpatient to consider capsule study. # Acute hypoxemic respiratory failure - resolved Patient with low level O2 requirement in ICU and transition to floor which resolved with use of incentive spirometer. This was likely secondary to PE vs. atelectasis from sedentary lifestyle. # Pneumobilia: noted to have pneumobilia on CT imaging as an inpatient and during EGD, per GI, he was noted to have a history of spinchterotomy in the past, which can help to explain the persistent pneumobilia. There was no further intervention indicated. # Irritant conjunctivitis: He was noted to have conjunctival injection/conjunctivitis, likely irritant in setting of eyelash given that patient notes history of prior episodes. He had no purulent drainage, visual changes, eye pain or headaches, and his irritant conjunctivitis improved prior to discharge. # Rosacea: Noted to have progression of his rosacea while inpatient. He would benefit from additional outpatient therapy. CHRONIC/STABLE ISSUES: ====================== # Hypothyroidism: Continued levothyroxine 88mcg daily # Bipolar disorder: continued risperidone 1mg qhs, carbamazepine 100mg qAM, 200mg qPM, clonazepam 0.25mg BID, buspirone 30mg BID # HTN: restarted home amlodipine # Insomnia: continued melatonin Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 88 mcg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Benzonatate 200 mg PO TID:PRN cough 4. Pantoprazole 40 mg PO Q12H 5. RisperiDONE 1 mg PO QHS 6. CarBAMazepine 100 mg PO QAM 7. CarBAMazepine 200 mg PO QPM 8. ClonazePAM 0.5 mg PO BID 9. BusPIRone 30 mg PO BID 10. Cyanocobalamin 1000 mcg PO DAILY 11. amLODIPine 5 mg PO DAILY 12. melatonin 10 mg oral QHS 13. Aspirin 81 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q8H RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every eight (8) hours Disp #13 Tablet Refills:0 2. Enoxaparin (Treatment) 120 mg SC Q12H RX enoxaparin 120 mg/0.8 mL 120 mg IM twice a day Disp #20 Syringe Refills:0 3. Warfarin 6.5 mg PO DAILY16 Take daily until instructed to change dose by a doctor 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. BusPIRone 30 mg PO BID 7. CarBAMazepine 100 mg PO QAM 8. CarBAMazepine 200 mg PO QPM 9. ClonazePAM 0.5 mg PO BID 10. Cyanocobalamin 1000 mcg PO DAILY 11. Furosemide 40 mg PO DAILY 12. Levothyroxine Sodium 88 mcg PO DAILY 13. melatonin 10 mg oral QHS 14. Pantoprazole 40 mg PO Q12H 15. RisperiDONE 1 mg PO QHS 16.Outpatient Lab Work ICD-9: 415.1 Please draw [MASKED] on [MASKED] Fax results to Dr. [MASKED]. FAX: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: ==================== Acute pulmonary embolism Acute deep venous thrombosis Diverticulitis SECONDARY DIAGNOSIS: ==================== partial small bowel obstruction Acute hypoxemic respiratory failure Concern for upper GI bleed, coffee ground emesis Hypothyroidism Bipolar disorder Hypertension Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was a pleasure taking part in your care here at [MASKED]! Why was I admitted to the hospital? - You were admitted for trouble breathing, abdominal pain, and bloody vomit. What was done for me while I was in the hospital? - We found a blood clot in your leg and lungs. - You were started on medications (warfarin and lovenox) to help prevent further blood clots - You underwent an endoscope to evaluate the cause of your bloody vomit and you were started on a medication to help prevent any more episodes of bloody vomiting. - You had a tube placed in your nose to help relieve the obstruction in your bowels - You were started on antibiotics to help treat diverticulitis, an infection of the bowel What should I do when I leave the hospital? -Please take all of your medications as prescribed. Please go to all of your follow up appointments as scheduled. -Please have blood work drawn on [MASKED] at the [MASKED] lab ([MASKED]) so your PCP can help adjust your dose of blood thinner medication (warfarin). -If you find you are not having a daily bowel movement, you may try taking Miralax (polyethylene gycol) which is available over the counter. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "J9601", "E872", "E039", "I10", "G4700", "K219", "G4733" ]	[ "K5793: Diverticulitis of intestine, part unspecified, without perforation or abscess with bleeding", "I2699: Other pulmonary embolism without acute cor pulmonale", "J9601: Acute respiratory failure with hypoxia", "I82412: Acute embolism and thrombosis of left femoral vein", "I82432: Acute embolism and thrombosis of left popliteal vein", "I824Z2: Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity", "E872: Acidosis", "E039: Hypothyroidism, unspecified", "F319: Bipolar disorder, unspecified", "I10: Essential (primary) hypertension", "G4700: Insomnia, unspecified", "E8889: Other specified metabolic disorders", "K219: Gastro-esophageal reflux disease without esophagitis", "K838: Other specified diseases of biliary tract", "L719: Rosacea, unspecified", "H1089: Other conjunctivitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E6601: Morbid (severe) obesity due to excess calories", "R197: Diarrhea, unspecified" ]
10,047,682	21,592,506	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / gluten Attending: ___. Chief Complaint: gangrene Major Surgical or Invasive Procedure: ___ - RIJ central line placed, removed ___ - bedside debridement by ACS ___ - PICC placed ___ - PICC removed History of Present Illness: This is a ___ with history notable for hypothyroidism ___ lithium) and psoriasis on chronic prednisone 7.5 mg daily, who presented to OSH ___ ___ on ___ with abdominal pain, vomiting, chills, found to have shock requiring ___s hypoxic respiratory failure. He was found to have strep pneumo bacteremia ___ the setting of an atrophic spleen. His course was complicated by multiorgan failure, cerebral edema, intra-ventricular hemorrhage, hypoxic ischemic encephalopathy, CVA (thought to be cardioembolic), acute hypoxic respiratory failure, stress induced cardiomyopathy, afib with RVR,ischemic nephropathy requiring CRRT on ___, DIC c/b purpura fulminans with associated digital ischemia and gangrene ISO multi-pressor requirement. He was transferred to the ___ MICU on ___. At ___, he was s/p trach and PEG, and was found to have Pseudomonal bacteremia, and acute exudative hemorrhageic pericardial effusion ___ setting of STEMI (clean cath). Detailed ___ Foundation (___) course is noted below: Pulmonary ----------------- #Acute respiratory failure Tracheostomy/peg placed ___ by thoracic surgery at ___ ___. ==> Trach collar 2424 hrs. versus ventilator overnight with trach collar during the day. Neurologic ---------------- #Cerebral edema and intraventricular hemorrhage Edema is likely multifactorial given pneumococcal meningitis and prolonged hypoperfusion due to septic shock. This was complicated by increased intracranial pressure and hyponatremia, which was treated with hypertonic saline drip. Patient did have an ICP monitor placed, increased ICP resolved, and was removed on ___. MR showed extensive anoxic brain injury and infarcts ___ regions consistent with central embolic source and no evidence of herniation, BEM showed bilateral cortical dysfunction ___ non-generalized slow waves, no focality. Due to patient being high risk for seizure activity, he was started on prophylactic Keppra, which is continued throughout the course. An MR on ___ showed progression of DWI restriction ___ caudate, putamen, globus pallidus, as well as diffusion restriction ___ multiple areas of cortex as per prior MR. ___ that time, there is some increase ___ IVH, small amount of SCh which was new ___ the right frontal region. An angiogram on ___ was negative for source of IVH or mycotic aneurysm, neurosurgery evaluated and thought the subarachnoid was likely procedural given the poor placement; they believe that the IVH was due to coagulopathy of DIC. A subsequent MR showed resolution of diffusion restriction, right resolution of mass-effect, and stable distribution of parenchymal FLAIR. The MR noted new mild ventricular megaly from ___. There was also evidence of hemosiderosis associated with prior IVH and SAH. EEG: Continuous video EEG showed bilateral cerebral dysfunction ___ through ___. There is evidence of moderate diffuse encephalopathy, however no epileptiform discharges or seizures. ==> Current plan at ___: -Target map 60-65 for cerebral perfusion -Target platelets greater than 50 -Hold heparin drip #Retinal hemorrhages ___ spots #Corneal exposures Evidence of hemorrhage and raw spots on ocular exam with subfoveal hemorrhage versus cherry red spot concerning for CRA O during embolic/anoxic injury. TEE deferred due to no probable change ___ management. ==> Ophthalmology was following, they recommended conservative management. Continued on erythromycin drops and ocular lubrication. Vascular --------------- #Purpura fulminans/dry gangrene Patient's ischemic injury is thought to be due to prolonged hypoxemia and vasopressor dependence. Patient had a skin biopsy on ___ which showed evidence of DIC. On ___, ___ vascular surgeons recommended no acute surgical intervention, and suggested amputations of ischemic limbs once other active issues are stable. Per vascular note, no pulses on Doppler of bilateral radial arteries and brachial/popliteal arteries. Family wanted a second opinion and wanted to transfer the patient to ___ for evaluation for possible vascular intervention. #IVC filter placement: Unclear indication. Infectious disease #Infections #Strep pneumonia #Pseudomonas bacteremia #Stenotrophomonas pneumonia Extensive history of antibiotics use and infections. Patient with persistent tachycardia, and recurrent episodes of hypotension and fevers prompting extensive antibiotics use. See below for a summary: ___: Ceftriaxone for strep pneumonia, 3 doses of IVIG for asplenia. ___: Increased pressor requirement, switched ceftriaxone to ___, plan for 6 weeks per ID ___: Off pressors ___: Intermittent hypotension requiring levophed ___: Fever, concern for drug fever ___: Last day of antibiotics ___: LP ___: Tmax 101.7. Started meropenem and cipro again for pseudomonas bacteremia ___: Switched to vanco and cipro, all lines taken out and replaced ___: Switched from cipro to aztreonam, vanc was given and discontinued ___: Switched from Aztreonam to cipro ___: Hypotension, addition of amikacin for double pseudomonas coverage. Found to have pericardial effusion s/p drainage. ___: Sputum culture positive for Stenotrophomonas, thought to be contaminant, continued on cipro ___: Persistent tachycardia, so changed to ___ ___: Added fluconazole ___: Stopped ___ ___: Stopped fluconazole ___: Off antibiotics, persistent tachycardia up to 140's, infectious workup repeated ___: Sputum culture with Stenotrophomonas, started Bactrim DC 2 tabs TID #Persistent tachycardia for several weeks #Worsening leukocytosis, intermittent hypotension ___ stopped on ___, fluconazole discontinued on ___ given extensive negative workup. Worsening leukocytosis since ___ (19 -> 26 -> 21 -> 21 -> 19 -> 20 -> 22 on ___. Infectious workup sent, notable for right lobe consolidation on CXR. On ___ Sputum culture grew Stenotrophomonas pneumonia, so started on Bactrim DS 2 tabs TID. #Pseudomonas bacteremia Cultures have all been negative at ___, until a ___ pseudomonal blood culture which required meropenem on ___ which was transitioned to ciprofloxacin on ___, and then to aztreonam on ___, and then back to ciprofloxacin and ___. Patient has now completed his 14 day course of ciprofloxacin. Patient had all lines exchanged on ___, HD line on the right on ___. Patient did have a left IJ placed after that. #Stenotrophomonas pneumonia On ___, patient found to have a tracheal aspirate positive for stenotrophomonas, which was susceptible to Bactrim. Patient was started on Bactrim IV 7.5 mg per kilo, and was continued on his ciprofloxacin. Stenotrophomonas thought to be a contaminant at that time. As noted above, sputum culture from ___ grew Stenotrophomonas pneumonia, so started on Bactrim DS 2 tabs TID. Cardiovascular ------------------ #Tachycardia Persistent tachycardia, sinus with rates 130-150's. Consider to be due to fevers vs. pain vs. pericarditis vs. infections. Patient status post extensive septic workup, including MR brain showing no abscess or empyema, LP showing no sign of infection/HSV negative/cryptococcal antigen negative, blood cultures on ___ were negative. See above for extensive ID workup and antibiotics use. ==> CCF was monitoring, controlling fever with Tylenol and cooling blanket. Fentanyl as needed for pain. As needed fluid boluses. Continued on colchicine and prednisone for pericarditis. #Hypotension Initially with shock requiring 4 pressors from strep pneumo bacteremia, eventually weaned off pressors. Subsequent intermittent hypotension episodes attributed to infections as well as pericardial effusion. Hypotension now thought to be possibly autonomic ___ the setting of cerebral edema pressures IVH vs. adrenal insufficiency. Has been off pressors for several days. #Pericardial effusion Patient found to have pericardial effusion on ___ with normal LVEF and normal RV size and function. There was a very large circumferential effusion at that time with some RA inversion but no RV collapse. IVC was noted to be normal with less than 50% collapsibility ___ the setting of PPV. No obvious tamponade was noted, however pericardial drain was placed on ___ with 800 cc initial drainage, 750 cc ___ the subsequent 24 hours. Repeat echo showed small residual effusion. ==>Patient was initially on IV Decadron 4 mg every 12 hours, was then transitioned to prednisone 0.5 mg/kg for 2 weeks, and then on ___ was tapered to 7.5 mg daily for chronic adrenal insufficiency as well as colchicine 0.6 makes twice daily for 3 months for post MI/postinfectious pericarditis. Patient is contraindicated to aspirin and NSAIDs due to hemorrhage and renal dysfunction. Gastrointestinal ------------------ #Nutrition PEG tube placed on ___, tube feeds started ___ at 8 ___. ==> Continue tube feeds; if high residuals then first-line is to give Reglan rather than stopping tube feeds. Nephrology ------------------ ___ due to ATN ISO septic shock -RRT began at outside hospital around ___, transition to IHD on ___. Patient did have 1 day of CRRT on ___, but resumed IHD on ___. Patient has had very high UOP from post ATN diuresis versus TIA versus osmotic diuresis (patient receiving D5W for hypernatremia). ==> Continue to trend renal function, replete fluids as needed. Hematologic ------------------ #Functional asplenia Patient received IVIG from ___ through ___, with repeat IgG being normal on ___ (962). IgG on ___ was also normal (1320). #Thrombocytopenia and anemia Patient with ACD, elevated ferritin to ___ with an iron of 41 and TIBC of 153. Patient required multiple transfusions during hospital stay, most recently ___. ==> Transfuse to hemoglobin less than 7 and platelets less than 50, CTM for active bleeding Endocrinology #Adrenal insufficiency Patient has a history of psoriasis on prednisone 7.5 mg daily. Patient had an ACTH stimulation (cosyntropin 250 mcg) three-time point test on ___ with cortisol of 10.6, 11.2, and 10.3; representing inadequate response. Patient underwent a taper of IV Decadron down to 40 mg of prednisone for 2 weeks, then to 7.5 mg of prednisone daily, now on 5 mg prednisone daily which started on ___. #Hypothyroidism This is thought to be lithium induced. On ___, patient found to be consistent with sick euthyroid state with a TSH of 13.3, FT4 1.5, F T3 of 1.7. For this he was kept on L-thyroxine to 220 mcg daily. Plan is to repeat TSH ___ 6 weeks. Past Medical History: Lithium-induced hypothyroidism Psoriasis on chronic steroids Seasonal affective disorder Social History: ___ Family History: No significant immunodeficiency or vascular disease. Physical Exam: ADMISSION EXAM ======================= VITALS: Reviewed ___ metavision GENERAL: Laying ___ bed, chronically ill appearing, eyes are open, no purposeful movement of the eyes, necrotic limbs, no movement noted for the extremities, multiple pressure ulcers ___ the back of the head, back, coccyx, extremities HEENT: Sclera anicteric LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Gangrenous limbs, up to elbow level for upper extremities and below the knees. Dopplerable popliteal and brachial arteries. DISCHARGE EXAM ========================== GENERAL: Laying ___ bed, chronically ill appearing, eyes are open, necrotic limbs, no movement noted for the extremities, multiple pressure ulcers ___ the back of the head, back, coccyx, extremities. Able to stick out tongue as yes/no response at times HEENT: Sclera anicteric LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, tender to palpation over epigastric region, non-distended, bowel sounds present, J tube ___ place EXT: Gangrenous limbs, below elbow level for upper extremities and below the knees. Dopplerable popliteal and brachial arteries. Pertinent Results: ADMISSION LABS ===================== ___ 12:29AM BLOOD WBC-22.5* RBC-2.96* Hgb-8.3* Hct-27.3* MCV-92 MCH-28.0 MCHC-30.4* RDW-16.8* RDWSD-55.4* Plt ___ ___ 10:49PM BLOOD ___ PTT-28.9 ___ ___ 10:49PM BLOOD Glucose-97 UreaN-78* Creat-1.8* Na-139 K-6.4* Cl-98 HCO3-23 AnGap-18 ___ 02:42AM BLOOD ALT-37 AST-39 AlkPhos-106 TotBili-0.3 ___ 10:49PM BLOOD Calcium-11.6* Phos-5.7* Mg-2.4 IMAGING ===================== RENAL US ___: No hydronephrosis. Findings suggestive of intrinsic medical renal disease. CT HEAD ___: No acute intracranial abnormality identified. No evidence of chronic extra-axial collection. ___ US: No evidence of acute deep venous thrombosis ___ the visualized right or left lower extremity veins. Views of the right and left calf veins, however, were limited by overlying ulcers. TTE ___: The left atrium is normal ___ size. There is no evidence for an atrial septal defect by 2D/color Doppler. The right atrial pressure could not be estimated. There is normal left ventricular wall thickness with a normal cavity size. There is mild global left ventricular hypokinesis. A left ventricular thrombus/mass is not seen but cannot be excluded. Quantitative biplane left ventricular ejection fraction is 45 %. The visually estimated left ventricular ejection fraction is 40-45%. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Mildly dilated right ventricular cavity with normal free wall motion. The aortic valve leaflets (?#) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a trivial pericardial effusion. ARTERIAL STUDIES ___: Findings duplex evaluations performed of the upper extremities ___ the areas that were not wrapped. The distal axillary and brachial arteries are patent with triphasic flow and normal velocities. Impression patent upper extremity arterial system down to the forearm Findings duplex evaluations for both lower extremities. Below the knee cannot be evaluated due to gangrene and dressings. The common femoral, deep femoral and superficial femoral arteries are patent with triphasic flow and normal velocities. Impression normal arterial duplex of both lower extremities down to the level of the knee were gangrene is present XRAY ARMS ___: The bilateral humeri appear intact with apparent normal mineralization, normal alignment, and without fracture. The there is waisting of the soft tissues. Left IJ catheter is partially imaged and tip appears to project at the superior cavoatrial junction, however these views are not optimized for evaluation of catheter tip position. Multiple lines and tubes overlie the patient obscuring views. Tracheostomy tube is seen. Hazy linear opacities at the bilateral lung bases likely represents atelectasis There is a soft tissue swelling surrounding the bilateral elbows and of the bilateral forearms. There may be soft tissue defect of the left forearm. Underlying ulna and radius appear relatively unremarkable. No definite fracture. There appears to be flexion contractures of the fingers of the bilateral hands. There appears to be wasting of the soft tissues. No definite fractures identified. Hands are suboptimally evaluated due to contortion from contractures. ___ TTE: (while septic with fungemia) Normal biventricular cavity sizes with moderate gloaval biventricular hypokinesis. No valvular pathology or pathologic flow identified. Small circumferential pericardial effusion without tamponade physiology. ___ US Buttocks, soft tissue: Transverse and sagittal images were obtained of the superficial tissues overlying the left ischial tuberosity. At the site of known decubitus ulcer, there is a defect ___ the skin with fluid pooling at the site of ulceration. There is no collection within the subcutaneous tissues or definite evidence for a sinus tract. ___ CT Abd/Pelvis: LOWER CHEST: Bibasal airspace opacification (suspected atelectasis) as well as trace pleural effusions appear improved compared to prior. Retained secretions present ___ the lower lobe bronchi bilaterally. Trace pericardial effusion is also improved compared to prior. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Small heterogenous residual spleen/splenule appears similar to prior. ADRENALS: The right and left adrenal glands are normal ___ size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal PELVIS: Distended bladder. There is no free fluid ___ the pelvis. REPRODUCTIVE ORGANS: The prostate is heterogeneous but otherwise unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. IVC filter ___ situ. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No new acute abdominopelvic process. 2. Bibasal airspace opacification (suspected atelectasis) with trace pleural effusions are improved compared to prior. 3. Small pericardial effusion is also improved compared to prior. MICROBIOLOGY ===================== ___ 3:46 am URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R ___ 3:46 am SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. 1+ (<1 per 1000X FIELD): YEAST(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. STENOTROPHOMONAS MALTOPHILIA. MODERATE GROWTH. test result performed by Microscan. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STENOTROPHOMONAS MALTOPHILIA \| TRIMETHOPRIM/SULFA---- <=2 S RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. Piperacillin/Tazobactam test result performed by ___ ___. YEAST. SPARSE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 16 I CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ 8 I MEROPENEM------------- 4 I PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S ___ 1:12 am BRONCHOALVEOLAR LAVAGE FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL. Piperacillin/Tazobactam test result performed by ___ ___. STENOTROPHOMONAS MALTOPHILIA. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| STENOTROPHOMONAS MALTOPHILIA \| \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ 8 I MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Time Taken Not Noted ___ Date/Time: ___ 11:46 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: ___ PARAPSILOSIS. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Yeast Susceptibility:. Fluconazole MIC OF 1.0 MCG/ML = SUSCEPTIBLE. Results were read after 24 hours of incubation. test result performed by Sensititre. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ ___ ON ___ - ___. YEAST(S). ___ 2:30 pm SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. ___ MORPHOLOGY. Piperacillin/Tazobactam test result performed by ___ ___. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 8 S 16 I CEFTAZIDIME----------- 16 I 4 S CIPROFLOXACIN--------- 0.5 S 1 S GENTAMICIN------------ <=1 S 8 I MEROPENEM------------- 8 R 4 I PIPERACILLIN/TAZO----- 16 S S TOBRAMYCIN------------ <=1 S <=1 S ___ 2:30 pm URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. Piperacillin/Tazobactam test result performed by ___ ___. VIRIDANS STREPTOCOCCI. >100,000 CFU/mL. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 0.5 I GENTAMICIN------------ 8 I MEROPENEM------------- 4 I PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S ___ 8:42 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile PCR (Final ___: NEGATIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. A negative C. diff PCR test indicates a low likelihood of CDI or carriage. ___ 12:11 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Preliminary): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. Piperacillin/Tazobactam test result performed by ___ ___. Ceftolozane/tazobactam & CEFTAZIDIME-AVIBACTAM SUSCEPTIBILITY REQUESTED PER ___ ___ (___) ___. YEAST. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. ___ MORPHOLOGY. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 16 I 2 S CEFTAZIDIME----------- 16 I 4 S CIPROFLOXACIN--------- 1 S <=0.25 S GENTAMICIN------------ 8 I <=1 S MEROPENEM------------- 4 I <=0.25 S PIPERACILLIN/TAZO----- R 8 S TOBRAMYCIN------------ <=1 S <=1 S ___ 1:10 pm BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Preliminary): YEAST, PRESUMPTIVELY NOT C. ALBICANS. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Aerobic Bottle Gram Stain (Final ___: YEAST(S). Reported to and read back by ___ (___) @ ___ ON ___. ___ 2:04 pm URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. YEAST. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R DISCHARGE/PERTINENT LABS ======================== ___ 03:05AM BLOOD WBC-21.3* RBC-2.95* Hgb-8.8* Hct-29.4* MCV-100* MCH-29.8 MCHC-29.9* RDW-21.2* RDWSD-77.7* Plt ___ ___ 03:05AM BLOOD ___ PTT-27.2 ___ ___ 03:05AM BLOOD Glucose-94 UreaN-33* Creat-0.7 Na-136 K-6.6* Cl-101 HCO3-19* AnGap-16 ___ 08:47AM BLOOD K-5.3* ___ 04:22AM BLOOD ALT-14 AST-13 AlkPhos-68 TotBili-<0.2 ___ 04:15AM BLOOD calTIBC-233* Ferritn-965* TRF-179* ___ 02:59AM BLOOD Triglyc-263* ___ 02:10AM BLOOD Triglyc-534* ___ 12:11PM BLOOD Triglyc-509* ___ 04:49AM BLOOD Triglyc-645* ___ 04:23AM BLOOD TSH-4.5* ___ 03:08AM BLOOD TSH-25* ___ 04:23AM BLOOD Free T4-1.6 ___ 04:53AM BLOOD 25VitD-19* ___ 06:39PM BLOOD ANCA-NEGATIVE B ___ 08:20PM BLOOD ___ pO2-37* pCO2-36 pH-7.44 calTCO2-25 Base XS-0 ___ 08:20PM BLOOD Lactate-1.___ is a ___ h/o hypothyroidism ___ lithium, who presents as a transfer from ___ for evaluation of necrotic limbs by vascular surgery. Patient initially presented to a ___ hospital w/ generalized illness, nausea, and vomiting, and was found to have septic shock ___ Streptococcus ___ the setting of ?atrophic spleen (unknown at time of presentation, CT scan from ___ with normal size spleen), w/ course complicated by respiratory failure, renal failure, hypoxic brain injury, intracerebral hemorrhage, myocardial infarction w/ resultant pericardial effusion s/p pericardial drain, DIC & purpura fulminans resulting ___ gangrene of all limbs. His course at ___ was complicated by Enterococcus UTI, VAP, and fungemia and endocrine abnormalities. He was briefly transferred to the floor ___ anticipation of possible discharge to ___, however, he became febrile, tachycardic, and hypotensive on ___ concerning for recurring sepsis and was transferred back to ___ for further care. Current Active Issues ===================== #Infection #Recurrent VAP d/t multiple strains of MDR PsA: Sputum cultures ___ growing 2 strains pseudomonas Aeruginosa, sensitive to ciprofloxacin. Given high risk of developing resistances to fluoroquinolones, infectious disease consulted. - Recommended ciprofloxacin IV and cefepime IV (prolonged infusion over 3 hours, 8 hours between end of one infusion and beginning of next). Day 1 = ___. End date ___. If still with respiratory compromise, can extend this to 10 days. #Fungemia, presumably recurrent C. parapsilosas, unknown source, CT abdomen/pelvis with contrast negative: Blood cultures on ___ growing C. parapsilosas sensitive to fluconazole. Septic ___ this setting during which TTE showed depressed global biventricular function. Given poor PO absorption, unclear if this was consistently treated optimally (switched IV to PO and ___ error missed one day). Blood cultures negative until ___, growing ___, awaiting speciation. Decompensated from this with tachycardia, fever and soft BP. Switched to IV micafungin on ___. ___ removed ___ for line holiday, currently with peripheral. - Per ID recs continue micafungin 100 mg IV daily x14 days from PICC removal. Day 1 = ___. Day 14 = ___. - Follow up ___ speciation from ___ sputum culture - NOTE: if fungemia recurs, recommend TEE to evaluate for endocarditis (considered during current presentation, though ___ the setting of likely incomplete/inadequate treatment with poor azole absorption through GI tract, will consider this same original infection.) # Bacteruria of unclear significance - Held on treating Enterococcus ___ most recent UCx ___ (exam felt more c/w abdominal as opposed to suprapubic pain, no e/o inflammation on UA like previously treated UTI, and no ___, fungemia and MDR pseudomonal pneumonia to explain fever, and improvement with treatment of above. # Wound care # Necrotic limbs # Dry gangrene Patient's ischemic injuries occurred ___ the setting of shock with ___s DIC w/ purpura fulminans. The patient's family desired a second opinion from ___, and this was the primary reason for transfer to ___. He was seen by the Vascular Surgery & Plastic Surgery teams at ___ who felt there was no need for urgent intervention. The patient should follow-up with Vascular surgery (Dr. ___ surgery (Dr. ___ two weeks after discharge. Pt also has several decubitus ulcers (right and left gluteal area) that required debridement from wound nurse while inpatient. Pt has been getting wound care daily. #Pain Palliative care consulted. Currently, difficult to assess pain given patient is minimally interactive. Can follow few commands but this waxes and wanes. Pain manifested as agitation, tachycardia. Also able to show us his tongue at times for yes and no answers. Location limbs, intermittently abdomen. Currently maintained on methadone and IV dilaudid. Can consider IV methadone if suspicious for poor PO absorption (iso intermittent vomiting which is his baseline). # Acute on chronic respiratory failure s/p trach placement: He had a tracheostomy placed ___ at ___. He was treated for Stenotrophomonas PNA found on tracheal aspirate ___ with TMP-SMX then levofloxacin due to hyperkalemia for a ___urrently being treated for VAP ___ multidrug resistant strains of pseudomonas, please see above. Currently on trach collar but has required vent for mucous plugging intermittently. #Nausea, vomiting With bilious projective vomiting occurring once every few days to once a day. GI consulted and concern for stress gastritis and ulcerations. GI loosened =external bumper of his PEG to avoid burring of internal bumper given it was found that connection between PEG tube and feeding pump was short and was tugging at PEG site. Recommended for lansoprazole to 30mg bid and giving enough slack to connection between feeding pump and PEG to avid tugging of PEG. Also recommended Hyoscyamine (improved cramping abdominal pain) and metoclopramide. Pt has also been receiving IV Ativan infrequently if vomiting. Patient should have tube feeds and ALL medications given through J part of GJ tube. Giving meds through G part of GJ tube can exacerbated vomiting. #Encephalopathy #Neurologic Status #ICH The etiology of his brain injury was felt to be ___ the setting of multifactorial Pneumococcal meningitis and prolonged hypoperfusion w/ resultant cerebral hypoxia and ICH ___ the setting of septic shock. Multiple MRIs at ___ showed extensive anoxic brain injury. On admission here, Neurology was consulted for prognostication. Ultimately, Neurology felt that he would likely suffer permanent deficits, however they were not able to prognosticate further than that. He did begin to become responsive and was able to follow some simple commands. He was given Keppra for seizure prophylaxis. - ___, OT, S/S - speech and swallow consult for ___ valve #) Endocrinopathies: Iatrogenic adrenal insufficiency, hypothyroidism, hypercalcemia of immobility. Endocrinology was consulted and recommended: -Prednisone 10 mg daily, unless stress dose steroids necessitated -Fludricortisone 0.1 mg -Levothyroxine 200 mcg #Anemia of inflammation Iron studies ___ keeping with inflammation. He was transfused for Hgb <7. He did not have evidence of active bleeding. #Left filamentary keratitis, xerophthalmia Patient was evaluated by ophthalmology and diagnosed with filamentary keratitis. He was started on vigamox antibiotics QID, and completed the course of antibiotics. He should continue lubricating eye drops per ophthalmology. He should follow-up with ophthalmology two weeks after discharge. - artificial tears ___ TID - artificial tears gel ___ #Severe protein-calorie malnutrition Continue tube feeds. Of note, found to be hyperTG. Given hyperTG and nausea vomiting (lipase normal), pt was switched to lower osm tube feeds and tolerating it better. Resolved issues from extended hospitalization ============================================= # Recurrent ___: # Hyperkalemia: # Hypernatremia: ___ records, RRT began at ___ around ___ & transitioned to IHD on ___ at ___. He was eventually liberated from dialysis & his creatinine then settled out ___ the mid-1 range. On admission to ___, his creatinine rose from 1.8 on arrival to 2.3 where it plateaued. His 24-hour urine collection with creatinine 2.2 showed creatinine clearance of only around ~15, indicating that his GFR is lower than would be predicted based on his serum creatinine, likely from lower creatinine generation. He was continually non-oliguric, w/ urine showing granular debris and cast fragments indicating tubular injury, which rose suspicion for ischemic +/- hemodynamic injury of unclear precipitant. Additionally, he had low urine specific gravity and isosthenuria suggesting a concentrating defect, and it was considered that he was not regulating his urine volume well. As such, he was given aggressive IVF PRN to maintain his volume status. A broad work-up was sent to investigate this ___ (ASO, ANCA, ___, UPEP) which was largely unrevealing (notably, had positive ASO which raised possibility of post-infectious GN, but as complement levels were normal it was felt that this positive result was not clearly pathogenic). Ultimately his ___ resolved and Cr normalized to 0.6. ___ the setting of his ___, he had persistent hypernatremia & hyperkalemia, which were managed with free water repletion and management of his adrenal insufficiency and initiation of fludrocortisone. #Primary adrenal insufficiency Patient does NOT have history of chronic prednisone use prior to initial illness as noted ___ ___ documentation. Patient had an ACTH stimulation (cosyntropin 250 mcg) three-time point test on ___ with cortisol of 10.6, 11.2, and 10.3 representing inadequate response. He underwent a taper of IV dexamethasone down to 40 mg of prednisone for 2 weeks, then to 7.5 mg of prednisone daily, now on 5 mg prednisone daily which started on ___. Repeat stim test showed ongoing insufficiency thus patient was transitioned to prednisone 10mg PO QD per the recommendations of endocrinology and 15 mg daily at times of stress. # Retinal hemorrhages: # Filamentous keratitis # Inferior corneal ulcer At ___, the patient had evidence of hemorrhage on ocular exam with subfoveal hemorrhage versus cherry red spot concerning for CRAO during embolic & anoxic injury. He was seen by ___ Ophthalmology for continued evaluation, who were concerned about the extensive eye dryness and recommended follow up two weeks following discharge. # Resistant Enterococcus UTI: Noted on urine culture. Based on sensitivities, he was treated with linezolid (___). # Sinus tachycardia Heart rates persistently >100, usually ___ the 110-120 range despite management of multiple infections, pain, fluid status. Patient received ___ LR/day for management of insensible losses that could be contributing to tachycardia to good effect. # Type II NSTEMI Mild troponin elevation with T wave inversions ___ setting of mucus plugging ___. Trop peaked at 0.64. MB was flat. Patient was not anticoagulated. #Nutrition PEJ tube placed on ___ at ___. Given recurrent aspiration events, he underwent ___ advancement to GJ on ___. The nutrition service followed him closely for evaluation and support. Patient should have tube feeds and ALL medications given through J part of GJ tube. Giving meds through G part of GJ tube can exacerbated vomiting. # Hypothyroidism: Known chronic problem thought to be lithium induced. On ___, patient found to be consistent with sick euthyroid state with a TSH of 13.3, FT4 1.5, F T3 of 1.7. For this he was kept on L-thyroxine 220 mcg daily. He was evaluated by ___ Endocrine who felt that it is very likely that he is not absorbing oral levothyroxine specially ___ the setting of high TF residual volume. He was given IV bolus of 150mcg IV LT4 at 3pm on ___ and then transitioned to IV LT4 for continued management. He was switched back to oral levothyroxine at a high dose (200 mcg) to overcome interference by tube feeds. # Hypercalcemia: The Endocrine service was consulted for management. He was given IV zoledronic acid 3mg given on ___ with some improvement ___ calcium. Endocrine felt that this was a PTH-independent process with high degree of bone resorption based on very elevated CTX, most likely due to immobilization given the clinical circumstances. There was no evidence of FHH, post-rhabdo delayed hypercalcemia (would not respond to bisphosphonate or have elevated CTx), malignancy, granulomatous disease, or lithium-induced Hypercalcemia. PTHrp is 23 and his 1,25-D is 31. He was continued on vitamin D therapy. TRANSITIONAL ISSUES: ==================== - Continue Keppra ___ months per neurology - Should continue to be seen by ___ Therapy - Per neuro, his prognosis is guarded, unclear how much neurologic function he will recover - Vascular surgery follow up should be done ___ ___ weeks after hospital discharge - ___ surgery should follow ___ weeks after hospital discharge - Opthalmology should follow 2 weeks after hospital discharge - Recheck TSH on 200mcg levothyroxine ___ ___ weeks - Repeat TTE ___ ___ weeks; last TTE ___ setting of septic shock with improved function on bedside exam - End date for abx: -- Ciprofloxacin and Cefepime for VAP ___ -- Micafungin for fungemia ___ - PICC to be placed ___ ___ on or after ___ - Wound care daily, debridement PRN - Follow up ___ speciation for ___ blood culture - Follow up ___ blood cultures (NGTD) - Hold on treating Enterococcus ___ most recent UCx for now (exam felt more c/w abdominal as opposed to suprapubic pain, no e/o inflammation on UA like previously treated UTI, and no ___ - If fungemia recurs, recommend TEE to evaluate for endocarditis (considered during current presentation, though ___ the setting of likely incomplete/inadequate treatment with poor azole absorption through GI tract, will consider this same original infxn) - Should need additional records from ___, fax to ___. Pt was ___ ICU on G62 there for 3 months. - QTC daily given pt on several QTc prolonging medications. Can space out less frequently after completion of ciprofloxacin # Access: PIV # Contact: Rabbi ___, ___ (___) # Code: Full, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 7.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Artificial Tears GEL 1% ___ DROP BOTH EYES ___ 3. Artificial Tears Preserv. Free ___ DROP BOTH EYES TID 4. Bisacodyl 10 mg PR ___ Constipation - Third Line 5. CefePIME 2 g IV Q8H 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 7. Ciprofloxacin 400 mg IV Q8H 8. Docusate Sodium 100 mg PO BID 9. Fludrocortisone Acetate 0.1 mg PO DAILY 10. Gabapentin 300 mg PO ___ 11. GuaiFENesin ___ mL PO Q6H:PRN mucous secretions 12. Heparin 5000 UNIT SC BID 13. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN Pain - Severe 14. Hyoscyamine 0.125 mg PO QID 15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing 16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H SOB/ wheezing 17. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 18. LevETIRAcetam 500 mg PO Q12H 19. Levothyroxine Sodium 200 mcg PO DAILY 20. Methadone 5 mg PO Q8H pain 21. Metoclopramide 10 mg PO TID 22. Micafungin 100 mg IV Q24H 23. Multivitamins W/minerals 15 mL PO DAILY 24. Polyethylene Glycol 17 g PO DAILY 25. Senna 8.6 mg PO BID 26. Vitamin D ___ UNIT PO 1X/WEEK (WE) 27. PredniSONE 10 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Four extremity dry gangrene Fungemia Adrenal insufficiency Mild Pericardial effusion Hypernatremia MDR pseudomonas PNA Discharge Condition: Mental Status: Minimally interactive Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___ and family, You were admitted to ___ for vascular surgery evaluation. While ___ the hospital, your course was complicated by several infections including pneumonia and fungus ___ the blood. You will be discharged to ___ where you will receive on going care to treat you infection as well as rehabilitation to make you stronger. Details regarding the specifics of the infectious are outlined below. Sincerely, Your ___ team Followup Instructions: ___	[ "I96", "D65", "I21A1", "E43", "J690", "J9621", "G9340", "B377", "J95851", "B49", "G931", "I313", "E870", "N390", "E273", "N179", "E872", "I428", "Z431", "Z930", "E038", "B965", "B952", "Z781", "T43595S", "E8352", "N141", "Y848", "Y92239", "L89150", "L89120", "T17990A", "R112", "Y92230", "T370X5A", "D6489", "H16122", "E875", "B9689" ]	Allergies: Penicillins / gluten Chief Complaint: gangrene Major Surgical or Invasive Procedure: [MASKED] - RIJ central line placed, removed [MASKED] - bedside debridement by ACS [MASKED] - PICC placed [MASKED] - PICC removed History of Present Illness: This is a [MASKED] with history notable for hypothyroidism [MASKED] lithium) and psoriasis on chronic prednisone 7.5 mg daily, who presented to OSH [MASKED] [MASKED] on [MASKED] with abdominal pain, vomiting, chills, found to have shock requiring s hypoxic respiratory failure. He was found to have strep pneumo bacteremia [MASKED] the setting of an atrophic spleen. His course was complicated by multiorgan failure, cerebral edema, intra-ventricular hemorrhage, hypoxic ischemic encephalopathy, CVA (thought to be cardioembolic), acute hypoxic respiratory failure, stress induced cardiomyopathy, afib with RVR,ischemic nephropathy requiring CRRT on [MASKED], DIC c/b purpura fulminans with associated digital ischemia and gangrene ISO multi-pressor requirement. He was transferred to the [MASKED] MICU on [MASKED]. At [MASKED], he was s/p trach and PEG, and was found to have Pseudomonal bacteremia, and acute exudative hemorrhageic pericardial effusion [MASKED] setting of STEMI (clean cath). Detailed [MASKED] Foundation ([MASKED]) course is noted below: Pulmonary ----------------- #Acute respiratory failure Tracheostomy/peg placed [MASKED] by thoracic surgery at [MASKED] [MASKED]. ==> Trach collar 2424 hrs. versus ventilator overnight with trach collar during the day. Neurologic ---------------- #Cerebral edema and intraventricular hemorrhage Edema is likely multifactorial given pneumococcal meningitis and prolonged hypoperfusion due to septic shock. This was complicated by increased intracranial pressure and hyponatremia, which was treated with hypertonic saline drip. Patient did have an ICP monitor placed, increased ICP resolved, and was removed on [MASKED]. MR showed extensive anoxic brain injury and infarcts [MASKED] regions consistent with central embolic source and no evidence of herniation, BEM showed bilateral cortical dysfunction [MASKED] non-generalized slow waves, no focality. Due to patient being high risk for seizure activity, he was started on prophylactic Keppra, which is continued throughout the course. An MR on [MASKED] showed progression of DWI restriction [MASKED] caudate, putamen, globus pallidus, as well as diffusion restriction [MASKED] multiple areas of cortex as per prior MR. [MASKED] that time, there is some increase [MASKED] IVH, small amount of SCh which was new [MASKED] the right frontal region. An angiogram on [MASKED] was negative for source of IVH or mycotic aneurysm, neurosurgery evaluated and thought the subarachnoid was likely procedural given the poor placement; they believe that the IVH was due to coagulopathy of DIC. A subsequent MR showed resolution of diffusion restriction, right resolution of mass-effect, and stable distribution of parenchymal FLAIR. The MR noted new mild ventricular megaly from [MASKED]. There was also evidence of hemosiderosis associated with prior IVH and SAH. EEG: Continuous video EEG showed bilateral cerebral dysfunction [MASKED] through [MASKED]. There is evidence of moderate diffuse encephalopathy, however no epileptiform discharges or seizures. ==> Current plan at [MASKED]: -Target map 60-65 for cerebral perfusion -Target platelets greater than 50 -Hold heparin drip #Retinal hemorrhages [MASKED] spots #Corneal exposures Evidence of hemorrhage and raw spots on ocular exam with subfoveal hemorrhage versus cherry red spot concerning for CRA O during embolic/anoxic injury. TEE deferred due to no probable change [MASKED] management. ==> Ophthalmology was following, they recommended conservative management. Continued on erythromycin drops and ocular lubrication. Vascular --------------- #Purpura fulminans/dry gangrene Patient's ischemic injury is thought to be due to prolonged hypoxemia and vasopressor dependence. Patient had a skin biopsy on [MASKED] which showed evidence of DIC. On [MASKED], [MASKED] vascular surgeons recommended no acute surgical intervention, and suggested amputations of ischemic limbs once other active issues are stable. Per vascular note, no pulses on Doppler of bilateral radial arteries and brachial/popliteal arteries. Family wanted a second opinion and wanted to transfer the patient to [MASKED] for evaluation for possible vascular intervention. #IVC filter placement: Unclear indication. Infectious disease #Infections #Strep pneumonia #Pseudomonas bacteremia #Stenotrophomonas pneumonia Extensive history of antibiotics use and infections. Patient with persistent tachycardia, and recurrent episodes of hypotension and fevers prompting extensive antibiotics use. See below for a summary: [MASKED]: Ceftriaxone for strep pneumonia, 3 doses of IVIG for asplenia. [MASKED]: Increased pressor requirement, switched ceftriaxone to [MASKED], plan for 6 weeks per ID [MASKED]: Off pressors [MASKED]: Intermittent hypotension requiring levophed [MASKED]: Fever, concern for drug fever [MASKED]: Last day of antibiotics [MASKED]: LP [MASKED]: Tmax 101.7. Started meropenem and cipro again for pseudomonas bacteremia [MASKED]: Switched to vanco and cipro, all lines taken out and replaced [MASKED]: Switched from cipro to aztreonam, vanc was given and discontinued [MASKED]: Switched from Aztreonam to cipro [MASKED]: Hypotension, addition of amikacin for double pseudomonas coverage. Found to have pericardial effusion s/p drainage. [MASKED]: Sputum culture positive for Stenotrophomonas, thought to be contaminant, continued on cipro [MASKED]: Persistent tachycardia, so changed to [MASKED] [MASKED]: Added fluconazole [MASKED]: Stopped [MASKED] [MASKED]: Stopped fluconazole [MASKED]: Off antibiotics, persistent tachycardia up to 140's, infectious workup repeated [MASKED]: Sputum culture with Stenotrophomonas, started Bactrim DC 2 tabs TID #Persistent tachycardia for several weeks #Worsening leukocytosis, intermittent hypotension [MASKED] stopped on [MASKED], fluconazole discontinued on [MASKED] given extensive negative workup. Worsening leukocytosis since [MASKED] (19 -> 26 -> 21 -> 21 -> 19 -> 20 -> 22 on [MASKED]. Infectious workup sent, notable for right lobe consolidation on CXR. On [MASKED] Sputum culture grew Stenotrophomonas pneumonia, so started on Bactrim DS 2 tabs TID. #Pseudomonas bacteremia Cultures have all been negative at [MASKED], until a [MASKED] pseudomonal blood culture which required meropenem on [MASKED] which was transitioned to ciprofloxacin on [MASKED], and then to aztreonam on [MASKED], and then back to ciprofloxacin and [MASKED]. Patient has now completed his 14 day course of ciprofloxacin. Patient had all lines exchanged on [MASKED], HD line on the right on [MASKED]. Patient did have a left IJ placed after that. #Stenotrophomonas pneumonia On [MASKED], patient found to have a tracheal aspirate positive for stenotrophomonas, which was susceptible to Bactrim. Patient was started on Bactrim IV 7.5 mg per kilo, and was continued on his ciprofloxacin. Stenotrophomonas thought to be a contaminant at that time. As noted above, sputum culture from [MASKED] grew Stenotrophomonas pneumonia, so started on Bactrim DS 2 tabs TID. Cardiovascular ------------------ #Tachycardia Persistent tachycardia, sinus with rates 130-150's. Consider to be due to fevers vs. pain vs. pericarditis vs. infections. Patient status post extensive septic workup, including MR brain showing no abscess or empyema, LP showing no sign of infection/HSV negative/cryptococcal antigen negative, blood cultures on [MASKED] were negative. See above for extensive ID workup and antibiotics use. ==> CCF was monitoring, controlling fever with Tylenol and cooling blanket. Fentanyl as needed for pain. As needed fluid boluses. Continued on colchicine and prednisone for pericarditis. #Hypotension Initially with shock requiring 4 pressors from strep pneumo bacteremia, eventually weaned off pressors. Subsequent intermittent hypotension episodes attributed to infections as well as pericardial effusion. Hypotension now thought to be possibly autonomic [MASKED] the setting of cerebral edema pressures IVH vs. adrenal insufficiency. Has been off pressors for several days. #Pericardial effusion Patient found to have pericardial effusion on [MASKED] with normal LVEF and normal RV size and function. There was a very large circumferential effusion at that time with some RA inversion but no RV collapse. IVC was noted to be normal with less than 50% collapsibility [MASKED] the setting of PPV. No obvious tamponade was noted, however pericardial drain was placed on [MASKED] with 800 cc initial drainage, 750 cc [MASKED] the subsequent 24 hours. Repeat echo showed small residual effusion. ==>Patient was initially on IV Decadron 4 mg every 12 hours, was then transitioned to prednisone 0.5 mg/kg for 2 weeks, and then on [MASKED] was tapered to 7.5 mg daily for chronic adrenal insufficiency as well as colchicine 0.6 makes twice daily for 3 months for post MI/postinfectious pericarditis. Patient is contraindicated to aspirin and NSAIDs due to hemorrhage and renal dysfunction. Gastrointestinal ------------------ #Nutrition PEG tube placed on [MASKED], tube feeds started [MASKED] at 8 [MASKED]. ==> Continue tube feeds; if high residuals then first-line is to give Reglan rather than stopping tube feeds. Nephrology ------------------ [MASKED] due to ATN ISO septic shock -RRT began at outside hospital around [MASKED], transition to IHD on [MASKED]. Patient did have 1 day of CRRT on [MASKED], but resumed IHD on [MASKED]. Patient has had very high UOP from post ATN diuresis versus TIA versus osmotic diuresis (patient receiving D5W for hypernatremia). ==> Continue to trend renal function, replete fluids as needed. Hematologic ------------------ #Functional asplenia Patient received IVIG from [MASKED] through [MASKED], with repeat IgG being normal on [MASKED] (962). IgG on [MASKED] was also normal (1320). #Thrombocytopenia and anemia Patient with ACD, elevated ferritin to [MASKED] with an iron of 41 and TIBC of 153. Patient required multiple transfusions during hospital stay, most recently [MASKED]. ==> Transfuse to hemoglobin less than 7 and platelets less than 50, CTM for active bleeding Endocrinology #Adrenal insufficiency Patient has a history of psoriasis on prednisone 7.5 mg daily. Patient had an ACTH stimulation (cosyntropin 250 mcg) three-time point test on [MASKED] with cortisol of 10.6, 11.2, and 10.3; representing inadequate response. Patient underwent a taper of IV Decadron down to 40 mg of prednisone for 2 weeks, then to 7.5 mg of prednisone daily, now on 5 mg prednisone daily which started on [MASKED]. #Hypothyroidism This is thought to be lithium induced. On [MASKED], patient found to be consistent with sick euthyroid state with a TSH of 13.3, FT4 1.5, F T3 of 1.7. For this he was kept on L-thyroxine to 220 mcg daily. Plan is to repeat TSH [MASKED] 6 weeks. Past Medical History: Lithium-induced hypothyroidism Psoriasis on chronic steroids Seasonal affective disorder Social History: [MASKED] Family History: No significant immunodeficiency or vascular disease. Physical Exam: ADMISSION EXAM ======================= VITALS: Reviewed [MASKED] metavision GENERAL: Laying [MASKED] bed, chronically ill appearing, eyes are open, no purposeful movement of the eyes, necrotic limbs, no movement noted for the extremities, multiple pressure ulcers [MASKED] the back of the head, back, coccyx, extremities HEENT: Sclera anicteric LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Gangrenous limbs, up to elbow level for upper extremities and below the knees. Dopplerable popliteal and brachial arteries. DISCHARGE EXAM ========================== GENERAL: Laying [MASKED] bed, chronically ill appearing, eyes are open, necrotic limbs, no movement noted for the extremities, multiple pressure ulcers [MASKED] the back of the head, back, coccyx, extremities. Able to stick out tongue as yes/no response at times HEENT: Sclera anicteric LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, tender to palpation over epigastric region, non-distended, bowel sounds present, J tube [MASKED] place EXT: Gangrenous limbs, below elbow level for upper extremities and below the knees. Dopplerable popliteal and brachial arteries. Pertinent Results: ADMISSION LABS ===================== [MASKED] 12:29AM BLOOD WBC-22.5* RBC-2.96* Hgb-8.3* Hct-27.3* MCV-92 MCH-28.0 MCHC-30.4* RDW-16.8* RDWSD-55.4* Plt [MASKED] [MASKED] 10:49PM BLOOD [MASKED] PTT-28.9 [MASKED] [MASKED] 10:49PM BLOOD Glucose-97 UreaN-78* Creat-1.8* Na-139 K-6.4* Cl-98 HCO3-23 AnGap-18 [MASKED] 02:42AM BLOOD ALT-37 AST-39 AlkPhos-106 TotBili-0.3 [MASKED] 10:49PM BLOOD Calcium-11.6* Phos-5.7* Mg-2.4 IMAGING ===================== RENAL US [MASKED]: No hydronephrosis. Findings suggestive of intrinsic medical renal disease. CT HEAD [MASKED]: No acute intracranial abnormality identified. No evidence of chronic extra-axial collection. [MASKED] US: No evidence of acute deep venous thrombosis [MASKED] the visualized right or left lower extremity veins. Views of the right and left calf veins, however, were limited by overlying ulcers. TTE [MASKED]: The left atrium is normal [MASKED] size. There is no evidence for an atrial septal defect by 2D/color Doppler. The right atrial pressure could not be estimated. There is normal left ventricular wall thickness with a normal cavity size. There is mild global left ventricular hypokinesis. A left ventricular thrombus/mass is not seen but cannot be excluded. Quantitative biplane left ventricular ejection fraction is 45 %. The visually estimated left ventricular ejection fraction is 40-45%. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Mildly dilated right ventricular cavity with normal free wall motion. The aortic valve leaflets (?#) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a trivial pericardial effusion. ARTERIAL STUDIES [MASKED]: Findings duplex evaluations performed of the upper extremities [MASKED] the areas that were not wrapped. The distal axillary and brachial arteries are patent with triphasic flow and normal velocities. Impression patent upper extremity arterial system down to the forearm Findings duplex evaluations for both lower extremities. Below the knee cannot be evaluated due to gangrene and dressings. The common femoral, deep femoral and superficial femoral arteries are patent with triphasic flow and normal velocities. Impression normal arterial duplex of both lower extremities down to the level of the knee were gangrene is present XRAY ARMS [MASKED]: The bilateral humeri appear intact with apparent normal mineralization, normal alignment, and without fracture. The there is waisting of the soft tissues. Left IJ catheter is partially imaged and tip appears to project at the superior cavoatrial junction, however these views are not optimized for evaluation of catheter tip position. Multiple lines and tubes overlie the patient obscuring views. Tracheostomy tube is seen. Hazy linear opacities at the bilateral lung bases likely represents atelectasis There is a soft tissue swelling surrounding the bilateral elbows and of the bilateral forearms. There may be soft tissue defect of the left forearm. Underlying ulna and radius appear relatively unremarkable. No definite fracture. There appears to be flexion contractures of the fingers of the bilateral hands. There appears to be wasting of the soft tissues. No definite fractures identified. Hands are suboptimally evaluated due to contortion from contractures. [MASKED] TTE: (while septic with fungemia) Normal biventricular cavity sizes with moderate gloaval biventricular hypokinesis. No valvular pathology or pathologic flow identified. Small circumferential pericardial effusion without tamponade physiology. [MASKED] US Buttocks, soft tissue: Transverse and sagittal images were obtained of the superficial tissues overlying the left ischial tuberosity. At the site of known decubitus ulcer, there is a defect [MASKED] the skin with fluid pooling at the site of ulceration. There is no collection within the subcutaneous tissues or definite evidence for a sinus tract. [MASKED] CT Abd/Pelvis: LOWER CHEST: Bibasal airspace opacification (suspected atelectasis) as well as trace pleural effusions appear improved compared to prior. Retained secretions present [MASKED] the lower lobe bronchi bilaterally. Trace pericardial effusion is also improved compared to prior. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Small heterogenous residual spleen/splenule appears similar to prior. ADRENALS: The right and left adrenal glands are normal [MASKED] size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal PELVIS: Distended bladder. There is no free fluid [MASKED] the pelvis. REPRODUCTIVE ORGANS: The prostate is heterogeneous but otherwise unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. IVC filter [MASKED] situ. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No new acute abdominopelvic process. 2. Bibasal airspace opacification (suspected atelectasis) with trace pleural effusions are improved compared to prior. 3. Small pericardial effusion is also improved compared to prior. MICROBIOLOGY ===================== [MASKED] 3:46 am URINE Source: Catheter. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R [MASKED] 3:46 am SPUTUM Source: Endotracheal. FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: [MASKED] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND SINGLY. 1+ (<1 per 1000X FIELD): YEAST(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [MASKED]: MODERATE GROWTH Commensal Respiratory Flora. STENOTROPHOMONAS MALTOPHILIA. MODERATE GROWTH. test result performed by Microscan. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] STENOTROPHOMONAS MALTOPHILIA \| TRIMETHOPRIM/SULFA---- <=2 S RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. Piperacillin/Tazobactam test result performed by [MASKED] [MASKED]. YEAST. SPARSE GROWTH. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 16 I CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ 8 I MEROPENEM------------- 4 I PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S [MASKED] 1:12 am BRONCHOALVEOLAR LAVAGE FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL. Piperacillin/Tazobactam test result performed by [MASKED] [MASKED]. STENOTROPHOMONAS MALTOPHILIA. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] PSEUDOMONAS AERUGINOSA \| STENOTROPHOMONAS MALTOPHILIA \| \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ 8 I MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Time Taken Not Noted [MASKED] Date/Time: [MASKED] 11:46 am BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: [MASKED] PARAPSILOSIS. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Yeast Susceptibility:. Fluconazole MIC OF 1.0 MCG/ML = SUSCEPTIBLE. Results were read after 24 hours of incubation. test result performed by Sensititre. Aerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED] @ [MASKED] ON [MASKED] - [MASKED]. YEAST(S). [MASKED] 2:30 pm SPUTUM Source: Endotracheal. FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: [MASKED] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [MASKED]: SPARSE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. [MASKED] MORPHOLOGY. Piperacillin/Tazobactam test result performed by [MASKED] [MASKED]. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 8 S 16 I CEFTAZIDIME----------- 16 I 4 S CIPROFLOXACIN--------- 0.5 S 1 S GENTAMICIN------------ <=1 S 8 I MEROPENEM------------- 8 R 4 I PIPERACILLIN/TAZO----- 16 S S TOBRAMYCIN------------ <=1 S <=1 S [MASKED] 2:30 pm URINE Source: Catheter. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. Piperacillin/Tazobactam test result performed by [MASKED] [MASKED]. VIRIDANS STREPTOCOCCI. >100,000 CFU/mL. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 0.5 I GENTAMICIN------------ 8 I MEROPENEM------------- 4 I PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S [MASKED] 8:42 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [MASKED] C. difficile PCR (Final [MASKED]: NEGATIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. A negative C. diff PCR test indicates a low likelihood of CDI or carriage. [MASKED] 12:11 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [MASKED]: >25 PMNs and <10 epithelial cells/100X field. 2+ [MASKED] per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Preliminary): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. Piperacillin/Tazobactam test result performed by [MASKED] [MASKED]. Ceftolozane/tazobactam & CEFTAZIDIME-AVIBACTAM SUSCEPTIBILITY REQUESTED PER [MASKED] [MASKED] ([MASKED]) [MASKED]. YEAST. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. [MASKED] MORPHOLOGY. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 16 I 2 S CEFTAZIDIME----------- 16 I 4 S CIPROFLOXACIN--------- 1 S <=0.25 S GENTAMICIN------------ 8 I <=1 S MEROPENEM------------- 4 I <=0.25 S PIPERACILLIN/TAZO----- R 8 S TOBRAMYCIN------------ <=1 S <=1 S [MASKED] 1:10 pm BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Preliminary): YEAST, PRESUMPTIVELY NOT C. ALBICANS. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Aerobic Bottle Gram Stain (Final [MASKED]: YEAST(S). Reported to and read back by [MASKED] ([MASKED]) @ [MASKED] ON [MASKED]. [MASKED] 2:04 pm URINE Source: [MASKED]. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROCOCCUS SP.. >100,000 CFU/mL. YEAST. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed [MASKED] MCG/ML [MASKED] ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R DISCHARGE/PERTINENT LABS ======================== [MASKED] 03:05AM BLOOD WBC-21.3* RBC-2.95* Hgb-8.8* Hct-29.4* MCV-100* MCH-29.8 MCHC-29.9* RDW-21.2* RDWSD-77.7* Plt [MASKED] [MASKED] 03:05AM BLOOD [MASKED] PTT-27.2 [MASKED] [MASKED] 03:05AM BLOOD Glucose-94 UreaN-33* Creat-0.7 Na-136 K-6.6* Cl-101 HCO3-19* AnGap-16 [MASKED] 08:47AM BLOOD K-5.3* [MASKED] 04:22AM BLOOD ALT-14 AST-13 AlkPhos-68 TotBili-<0.2 [MASKED] 04:15AM BLOOD calTIBC-233* Ferritn-965* TRF-179* [MASKED] 02:59AM BLOOD Triglyc-263* [MASKED] 02:10AM BLOOD Triglyc-534* [MASKED] 12:11PM BLOOD Triglyc-509* [MASKED] 04:49AM BLOOD Triglyc-645* [MASKED] 04:23AM BLOOD TSH-4.5* [MASKED] 03:08AM BLOOD TSH-25* [MASKED] 04:23AM BLOOD Free T4-1.6 [MASKED] 04:53AM BLOOD 25VitD-19* [MASKED] 06:39PM BLOOD ANCA-NEGATIVE B [MASKED] 08:20PM BLOOD [MASKED] pO2-37* pCO2-36 pH-7.44 calTCO2-25 Base XS-0 [MASKED] 08:20PM BLOOD Lactate-1.[MASKED] is a [MASKED] h/o hypothyroidism [MASKED] lithium, who presents as a transfer from [MASKED] for evaluation of necrotic limbs by vascular surgery. Patient initially presented to a [MASKED] hospital w/ generalized illness, nausea, and vomiting, and was found to have septic shock [MASKED] Streptococcus [MASKED] the setting of ?atrophic spleen (unknown at time of presentation, CT scan from [MASKED] with normal size spleen), w/ course complicated by respiratory failure, renal failure, hypoxic brain injury, intracerebral hemorrhage, myocardial infarction w/ resultant pericardial effusion s/p pericardial drain, DIC & purpura fulminans resulting [MASKED] gangrene of all limbs. His course at [MASKED] was complicated by Enterococcus UTI, VAP, and fungemia and endocrine abnormalities. He was briefly transferred to the floor [MASKED] anticipation of possible discharge to [MASKED], however, he became febrile, tachycardic, and hypotensive on [MASKED] concerning for recurring sepsis and was transferred back to [MASKED] for further care. Current Active Issues ===================== #Infection #Recurrent VAP d/t multiple strains of MDR PsA: Sputum cultures [MASKED] growing 2 strains pseudomonas Aeruginosa, sensitive to ciprofloxacin. Given high risk of developing resistances to fluoroquinolones, infectious disease consulted. - Recommended ciprofloxacin IV and cefepime IV (prolonged infusion over 3 hours, 8 hours between end of one infusion and beginning of next). Day 1 = [MASKED]. End date [MASKED]. If still with respiratory compromise, can extend this to 10 days. #Fungemia, presumably recurrent C. parapsilosas, unknown source, CT abdomen/pelvis with contrast negative: Blood cultures on [MASKED] growing C. parapsilosas sensitive to fluconazole. Septic [MASKED] this setting during which TTE showed depressed global biventricular function. Given poor PO absorption, unclear if this was consistently treated optimally (switched IV to PO and [MASKED] error missed one day). Blood cultures negative until [MASKED], growing [MASKED], awaiting speciation. Decompensated from this with tachycardia, fever and soft BP. Switched to IV micafungin on [MASKED]. [MASKED] removed [MASKED] for line holiday, currently with peripheral. - Per ID recs continue micafungin 100 mg IV daily x14 days from PICC removal. Day 1 = [MASKED]. Day 14 = [MASKED]. - Follow up [MASKED] speciation from [MASKED] sputum culture - NOTE: if fungemia recurs, recommend TEE to evaluate for endocarditis (considered during current presentation, though [MASKED] the setting of likely incomplete/inadequate treatment with poor azole absorption through GI tract, will consider this same original infection.) # Bacteruria of unclear significance - Held on treating Enterococcus [MASKED] most recent UCx [MASKED] (exam felt more c/w abdominal as opposed to suprapubic pain, no e/o inflammation on UA like previously treated UTI, and no [MASKED], fungemia and MDR pseudomonal pneumonia to explain fever, and improvement with treatment of above. # Wound care # Necrotic limbs # Dry gangrene Patient's ischemic injuries occurred [MASKED] the setting of shock with s DIC w/ purpura fulminans. The patient's family desired a second opinion from [MASKED], and this was the primary reason for transfer to [MASKED]. He was seen by the Vascular Surgery & Plastic Surgery teams at [MASKED] who felt there was no need for urgent intervention. The patient should follow-up with Vascular surgery (Dr. [MASKED] surgery (Dr. [MASKED] two weeks after discharge. Pt also has several decubitus ulcers (right and left gluteal area) that required debridement from wound nurse while inpatient. Pt has been getting wound care daily. #Pain Palliative care consulted. Currently, difficult to assess pain given patient is minimally interactive. Can follow few commands but this waxes and wanes. Pain manifested as agitation, tachycardia. Also able to show us his tongue at times for yes and no answers. Location limbs, intermittently abdomen. Currently maintained on methadone and IV dilaudid. Can consider IV methadone if suspicious for poor PO absorption (iso intermittent vomiting which is his baseline). # Acute on chronic respiratory failure s/p trach placement: He had a tracheostomy placed [MASKED] at [MASKED]. He was treated for Stenotrophomonas PNA found on tracheal aspirate [MASKED] with TMP-SMX then levofloxacin due to hyperkalemia for a urrently being treated for VAP [MASKED] multidrug resistant strains of pseudomonas, please see above. Currently on trach collar but has required vent for mucous plugging intermittently. #Nausea, vomiting With bilious projective vomiting occurring once every few days to once a day. GI consulted and concern for stress gastritis and ulcerations. GI loosened =external bumper of his PEG to avoid burring of internal bumper given it was found that connection between PEG tube and feeding pump was short and was tugging at PEG site. Recommended for lansoprazole to 30mg bid and giving enough slack to connection between feeding pump and PEG to avid tugging of PEG. Also recommended Hyoscyamine (improved cramping abdominal pain) and metoclopramide. Pt has also been receiving IV Ativan infrequently if vomiting. Patient should have tube feeds and ALL medications given through J part of GJ tube. Giving meds through G part of GJ tube can exacerbated vomiting. #Encephalopathy #Neurologic Status #ICH The etiology of his brain injury was felt to be [MASKED] the setting of multifactorial Pneumococcal meningitis and prolonged hypoperfusion w/ resultant cerebral hypoxia and ICH [MASKED] the setting of septic shock. Multiple MRIs at [MASKED] showed extensive anoxic brain injury. On admission here, Neurology was consulted for prognostication. Ultimately, Neurology felt that he would likely suffer permanent deficits, however they were not able to prognosticate further than that. He did begin to become responsive and was able to follow some simple commands. He was given Keppra for seizure prophylaxis. - [MASKED], OT, S/S - speech and swallow consult for [MASKED] valve #) Endocrinopathies: Iatrogenic adrenal insufficiency, hypothyroidism, hypercalcemia of immobility. Endocrinology was consulted and recommended: -Prednisone 10 mg daily, unless stress dose steroids necessitated -Fludricortisone 0.1 mg -Levothyroxine 200 mcg #Anemia of inflammation Iron studies [MASKED] keeping with inflammation. He was transfused for Hgb <7. He did not have evidence of active bleeding. #Left filamentary keratitis, xerophthalmia Patient was evaluated by ophthalmology and diagnosed with filamentary keratitis. He was started on vigamox antibiotics QID, and completed the course of antibiotics. He should continue lubricating eye drops per ophthalmology. He should follow-up with ophthalmology two weeks after discharge. - artificial tears [MASKED] TID - artificial tears gel [MASKED] #Severe protein-calorie malnutrition Continue tube feeds. Of note, found to be hyperTG. Given hyperTG and nausea vomiting (lipase normal), pt was switched to lower osm tube feeds and tolerating it better. Resolved issues from extended hospitalization ============================================= # Recurrent [MASKED]: # Hyperkalemia: # Hypernatremia: [MASKED] records, RRT began at [MASKED] around [MASKED] & transitioned to IHD on [MASKED] at [MASKED]. He was eventually liberated from dialysis & his creatinine then settled out [MASKED] the mid-1 range. On admission to [MASKED], his creatinine rose from 1.8 on arrival to 2.3 where it plateaued. His 24-hour urine collection with creatinine 2.2 showed creatinine clearance of only around ~15, indicating that his GFR is lower than would be predicted based on his serum creatinine, likely from lower creatinine generation. He was continually non-oliguric, w/ urine showing granular debris and cast fragments indicating tubular injury, which rose suspicion for ischemic +/- hemodynamic injury of unclear precipitant. Additionally, he had low urine specific gravity and isosthenuria suggesting a concentrating defect, and it was considered that he was not regulating his urine volume well. As such, he was given aggressive IVF PRN to maintain his volume status. A broad work-up was sent to investigate this [MASKED] (ASO, ANCA, [MASKED], UPEP) which was largely unrevealing (notably, had positive ASO which raised possibility of post-infectious GN, but as complement levels were normal it was felt that this positive result was not clearly pathogenic). Ultimately his [MASKED] resolved and Cr normalized to 0.6. [MASKED] the setting of his [MASKED], he had persistent hypernatremia & hyperkalemia, which were managed with free water repletion and management of his adrenal insufficiency and initiation of fludrocortisone. #Primary adrenal insufficiency Patient does NOT have history of chronic prednisone use prior to initial illness as noted [MASKED] [MASKED] documentation. Patient had an ACTH stimulation (cosyntropin 250 mcg) three-time point test on [MASKED] with cortisol of 10.6, 11.2, and 10.3 representing inadequate response. He underwent a taper of IV dexamethasone down to 40 mg of prednisone for 2 weeks, then to 7.5 mg of prednisone daily, now on 5 mg prednisone daily which started on [MASKED]. Repeat stim test showed ongoing insufficiency thus patient was transitioned to prednisone 10mg PO QD per the recommendations of endocrinology and 15 mg daily at times of stress. # Retinal hemorrhages: # Filamentous keratitis # Inferior corneal ulcer At [MASKED], the patient had evidence of hemorrhage on ocular exam with subfoveal hemorrhage versus cherry red spot concerning for CRAO during embolic & anoxic injury. He was seen by [MASKED] Ophthalmology for continued evaluation, who were concerned about the extensive eye dryness and recommended follow up two weeks following discharge. # Resistant Enterococcus UTI: Noted on urine culture. Based on sensitivities, he was treated with linezolid ([MASKED]). # Sinus tachycardia Heart rates persistently >100, usually [MASKED] the 110-120 range despite management of multiple infections, pain, fluid status. Patient received [MASKED] LR/day for management of insensible losses that could be contributing to tachycardia to good effect. # Type II NSTEMI Mild troponin elevation with T wave inversions [MASKED] setting of mucus plugging [MASKED]. Trop peaked at 0.64. MB was flat. Patient was not anticoagulated. #Nutrition PEJ tube placed on [MASKED] at [MASKED]. Given recurrent aspiration events, he underwent [MASKED] advancement to GJ on [MASKED]. The nutrition service followed him closely for evaluation and support. Patient should have tube feeds and ALL medications given through J part of GJ tube. Giving meds through G part of GJ tube can exacerbated vomiting. # Hypothyroidism: Known chronic problem thought to be lithium induced. On [MASKED], patient found to be consistent with sick euthyroid state with a TSH of 13.3, FT4 1.5, F T3 of 1.7. For this he was kept on L-thyroxine 220 mcg daily. He was evaluated by [MASKED] Endocrine who felt that it is very likely that he is not absorbing oral levothyroxine specially [MASKED] the setting of high TF residual volume. He was given IV bolus of 150mcg IV LT4 at 3pm on [MASKED] and then transitioned to IV LT4 for continued management. He was switched back to oral levothyroxine at a high dose (200 mcg) to overcome interference by tube feeds. # Hypercalcemia: The Endocrine service was consulted for management. He was given IV zoledronic acid 3mg given on [MASKED] with some improvement [MASKED] calcium. Endocrine felt that this was a PTH-independent process with high degree of bone resorption based on very elevated CTX, most likely due to immobilization given the clinical circumstances. There was no evidence of FHH, post-rhabdo delayed hypercalcemia (would not respond to bisphosphonate or have elevated CTx), malignancy, granulomatous disease, or lithium-induced Hypercalcemia. PTHrp is 23 and his 1,25-D is 31. He was continued on vitamin D therapy. TRANSITIONAL ISSUES: ==================== - Continue Keppra [MASKED] months per neurology - Should continue to be seen by [MASKED] Therapy - Per neuro, his prognosis is guarded, unclear how much neurologic function he will recover - Vascular surgery follow up should be done [MASKED] [MASKED] weeks after hospital discharge - [MASKED] surgery should follow [MASKED] weeks after hospital discharge - Opthalmology should follow 2 weeks after hospital discharge - Recheck TSH on 200mcg levothyroxine [MASKED] [MASKED] weeks - Repeat TTE [MASKED] [MASKED] weeks; last TTE [MASKED] setting of septic shock with improved function on bedside exam - End date for abx: -- Ciprofloxacin and Cefepime for VAP [MASKED] -- Micafungin for fungemia [MASKED] - PICC to be placed [MASKED] [MASKED] on or after [MASKED] - Wound care daily, debridement PRN - Follow up [MASKED] speciation for [MASKED] blood culture - Follow up [MASKED] blood cultures (NGTD) - Hold on treating Enterococcus [MASKED] most recent UCx for now (exam felt more c/w abdominal as opposed to suprapubic pain, no e/o inflammation on UA like previously treated UTI, and no [MASKED] - If fungemia recurs, recommend TEE to evaluate for endocarditis (considered during current presentation, though [MASKED] the setting of likely incomplete/inadequate treatment with poor azole absorption through GI tract, will consider this same original infxn) - Should need additional records from [MASKED], fax to [MASKED]. Pt was [MASKED] ICU on G62 there for 3 months. - QTC daily given pt on several QTc prolonging medications. Can space out less frequently after completion of ciprofloxacin # Access: PIV # Contact: Rabbi [MASKED], [MASKED] ([MASKED]) # Code: Full, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 7.5 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Artificial Tears GEL 1% [MASKED] DROP BOTH EYES [MASKED] 3. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES TID 4. Bisacodyl 10 mg PR [MASKED] Constipation - Third Line 5. CefePIME 2 g IV Q8H 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 7. Ciprofloxacin 400 mg IV Q8H 8. Docusate Sodium 100 mg PO BID 9. Fludrocortisone Acetate 0.1 mg PO DAILY 10. Gabapentin 300 mg PO [MASKED] 11. GuaiFENesin [MASKED] mL PO Q6H:PRN mucous secretions 12. Heparin 5000 UNIT SC BID 13. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN Pain - Severe 14. Hyoscyamine 0.125 mg PO QID 15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing 16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H SOB/ wheezing 17. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 18. LevETIRAcetam 500 mg PO Q12H 19. Levothyroxine Sodium 200 mcg PO DAILY 20. Methadone 5 mg PO Q8H pain 21. Metoclopramide 10 mg PO TID 22. Micafungin 100 mg IV Q24H 23. Multivitamins W/minerals 15 mL PO DAILY 24. Polyethylene Glycol 17 g PO DAILY 25. Senna 8.6 mg PO BID 26. Vitamin D [MASKED] UNIT PO 1X/WEEK (WE) 27. PredniSONE 10 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Four extremity dry gangrene Fungemia Adrenal insufficiency Mild Pericardial effusion Hypernatremia MDR pseudomonas PNA Discharge Condition: Mental Status: Minimally interactive Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [MASKED] and family, You were admitted to [MASKED] for vascular surgery evaluation. While [MASKED] the hospital, your course was complicated by several infections including pneumonia and fungus [MASKED] the blood. You will be discharged to [MASKED] where you will receive on going care to treat you infection as well as rehabilitation to make you stronger. Details regarding the specifics of the infectious are outlined below. Sincerely, Your [MASKED] team Followup Instructions: [MASKED]	[]	[ "N390", "N179", "E872", "Y92230" ]	[ "I96: Gangrene, not elsewhere classified", "D65: Disseminated intravascular coagulation [defibrination syndrome]", "I21A1: Myocardial infarction type 2", "E43: Unspecified severe protein-calorie malnutrition", "J690: Pneumonitis due to inhalation of food and vomit", "J9621: Acute and chronic respiratory failure with hypoxia", "G9340: Encephalopathy, unspecified", "B377: Candidal sepsis", "J95851: Ventilator associated pneumonia", "B49: Unspecified mycosis", "G931: Anoxic brain damage, not elsewhere classified", "I313: Pericardial effusion (noninflammatory)", "E870: Hyperosmolality and hypernatremia", "N390: Urinary tract infection, site not specified", "E273: Drug-induced adrenocortical insufficiency", "N179: Acute kidney failure, unspecified", "E872: Acidosis", "I428: Other cardiomyopathies", "Z431: Encounter for attention to gastrostomy", "Z930: Tracheostomy status", "E038: Other specified hypothyroidism", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "B952: Enterococcus as the cause of diseases classified elsewhere", "Z781: Physical restraint status", "T43595S: Adverse effect of other antipsychotics and neuroleptics, sequela", "E8352: Hypercalcemia", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "L89150: Pressure ulcer of sacral region, unstageable", "L89120: Pressure ulcer of left upper back, unstageable", "T17990A: Other foreign object in respiratory tract, part unspecified in causing asphyxiation, initial encounter", "R112: Nausea with vomiting, unspecified", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "T370X5A: Adverse effect of sulfonamides, initial encounter", "D6489: Other specified anemias", "H16122: Filamentary keratitis, left eye", "E875: Hyperkalemia", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere" ]
10,047,682	24,221,558	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: gluten / ceftazidime Attending: ___ Chief Complaint: Four Limb Ischemia Major Surgical or Invasive Procedure: four limb amputation on ___ History of Present Illness: Mr. ___ is a ___ year old man with history of hypothyroidism and psoriasis (on chronic prednisone 7.5mg daily) who has had a long complicated course resulting in multiorgan failure, hypoxic ischemic encephalopathy (is now non verbal), diffuse bacteremia, stress induced cardiomyopathy and four limb ischemia. After demarcation the decision was made to pursue a four limb amputation in conjunction with orthopedics on ___. Briefly the patient initially presented to an OSH in ___ on ___ with abdominal pain, vomiting, chills. He was found to have septic shock (bacteremia with S. pneumopniae) requiring 4 vasopressors and developed hypoxic respiratory failure. He developed hypoxic ischemic encephalopathy with intra-ventricular hemorrhage, and CVA thought to be cardioembolic. He also had acute renal failure requiring CRRT. Part of his care was the ___ where he received a trach and PEG that was later converted to a GJ by ___. He was transferred from ___ ___ to ___ and he was in our hospital during the period ___ where he was also found to have multiudrug resistant pseudomonas pneumonia, depressed EF heart failure, Fungemia (presumably recurrent C. parapsilosas, s/p treatment with IV micafungin). His four limb ischemia was thought to be in the setting of shock with ___s DIC w/ purpura fulminans. He was discharged to ___ and he has remained there up until today. Of note, recently he had his GJ tube exchanged by ___ on ___ and converted to a ___ MIC GJ due to malfunctioning. He has been on lovenox for DVTs which we have instructed to stop on ___. He now presents as a direct admit from ___ in anticipation of his surgery. He is non verbal and the history is acquired from chart review. Past Medical History: Lithium-induced hypothyroidism Psoriasis on chronic steroids Seasonal affective disorder Social History: ___ Family History: No significant immunodeficiency or vascular disease. Physical Exam: DISCHARGE PHYSICAL EXAM: ======================== GEN: Resting in bed, thin, trach in place. appears uncomfortable. HEENT: NC/AT, Moist mucous membranes. No lesions. NECK: Trach in place. JVP does not appear elevated. CV: Regular rate, normal rhythm. No murmurs appreciated. RESP: Clear to auscultation bilaterally. GI: Soft, GJ tube in place MSK: all 4 limbs wrapped from amputations but incisions are cdi with slight granulation tissue on RUE and LLE, RLE incision cdi except for packing of previously slightly purulent area SKIN: No rashes on exposed skin. Scars on LLE NEURO/psych: alert, answers yes/no at times to questions, opens his eyes and tracks, PERRL Pertinent Results: DISCHARGE LABS ============== ___ 04:24AM ___ WBC-13.6* RBC-2.85* Hgb-9.2* Hct-29.4* MCV-103* MCH- 32.3* MCHC-31.3* RDW-17.1* RDWSD-59.2* Plt ___ ___ 05:04AM ___ Neuts-48 Bands-2 ___ Monos-7 Eos-1 ___ Metas-7* Myelos-3* NRBC-1.2* AbsNeut-7.25* AbsLymp-4.64* AbsMono-1.02* AbsEos-0.15 AbsBaso-0.00* ___ 04:24AM ___ ___ PTT-26.1 ___ ___ 04:24AM ___ Glucose-95 UreaN-35* Creat-0.8 Na-145 K-4.2 Cl-109* HCO3-27 AnGap-9* ___ 04:24AM ___ Calcium-9.0 Phos-3.4 Mg-2.4 PERTINENT INTERVAL LABS ======================= ___ 04:32PM ___ ___ ___ 03:19PM ___ ___ ___ 04:32PM ___ Hapto-381* ___ 04:08AM ___ Hapto-362* ___ 11:46AM ___ calTIBC-144* Ferritn-1055* TRF-111* ___ 03:19PM ___ T4-8.7 Free T4-1.9* ___ 05:15AM ___ TSH-0.24* ___ 05:00AM ___ TSH-0.39 ___ 04:19PM ___ Prolact-63* ___ 03:19PM ___ T4-8.7 Free T4-1.9* ADMISSION LABS ============== ___ 09:03PM ___ WBC-17.7* RBC-2.91* Hgb-9.1* Hct-30.1* MCV-103* MCH-31.3 MCHC-30.2* RDW-14.2 RDWSD-53.8* Plt ___ ___ 11:46AM ___ Neuts-78.0* Lymphs-12.2* Monos-8.1 Eos-0.0* Baso-0.3 Im ___ AbsNeut-19.36* AbsLymp-3.02 AbsMono-2.00* AbsEos-0.01* AbsBaso-0.08 ___ 03:55AM ___ ___ PTT-33.1 ___ ___ 09:03PM ___ Glucose-130* UreaN-29* Creat-1.4* Na-137 K-4.4 Cl-99 HCO3-27 AnGap-11 ___ 03:19PM ___ ALT-73* AST-29 AlkPhos-82 TotBili-0.3 ___ 09:03PM ___ Calcium-10.1 Phos-3.5 Mg-2.0 MICROBIOLOGY DATA ================= - ___ Culture, Routine (Final ___: ___ PARAPSILOSIS. Susceptibility:. Fluconazole MIC OF 0.5 MCG/ML = SUSCEPTIBLE. Results were read after 24 hours of incubation. test result performed by Sensititre. - ___: URINE CULTURE * PSEUDOMONAS AERUGINOSA: >100,000 CFU/mL OF TWO COLONIAL MORPHOLOGIES. PSEUDOMONAS AERUGINOSA CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S - ___: CSF Studies Enterovirus Culture- NEGATIVE GRAM STAIN-FINAL; FLUID CULTURE- NGTD CRYPTOCOCCAL ANTIGEN- Negative - ___: ___ CRYPTOCOCCAL ANTIGEN-Negative - ___: WOUND GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. - ___: WOUND CULTURE (Preliminary): MIXED BACTERIAL FLORA. PSEUDOMONAS AERUGINOSA: RARE GROWTH OF TWO COLONIAL MORPHOLOGIES. - ___: ANAEROBIC CULTURE (Preliminary): NO ANAEROBES - ___: ___ Cultures x2: PND - ___: URINE CULTURE (Final ___: GRAM POSITIVE COCCUS(COCCI). ~3000 CFU/mL. ___ 11:11 am URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R - ___ 7:20 am SWAB Source: R leg. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. WOUND CULTURE (Preliminary): 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 in this culture. ANAEROBIC CULTURE (Preliminary): ___ 9:37 pm SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. C. difficile PCR (Final ___: NEGATIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. A negative C. diff PCR test indicates a low likelihood of CDI or carriage. RADIOLOGY DATA ============== CXR ___: New focal consolidation in the left lower lung consistent with infection. Small left pleural effusion. Interval placement of right PICC line terminating in the right atrium. CT HEAD ___ Increased in ventricular system which may indicate development of communicating hydrocephalus since the prior study. Although temporal horn dilatation, which has increased in particular, may be associated with temporal lobe atrophy, degree of atrophy is not obviously increased. MRI HEAD 1. No evidence of acute infarction, hemorrhage or mass. 2. Generalized atrophy. 3. Evolution of the multiple infarctions demonstrated in ___. 4. Small amount of residual old ___ products in the fourth ventricle. Brief Hospital Course: ___ year old man with PMHx of lithium-induced hypothyroidism, psoriasis on chronic steroids, who had a prolonged and complicated series of hospitalization from ___ to ___ for sepsis with DIC complicated by limb ischemia from pressors and DIC, as well as multiple other complications, during which ___ Endocrinology was consulted for hypercalcemia, hypothyroidism and adrenal insufficiency. He has been re-admitted for a planned 4 limb amputation which took place on ___. The patient has now been transferred to medicine for further management of fungemia and pseudomonas UTI. Since being on the medicine service he had a seizure as well as ___ cultures positive for ___ Fungemia and subsequent HAP. # History of strep bacteremia with 4 limb ischemia s/p amputation The patient developed Ischemic limbs secondary to purpura fulminans as a sequelae of Strep pneumo bacteremia and 4-pressor shock. The patient was admitted for and underwent a four limb amputation on ___. The patient had Epidural and Supraclavicular blocks performed and was continued on a Ketamine gtt as well as Dilaudid IV and Oxycodone PRN. The pain service was consulted and per their recommendations, the patient's gabapentin and methadone were increased and he was continued on oxycodone to 15 mg Q4H PRN, and hydromorphone to ___ mg Q2H PRN for severe pain. Per plastics and vascular surgery the patient's Ketamine was discontinued on ___ and the epidural was removed. On ___ the patient was transferred out of the ICU without issue. # Hospital Acquired Pneumonia versus Recurrent UTI In the setting of up trending leukocytosis, low grade fevers, and softer ___ pressures a CXR was done on ___ showing a new LLL opacity c/f infection/PNA. Given the patient's prolonged hospitalization, he was diagnosed with HAP and his ciprofloxacin was discontinued and he was broadened to Zosyn. Of note, the patient developed eosinophilia and ?seizure while on a cephalosporin, which is why Zosyn was chosen. He was continued on Vancomycin. A UCx was drawn at the same time, and returned as VRE just after discharge; although it is not completely clear patient actually had a UTI rather than just colonization (particularly since his WBCs improved with addition of Zosyn), it was thought prudent to change vancomycin to linezolid, so the discharging attending called over to inform the receiving attending of the above and to give a detailed warm handoff. # Intermittent Hypotension # Primary adrenal insufficiency: The patient was intermittently hypotensive during his hospitalization when trying to taper his steroids. His hypotension is most likely multifactorial, but largely due to his primary adrenal insufficiency. His Lactate was normal when checked during hypotensive episodes. The patient received multiple IVF boluses. Of note, his prior testing showed: ___ 3 (L), renin 25 (H) and cortisol 3.2 (L), and ACTH 118(high), which was consistent with primary adrenal insufficiency. Adrenal antibodies were negative. Endocrinology was consulted and managed tapering of his steroids, which were complicated by hypotension when decreased too rapidly. Discharged on hydrocortisone 20mg IV Q8hrs for 4 days (END ___ then switch to 15mg PO QAM and then 5mg PO Q2-3PM . Resume fludrocortisone on ___. # Leukocytosis The patient initially had a leukocytosis to 17.7 when he presented on ___. This trended up to 33 and began to resolved to 11.7 on ___ with the treatment of his ___ Bloodstream Infection, wound dehiscence, and pseudomonas UTI (as described below). On ___ his WBC count increased from 11.7--> 21.2--> 29.2 and was down trending until ___ when it again spiked to 20. At this time a CXR was done showing a new pneumonia (as described as above). His c. diff was negative. The remainder of his infections were treated as described elsewhere. # ___ Bloodstream Infection The patient's course was complicated by ___ cultures growing ___. He was initially treated with Micafungin, them escalated to Amphotericin before being tailored to Fluconazole based on sensitivities. Infectious Disease signed off and recommended Fluconazole IV for 2 weeks (___). PICC line exchanged by ___ on ___. Ophthalmology was consulted and found no evidence of endophthalmitis. A LP was done ___ (see below)which was unremarkable and showed no signs of infection. # LLE Wound Dehiscence The patient was noted to have a wound dehiscence by the surgical teams. Wound cultures grew pseudomonas as well as CoNS and enterococcus. The patient was initially stared on vancomycin and ciprofloxacin for a planned 2 week course (___). The cipro was changed to Zosyn for coverage of HAP (as described above). Wound care, plastics, and orthopedics continued to follow the patient while inpatient. Given some mild purulent discharge at a stitch on RLE, a swab cx was performed on ___, the results of which are still pending (but anticipate covered by addition of Zosyn to vanc). # Complicated UTI The patient had a UA done which was positive for nitrites, and moderate bacteria. His culture grew pan-sensitive pseudomonas aeruginosa. On ___ ID was consulted and recommended a 2 week course of antibiotics for complicated UTI. The patient completed a 2 week course of ciprofloxacin ___ a complicated UTI. # First-time Generalized Seizure # Communicating Hydrocephalus The patient had a had a first time generalized seizure on ___ which resolved with 2mg IV Ativan. Subsequently started on Keppra 1000 mg bid. Had imaging done which was concerning for communicating hydrocephalus. He underwent an LP which showed 0 WBC, elevated protein (possibly due to the residual intraventricular ___ products seen on MRI). CSF Gram Stain, Enterovirus and Cryptococcus antigen was negative. CSF cultures were negative. EEG was without evidence of seizure activity. He had no further clinical or electrographic seizures while inpatient. Neurology was consulted and signed off on ___ with their final recommendations being to continue Keppra. # Malnutrition # GJ Tube Dysfunction # Tube Feeds The patient's GJ tube came out on ___ and was replaced by ___ on ___. On ___, the was a "foamy" appearance to GJ tube drainage so ___ ordered showing coiling of the GJ tube into the stomach. ___ was re-consulted and patient underwent another tube replacement on ___. Nutrition was following for TF recommendations and he was switched to nepro tube feeds given hyperkalemia. # Anemia While inpatient, the patient had hemoglobin's that are widely variant with his HgB usually being in the ___ range. On ___ his HgB dropped from 8.0 to 6.9 with an appropriate response to 1U PRBCs. There was no sign of bleeding and his labs were not consistent with hemolysis. # Eosinophilia, drug-induced (resolved) The patient was noted to have an eosinophilia which was thought to be from Ceftazidime. This resolved after switching to ciprofloxacin. # Chronic Pain # Post Operative Pain The Chronic Pain service was consulted and recommended continuing Hydromorphone ___ mg IV Q2H:PRN for breakthrough pain & dressing changes. The also recommended continuing Methadone 15 mg PO/NG Q8H pain and oxycodone Liquid 15mg PRN. He was continued on gabapentin 600mg TID and standing acetaminophen 650mg q6h. # Hypothyroidism: The patient has a history of hypothyroidism with negative TPO ab and Tg Ab. On prior admission, the patient required IV and high dose levothyroxine administration to overcome tube feeds but he has been weaned to 100mcg at rehab. TFTs obtained this admission show: T4: 8.7 Free T4: 1.9 confirming adequate replacement as an outpatient. He is now on continuous TF. Endocrinology was consulted and stated that if TFs are switched to cycled, his IV levothyroxine can be converted to PO levothyroxine. Their dosing recommendations: LT4 75mcg IV (75% of oral dose) if on continuous TF which impacts absorption; when he is switched to bolus TF, he can be converted to PO LT4 (100 mcg daily) with holding tube feeds for 4 hours prior & 1 hour after TF. >30 minutes spent on patient care and coordination on day of discharge TRANSITIONAL ISSUES =================== [] Antibiotics: [] Vancomycin for HAP and wound dehiscence (End ___ [] Zosyn for wound dehiscence and HAP (End ___ [] Routine EKG monitoring for QT interval while on methadone [] Patient was noted to have metas on his differential-- consider following with hematology and potential bone marrow biopsy [] Consider switching TFs to cycled [] If TFs are switched to cycled, his IV levothyroxine can be converted to PO levothyroxine. Their dosing recommendations: LT4 75mcg IV (75% of oral dose) if on continuous TF which impacts absorption; when he is switched to bolus TF, he can be converted to PO LT4 (100 mcg daily) with holding tube feeds for 4 hours prior & 1 hour after TF. [] Please check TFTs on ___ per endocrine [] Wean pain medications as able [] Steroid taper per endocrine recommendations-- Discharged on hydrocortisone 20mg IV Q8hrs for 4 days (END ___ then switch to 15mg PO QAM and then 5mg PO Q2-3PM . Resume fludrocortisone on ___. [] Follow up CBC with differential [] F/u wound swab from ___ and adjust antibiotics pending results (would need to also cover HAP as above) [] monitor Na which has been almost borderline elevated and consider more free water or volume [] As discussed on phone by discharging attending, please change vancomycin to linezolid to cover for possibility of UTI (which would also cover HAP) [] PCP was unknown to patient's wife, but may be known to father in law; please assess who is his PCP and please pass on this discharge summary to that person [] Should follow up with orthopedics, plastics, endocrinology, Infectious Disease [] CODE: FULL This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Artificial Tears Preserv. Free ___ DROP BOTH EYES TID 2. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 4. GuaiFENesin ___ mL PO Q6H:PRN mucous secretions 5. Hyoscyamine 0.125 mg PO BID 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Methadone 10 mg PO Q8H pain 8. Metoclopramide 5 mg PO Q12H 9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 10. Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN Pain - Mild/Fever 11. Amantadine Syrup 125 mg PO/NG BID 12. Collagenase Ointment 1 Appl TP DAILY 13. cranberry 800 mg J tube DAILY 14. Enoxaparin Sodium 30 mg SC DAILY 15. HYDROmorphone (Dilaudid) 2 mg IV Q3H:PRN Pain - Severe 16. gabapentin 500 mg J tube QHS 17. Hydrocortisone 15 mg PO BID 18. Hydroxypropyl Meth. 2.5% Ophth 0.3 % Each eye NIGHTLY 19. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell oral DAILY 20. Miconazole Powder 2% 1 Appl TP BID 21. Omeprazole 20 mg PO DAILY 22. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye) TID 23. sodium hypochlorite 0.0125 % topical DAILY Discharge Medications: 1. Cyclobenzaprine 10 mg PO BID:PRN Muscle spasm 2. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID 3. Glutamine 20 gm PO DAILY 4. Hydrocortisone Na Succ. 20 mg IV Q8H 5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 6. LevETIRAcetam Oral Solution 1000 mg PO Q12H 7. Levothyroxine Sodium 75 mcg IV DAILY 8. OxycoDONE Liquid 15 mg PO Q4H:PRN Pain - Moderate 9. Piperacillin-Tazobactam 4.5 g IV Q8H Duration: 6 Days 10. Vancomycin 1000 mg IV Q 24H Duration: 6 Days 11. Methadone 15 mg PO Q8H pain Consider prescribing naloxone at discharge 12. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever 13. Amantadine Syrup 125 mg PO BID 14. Artificial Tears Preserv. Free ___ DROP BOTH EYES TID 15. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line 16. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 17. Collagenase Ointment 1 Appl TP DAILY 18. cranberry 800 mg J tube DAILY 19. Enoxaparin Sodium 30 mg SC DAILY 20. gabapentin 500 mg J tube QHS 21. GuaiFENesin ___ mL PO Q6H:PRN mucous secretions 22. HYDROmorphone (Dilaudid) 2 mg IV Q3H:PRN Pain - Severe 23. Hydroxypropyl Meth. 2.5% Ophth 0.3 % Each eye NIGHTLY 24. Hyoscyamine 0.125 mg PO BID 25. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell oral DAILY 26. Metoclopramide 5 mg PO Q12H 27. Miconazole Powder 2% 1 Appl TP BID 28. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 29. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye) TID 30. sodium hypochlorite 0.0125 % topical DAILY 31. HELD- Levothyroxine Sodium 100 mcg PO DAILY This medication was held. Do not restart Levothyroxine Sodium until your tube feeds are switched to cycled Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Dry gangrene of all 4 limbs Complicated ___ ___ Acquired Pneumonia ___ Stream Infection Generalized Tonic Clonic Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital for an amputation of your arms and legs because they were not getting enough ___. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had an amputation of your arms and legs - You developed a fungal ___ stream infection which was treated with antifungal medications at the recommendations of our Infectious Disease team - You developed a Urinary Tract Infection which was treated with antibiotic medications at the recommendations of our Infectious Disease team - You had a seizure. The neurology team was consulted and you were started on anti-seizure medications - You had a lumbar puncture to look for an infection of your spinal cord or brain. This did not show any evidence of infection - You developed a pneumonia which was treated with antibiotic medications at the recommendations of our Infectious Disease team - Our endocrinology team was consulted to mange your steroids and thyroid medications WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please take your medications and go to your follow up appointments as described in this discharge summary. - If you experience any of the danger signs listed below, please call your primary care doctor or go to the emergency department immediately. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "I96", "J189", "E271", "N390", "E46", "G931", "B3789", "J9611", "K9423", "I998", "E032", "L409", "Z7952", "E875", "B965", "Z930", "E861", "Z6824", "G8918", "T8781", "Y835", "Y92230", "R569", "Y838", "D649" ]	Allergies: gluten / ceftazidime Chief Complaint: Four Limb Ischemia Major Surgical or Invasive Procedure: four limb amputation on [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with history of hypothyroidism and psoriasis (on chronic prednisone 7.5mg daily) who has had a long complicated course resulting in multiorgan failure, hypoxic ischemic encephalopathy (is now non verbal), diffuse bacteremia, stress induced cardiomyopathy and four limb ischemia. After demarcation the decision was made to pursue a four limb amputation in conjunction with orthopedics on [MASKED]. Briefly the patient initially presented to an OSH in [MASKED] on [MASKED] with abdominal pain, vomiting, chills. He was found to have septic shock (bacteremia with S. pneumopniae) requiring 4 vasopressors and developed hypoxic respiratory failure. He developed hypoxic ischemic encephalopathy with intra-ventricular hemorrhage, and CVA thought to be cardioembolic. He also had acute renal failure requiring CRRT. Part of his care was the [MASKED] where he received a trach and PEG that was later converted to a GJ by [MASKED]. He was transferred from [MASKED] [MASKED] to [MASKED] and he was in our hospital during the period [MASKED] where he was also found to have multiudrug resistant pseudomonas pneumonia, depressed EF heart failure, Fungemia (presumably recurrent C. parapsilosas, s/p treatment with IV micafungin). His four limb ischemia was thought to be in the setting of shock with s DIC w/ purpura fulminans. He was discharged to [MASKED] and he has remained there up until today. Of note, recently he had his GJ tube exchanged by [MASKED] on [MASKED] and converted to a [MASKED] MIC GJ due to malfunctioning. He has been on lovenox for DVTs which we have instructed to stop on [MASKED]. He now presents as a direct admit from [MASKED] in anticipation of his surgery. He is non verbal and the history is acquired from chart review. Past Medical History: Lithium-induced hypothyroidism Psoriasis on chronic steroids Seasonal affective disorder Social History: [MASKED] Family History: No significant immunodeficiency or vascular disease. Physical Exam: DISCHARGE PHYSICAL EXAM: ======================== GEN: Resting in bed, thin, trach in place. appears uncomfortable. HEENT: NC/AT, Moist mucous membranes. No lesions. NECK: Trach in place. JVP does not appear elevated. CV: Regular rate, normal rhythm. No murmurs appreciated. RESP: Clear to auscultation bilaterally. GI: Soft, GJ tube in place MSK: all 4 limbs wrapped from amputations but incisions are cdi with slight granulation tissue on RUE and LLE, RLE incision cdi except for packing of previously slightly purulent area SKIN: No rashes on exposed skin. Scars on LLE NEURO/psych: alert, answers yes/no at times to questions, opens his eyes and tracks, PERRL Pertinent Results: DISCHARGE LABS ============== [MASKED] 04:24AM [MASKED] WBC-13.6* RBC-2.85* Hgb-9.2* Hct-29.4* MCV-103* MCH- 32.3* MCHC-31.3* RDW-17.1* RDWSD-59.2* Plt [MASKED] [MASKED] 05:04AM [MASKED] Neuts-48 Bands-2 [MASKED] Monos-7 Eos-1 [MASKED] Metas-7* Myelos-3* NRBC-1.2* AbsNeut-7.25* AbsLymp-4.64* AbsMono-1.02* AbsEos-0.15 AbsBaso-0.00* [MASKED] 04:24AM [MASKED] [MASKED] PTT-26.1 [MASKED] [MASKED] 04:24AM [MASKED] Glucose-95 UreaN-35* Creat-0.8 Na-145 K-4.2 Cl-109* HCO3-27 AnGap-9* [MASKED] 04:24AM [MASKED] Calcium-9.0 Phos-3.4 Mg-2.4 PERTINENT INTERVAL LABS ======================= [MASKED] 04:32PM [MASKED] [MASKED] [MASKED] 03:19PM [MASKED] [MASKED] [MASKED] 04:32PM [MASKED] Hapto-381* [MASKED] 04:08AM [MASKED] Hapto-362* [MASKED] 11:46AM [MASKED] calTIBC-144* Ferritn-1055* TRF-111* [MASKED] 03:19PM [MASKED] T4-8.7 Free T4-1.9* [MASKED] 05:15AM [MASKED] TSH-0.24* [MASKED] 05:00AM [MASKED] TSH-0.39 [MASKED] 04:19PM [MASKED] Prolact-63* [MASKED] 03:19PM [MASKED] T4-8.7 Free T4-1.9* ADMISSION LABS ============== [MASKED] 09:03PM [MASKED] WBC-17.7* RBC-2.91* Hgb-9.1* Hct-30.1* MCV-103* MCH-31.3 MCHC-30.2* RDW-14.2 RDWSD-53.8* Plt [MASKED] [MASKED] 11:46AM [MASKED] Neuts-78.0* Lymphs-12.2* Monos-8.1 Eos-0.0* Baso-0.3 Im [MASKED] AbsNeut-19.36* AbsLymp-3.02 AbsMono-2.00* AbsEos-0.01* AbsBaso-0.08 [MASKED] 03:55AM [MASKED] [MASKED] PTT-33.1 [MASKED] [MASKED] 09:03PM [MASKED] Glucose-130* UreaN-29* Creat-1.4* Na-137 K-4.4 Cl-99 HCO3-27 AnGap-11 [MASKED] 03:19PM [MASKED] ALT-73* AST-29 AlkPhos-82 TotBili-0.3 [MASKED] 09:03PM [MASKED] Calcium-10.1 Phos-3.5 Mg-2.0 MICROBIOLOGY DATA ================= - [MASKED] Culture, Routine (Final [MASKED]: [MASKED] PARAPSILOSIS. Susceptibility:. Fluconazole MIC OF 0.5 MCG/ML = SUSCEPTIBLE. Results were read after 24 hours of incubation. test result performed by Sensititre. - [MASKED]: URINE CULTURE * PSEUDOMONAS AERUGINOSA: >100,000 CFU/mL OF TWO COLONIAL MORPHOLOGIES. PSEUDOMONAS AERUGINOSA CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S - [MASKED]: CSF Studies Enterovirus Culture- NEGATIVE GRAM STAIN-FINAL; FLUID CULTURE- NGTD CRYPTOCOCCAL ANTIGEN- Negative - [MASKED]: [MASKED] CRYPTOCOCCAL ANTIGEN-Negative - [MASKED]: WOUND GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. - [MASKED]: WOUND CULTURE (Preliminary): MIXED BACTERIAL FLORA. PSEUDOMONAS AERUGINOSA: RARE GROWTH OF TWO COLONIAL MORPHOLOGIES. - [MASKED]: ANAEROBIC CULTURE (Preliminary): NO ANAEROBES - [MASKED]: [MASKED] Cultures x2: PND - [MASKED]: URINE CULTURE (Final [MASKED]: GRAM POSITIVE COCCUS(COCCI). ~3000 CFU/mL. [MASKED] 11:11 am URINE Source: [MASKED]. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R - [MASKED] 7:20 am SWAB Source: R leg. GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. WOUND CULTURE (Preliminary): 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 in this culture. ANAEROBIC CULTURE (Preliminary): [MASKED] 9:37 pm SPUTUM Source: Endotracheal. FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. C. difficile PCR (Final [MASKED]: NEGATIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. A negative C. diff PCR test indicates a low likelihood of CDI or carriage. RADIOLOGY DATA ============== CXR [MASKED]: New focal consolidation in the left lower lung consistent with infection. Small left pleural effusion. Interval placement of right PICC line terminating in the right atrium. CT HEAD [MASKED] Increased in ventricular system which may indicate development of communicating hydrocephalus since the prior study. Although temporal horn dilatation, which has increased in particular, may be associated with temporal lobe atrophy, degree of atrophy is not obviously increased. MRI HEAD 1. No evidence of acute infarction, hemorrhage or mass. 2. Generalized atrophy. 3. Evolution of the multiple infarctions demonstrated in [MASKED]. 4. Small amount of residual old [MASKED] products in the fourth ventricle. Brief Hospital Course: [MASKED] year old man with PMHx of lithium-induced hypothyroidism, psoriasis on chronic steroids, who had a prolonged and complicated series of hospitalization from [MASKED] to [MASKED] for sepsis with DIC complicated by limb ischemia from pressors and DIC, as well as multiple other complications, during which [MASKED] Endocrinology was consulted for hypercalcemia, hypothyroidism and adrenal insufficiency. He has been re-admitted for a planned 4 limb amputation which took place on [MASKED]. The patient has now been transferred to medicine for further management of fungemia and pseudomonas UTI. Since being on the medicine service he had a seizure as well as [MASKED] cultures positive for [MASKED] Fungemia and subsequent HAP. # History of strep bacteremia with 4 limb ischemia s/p amputation The patient developed Ischemic limbs secondary to purpura fulminans as a sequelae of Strep pneumo bacteremia and 4-pressor shock. The patient was admitted for and underwent a four limb amputation on [MASKED]. The patient had Epidural and Supraclavicular blocks performed and was continued on a Ketamine gtt as well as Dilaudid IV and Oxycodone PRN. The pain service was consulted and per their recommendations, the patient's gabapentin and methadone were increased and he was continued on oxycodone to 15 mg Q4H PRN, and hydromorphone to [MASKED] mg Q2H PRN for severe pain. Per plastics and vascular surgery the patient's Ketamine was discontinued on [MASKED] and the epidural was removed. On [MASKED] the patient was transferred out of the ICU without issue. # Hospital Acquired Pneumonia versus Recurrent UTI In the setting of up trending leukocytosis, low grade fevers, and softer [MASKED] pressures a CXR was done on [MASKED] showing a new LLL opacity c/f infection/PNA. Given the patient's prolonged hospitalization, he was diagnosed with HAP and his ciprofloxacin was discontinued and he was broadened to Zosyn. Of note, the patient developed eosinophilia and ?seizure while on a cephalosporin, which is why Zosyn was chosen. He was continued on Vancomycin. A UCx was drawn at the same time, and returned as VRE just after discharge; although it is not completely clear patient actually had a UTI rather than just colonization (particularly since his WBCs improved with addition of Zosyn), it was thought prudent to change vancomycin to linezolid, so the discharging attending called over to inform the receiving attending of the above and to give a detailed warm handoff. # Intermittent Hypotension # Primary adrenal insufficiency: The patient was intermittently hypotensive during his hospitalization when trying to taper his steroids. His hypotension is most likely multifactorial, but largely due to his primary adrenal insufficiency. His Lactate was normal when checked during hypotensive episodes. The patient received multiple IVF boluses. Of note, his prior testing showed: [MASKED] 3 (L), renin 25 (H) and cortisol 3.2 (L), and ACTH 118(high), which was consistent with primary adrenal insufficiency. Adrenal antibodies were negative. Endocrinology was consulted and managed tapering of his steroids, which were complicated by hypotension when decreased too rapidly. Discharged on hydrocortisone 20mg IV Q8hrs for 4 days (END [MASKED] then switch to 15mg PO QAM and then 5mg PO Q2-3PM . Resume fludrocortisone on [MASKED]. # Leukocytosis The patient initially had a leukocytosis to 17.7 when he presented on [MASKED]. This trended up to 33 and began to resolved to 11.7 on [MASKED] with the treatment of his [MASKED] Bloodstream Infection, wound dehiscence, and pseudomonas UTI (as described below). On [MASKED] his WBC count increased from 11.7--> 21.2--> 29.2 and was down trending until [MASKED] when it again spiked to 20. At this time a CXR was done showing a new pneumonia (as described as above). His c. diff was negative. The remainder of his infections were treated as described elsewhere. # [MASKED] Bloodstream Infection The patient's course was complicated by [MASKED] cultures growing [MASKED]. He was initially treated with Micafungin, them escalated to Amphotericin before being tailored to Fluconazole based on sensitivities. Infectious Disease signed off and recommended Fluconazole IV for 2 weeks ([MASKED]). PICC line exchanged by [MASKED] on [MASKED]. Ophthalmology was consulted and found no evidence of endophthalmitis. A LP was done [MASKED] (see below)which was unremarkable and showed no signs of infection. # LLE Wound Dehiscence The patient was noted to have a wound dehiscence by the surgical teams. Wound cultures grew pseudomonas as well as CoNS and enterococcus. The patient was initially stared on vancomycin and ciprofloxacin for a planned 2 week course ([MASKED]). The cipro was changed to Zosyn for coverage of HAP (as described above). Wound care, plastics, and orthopedics continued to follow the patient while inpatient. Given some mild purulent discharge at a stitch on RLE, a swab cx was performed on [MASKED], the results of which are still pending (but anticipate covered by addition of Zosyn to vanc). # Complicated UTI The patient had a UA done which was positive for nitrites, and moderate bacteria. His culture grew pan-sensitive pseudomonas aeruginosa. On [MASKED] ID was consulted and recommended a 2 week course of antibiotics for complicated UTI. The patient completed a 2 week course of ciprofloxacin [MASKED] a complicated UTI. # First-time Generalized Seizure # Communicating Hydrocephalus The patient had a had a first time generalized seizure on [MASKED] which resolved with 2mg IV Ativan. Subsequently started on Keppra 1000 mg bid. Had imaging done which was concerning for communicating hydrocephalus. He underwent an LP which showed 0 WBC, elevated protein (possibly due to the residual intraventricular [MASKED] products seen on MRI). CSF Gram Stain, Enterovirus and Cryptococcus antigen was negative. CSF cultures were negative. EEG was without evidence of seizure activity. He had no further clinical or electrographic seizures while inpatient. Neurology was consulted and signed off on [MASKED] with their final recommendations being to continue Keppra. # Malnutrition # GJ Tube Dysfunction # Tube Feeds The patient's GJ tube came out on [MASKED] and was replaced by [MASKED] on [MASKED]. On [MASKED], the was a "foamy" appearance to GJ tube drainage so [MASKED] ordered showing coiling of the GJ tube into the stomach. [MASKED] was re-consulted and patient underwent another tube replacement on [MASKED]. Nutrition was following for TF recommendations and he was switched to nepro tube feeds given hyperkalemia. # Anemia While inpatient, the patient had hemoglobin's that are widely variant with his HgB usually being in the [MASKED] range. On [MASKED] his HgB dropped from 8.0 to 6.9 with an appropriate response to 1U PRBCs. There was no sign of bleeding and his labs were not consistent with hemolysis. # Eosinophilia, drug-induced (resolved) The patient was noted to have an eosinophilia which was thought to be from Ceftazidime. This resolved after switching to ciprofloxacin. # Chronic Pain # Post Operative Pain The Chronic Pain service was consulted and recommended continuing Hydromorphone [MASKED] mg IV Q2H:PRN for breakthrough pain & dressing changes. The also recommended continuing Methadone 15 mg PO/NG Q8H pain and oxycodone Liquid 15mg PRN. He was continued on gabapentin 600mg TID and standing acetaminophen 650mg q6h. # Hypothyroidism: The patient has a history of hypothyroidism with negative TPO ab and Tg Ab. On prior admission, the patient required IV and high dose levothyroxine administration to overcome tube feeds but he has been weaned to 100mcg at rehab. TFTs obtained this admission show: T4: 8.7 Free T4: 1.9 confirming adequate replacement as an outpatient. He is now on continuous TF. Endocrinology was consulted and stated that if TFs are switched to cycled, his IV levothyroxine can be converted to PO levothyroxine. Their dosing recommendations: LT4 75mcg IV (75% of oral dose) if on continuous TF which impacts absorption; when he is switched to bolus TF, he can be converted to PO LT4 (100 mcg daily) with holding tube feeds for 4 hours prior & 1 hour after TF. >30 minutes spent on patient care and coordination on day of discharge TRANSITIONAL ISSUES =================== [] Antibiotics: [] Vancomycin for HAP and wound dehiscence (End [MASKED] [] Zosyn for wound dehiscence and HAP (End [MASKED] [] Routine EKG monitoring for QT interval while on methadone [] Patient was noted to have metas on his differential-- consider following with hematology and potential bone marrow biopsy [] Consider switching TFs to cycled [] If TFs are switched to cycled, his IV levothyroxine can be converted to PO levothyroxine. Their dosing recommendations: LT4 75mcg IV (75% of oral dose) if on continuous TF which impacts absorption; when he is switched to bolus TF, he can be converted to PO LT4 (100 mcg daily) with holding tube feeds for 4 hours prior & 1 hour after TF. [] Please check TFTs on [MASKED] per endocrine [] Wean pain medications as able [] Steroid taper per endocrine recommendations-- Discharged on hydrocortisone 20mg IV Q8hrs for 4 days (END [MASKED] then switch to 15mg PO QAM and then 5mg PO Q2-3PM . Resume fludrocortisone on [MASKED]. [] Follow up CBC with differential [] F/u wound swab from [MASKED] and adjust antibiotics pending results (would need to also cover HAP as above) [] monitor Na which has been almost borderline elevated and consider more free water or volume [] As discussed on phone by discharging attending, please change vancomycin to linezolid to cover for possibility of UTI (which would also cover HAP) [] PCP was unknown to patient's wife, but may be known to father in law; please assess who is his PCP and please pass on this discharge summary to that person [] Should follow up with orthopedics, plastics, endocrinology, Infectious Disease [] CODE: FULL This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES TID 2. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line 3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 4. GuaiFENesin [MASKED] mL PO Q6H:PRN mucous secretions 5. Hyoscyamine 0.125 mg PO BID 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Methadone 10 mg PO Q8H pain 8. Metoclopramide 5 mg PO Q12H 9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 10. Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN Pain - Mild/Fever 11. Amantadine Syrup 125 mg PO/NG BID 12. Collagenase Ointment 1 Appl TP DAILY 13. cranberry 800 mg J tube DAILY 14. Enoxaparin Sodium 30 mg SC DAILY 15. HYDROmorphone (Dilaudid) 2 mg IV Q3H:PRN Pain - Severe 16. gabapentin 500 mg J tube QHS 17. Hydrocortisone 15 mg PO BID 18. Hydroxypropyl Meth. 2.5% Ophth 0.3 % Each eye NIGHTLY 19. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell oral DAILY 20. Miconazole Powder 2% 1 Appl TP BID 21. Omeprazole 20 mg PO DAILY 22. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye) TID 23. sodium hypochlorite 0.0125 % topical DAILY Discharge Medications: 1. Cyclobenzaprine 10 mg PO BID:PRN Muscle spasm 2. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID 3. Glutamine 20 gm PO DAILY 4. Hydrocortisone Na Succ. 20 mg IV Q8H 5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 6. LevETIRAcetam Oral Solution 1000 mg PO Q12H 7. Levothyroxine Sodium 75 mcg IV DAILY 8. OxycoDONE Liquid 15 mg PO Q4H:PRN Pain - Moderate 9. Piperacillin-Tazobactam 4.5 g IV Q8H Duration: 6 Days 10. Vancomycin 1000 mg IV Q 24H Duration: 6 Days 11. Methadone 15 mg PO Q8H pain Consider prescribing naloxone at discharge 12. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever 13. Amantadine Syrup 125 mg PO BID 14. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES TID 15. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line 16. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 17. Collagenase Ointment 1 Appl TP DAILY 18. cranberry 800 mg J tube DAILY 19. Enoxaparin Sodium 30 mg SC DAILY 20. gabapentin 500 mg J tube QHS 21. GuaiFENesin [MASKED] mL PO Q6H:PRN mucous secretions 22. HYDROmorphone (Dilaudid) 2 mg IV Q3H:PRN Pain - Severe 23. Hydroxypropyl Meth. 2.5% Ophth 0.3 % Each eye NIGHTLY 24. Hyoscyamine 0.125 mg PO BID 25. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell oral DAILY 26. Metoclopramide 5 mg PO Q12H 27. Miconazole Powder 2% 1 Appl TP BID 28. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 29. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye) TID 30. sodium hypochlorite 0.0125 % topical DAILY 31. HELD- Levothyroxine Sodium 100 mcg PO DAILY This medication was held. Do not restart Levothyroxine Sodium until your tube feeds are switched to cycled Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Dry gangrene of all 4 limbs Complicated [MASKED] [MASKED] Acquired Pneumonia [MASKED] Stream Infection Generalized Tonic Clonic Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital for an amputation of your arms and legs because they were not getting enough [MASKED]. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had an amputation of your arms and legs - You developed a fungal [MASKED] stream infection which was treated with antifungal medications at the recommendations of our Infectious Disease team - You developed a Urinary Tract Infection which was treated with antibiotic medications at the recommendations of our Infectious Disease team - You had a seizure. The neurology team was consulted and you were started on anti-seizure medications - You had a lumbar puncture to look for an infection of your spinal cord or brain. This did not show any evidence of infection - You developed a pneumonia which was treated with antibiotic medications at the recommendations of our Infectious Disease team - Our endocrinology team was consulted to mange your steroids and thyroid medications WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please take your medications and go to your follow up appointments as described in this discharge summary. - If you experience any of the danger signs listed below, please call your primary care doctor or go to the emergency department immediately. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "N390", "Y92230", "D649" ]	[ "I96: Gangrene, not elsewhere classified", "J189: Pneumonia, unspecified organism", "E271: Primary adrenocortical insufficiency", "N390: Urinary tract infection, site not specified", "E46: Unspecified protein-calorie malnutrition", "G931: Anoxic brain damage, not elsewhere classified", "B3789: Other sites of candidiasis", "J9611: Chronic respiratory failure with hypoxia", "K9423: Gastrostomy malfunction", "I998: Other disorder of circulatory system", "E032: Hypothyroidism due to medicaments and other exogenous substances", "L409: Psoriasis, unspecified", "Z7952: Long term (current) use of systemic steroids", "E875: Hyperkalemia", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "Z930: Tracheostomy status", "E861: Hypovolemia", "Z6824: Body mass index [BMI] 24.0-24.9, adult", "G8918: Other acute postprocedural pain", "T8781: Dehiscence of amputation stump", "Y835: Amputation of limb(s) 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", "R569: Unspecified convulsions", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "D649: Anemia, unspecified" ]
10,047,766	23,271,313	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: triamterene / verapamil / hydrochlorothiazide Attending: ___. Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: ___ 1. Aortic valve replacement, 27 mm ___ Epic tissue valve. 2. Coronary artery bypass grafting x2, reverse saphenous vein graft to the posterior descending artery and the marginal branch of the circumflex. History of Present Illness: Very nice ___ year old gentleman previously seen at the time of his cardiac catheterization who has known aortic stenosis. Previously noted as moderate but is now severe echocardiogram. He notes significant fatigue and exertional dyspnea. He underwent a cardiac catheterization on ___ which showed two vessel coronary artery disease, not amendable to percutaneous intervention. Given his symptoms and degree of aortic stenosis, he has been referred for higher risk surgical intervention. Past Medical History: Hypertension Hyperlipidemia TBI/post-concussion syndrome ___ - s/p drain and plate place Macular degeneration Abdominal hernia Bilateral hallux rigidus Polynueropathy Polymyalgia Rheumatica Gait disturbance Carpal tunnel syndrome s/p CVA still with some mild left sided weakness Memory loss Seizures - remote DVT >> PE s/p IVC filter ___ years ago Hypothyroidism Prostate CA s/p XRT and hormonal therapy OSA Left shoulder pain s/p cortisone injections q 3 months Hx of remote falls Depression Social History: ___ Family History: Non-Contributory Physical Exam: Pulse: 62 Resp: 17 O2 sat: 97% RA B/P Right: 123/62 Left: Height: 72" Weight: 175 lbs 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] venous stasis changes Neuro: Grossly intact [x] Pulses: Femoral Right: cath site Left: 2+ DP Right: 1+ Left: 1+ ___ Right: 1+ Left: 1+ Radial Right: cath site Left: 2+ Carotid Bruit Right: + rad murmur Left: + rad murmur =========================================================== DISCHARGE EXAM: Gen- NAD, A&Ox2, non-focal CV: RRR Lungs: no resp. distress, diminished at bases Abd: +BS, soft, non-tender, non-distended Ext: no CCE, palpable pulses sternal incision: c/d/I, no erythema or drainage Pertinent Results: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Moderate AS (area 1.0-1.2cm2) Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR ___ normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. 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 simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). POSTBYPASS There is preserved biventricular systolic function/ There is a well seated, well functioning bioprosthesis in the aortic position. No AI is visualized. Limited exam due to poor windows. Chest Film ___ Large left pleural effusion has increased. Right pleural effusion and right lower lobe and right middle lobe consolidations have increased. There are low lung volumes. Cardiomegaly cannot be assessed. There is no evident pneumothorax. Admission Labs: ___: WBC-15.3# RBC-2.47# Hgb-7.5# Hct-23.1# MCV-94 MCH-30.4 MCHC-32.5 RDW-14.5 RDWSD-49.2* Plt Ct-69* ___ UreaN-16 Creat-0.6 Cl-105 HCO3-20* AnGap-17 ___ ALT-30 AST-80* LD(LDH)-288* AlkPhos-62 Amylase-57 TotBili-1.4 ___ Mg-2.1 Discharge Labs: ___ 05:00AM BLOOD WBC-8.5 RBC-3.87* Hgb-11.6* Hct-35.3* MCV-91 MCH-30.0 MCHC-32.9 RDW-15.0 RDWSD-49.4* Plt ___ ___ 02:38AM BLOOD WBC-13.3* RBC-3.08# Hgb-9.4 Hct-27.1* MCV-88 MCH-30.5 MCHC-34.7 RDW-14.6 RDWSD-46.2 Plt Ct-91* ___ 12:40PM BLOOD WBC-17.6* RBC-2.43* Hgb-7.4* Hct-22.3* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.4 RDWSD-48.7* Plt ___ ___ 03:13AM BLOOD ___ PTT-29.2 ___ ___ 05:00AM BLOOD Glucose-103* UreaN-19 Creat-0.8 Na-136 K-4.4 Cl-99 HCO3-23 AnGap-18 ___ 06:56AM BLOOD Glucose-123* UreaN-18 Creat-0.9 Na-134 K-4.0 Cl-97 HCO3-24 AnGap-17 ___ 08:39PM BLOOD ALT-30 AST-80* LD(LDH)-288* AlkPhos-62 Amylase-57 TotBili-1.4 ___ 05:00AM BLOOD Mg-2.0 Brief Hospital Course: The patient was brought to the Operating Room on ___ where the patient underwent Aortic valve replacement, 27 mm ___ ___ Epic tissue valve. Coronary artery bypass grafting x2, reverse saphenous vein graft to the posterior descending artery and the marginal branch of the circumflex. The Cardiopulmonary Bypass time was 115 minutes. The Cross-Clamp time was 82 minutes. 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 hemodynamically stable, weaned from inotropic and vasopressor support. He had periods of brief delirium but overall remained oriented. Beta blocker were held secondary to his prolonged PR interval. He was transfused with 1 unit of PRBC for HCT of 22 to a HCT of 27. His platelet count trend down. HIT was negative and platelet count trended up. He tolerated initiation of low dose beta blocker. His seizure medication and dementia medication were restarted. He was gently diuresed toward his preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was seen by Occupational Therapy to evaluate and assist with his cognitive function. He remained oriented with brief periods of confusion. By the time of discharge on POD 6 the patient was ambulating, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to ___ in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dipyridamole-Aspirin 1 CAP PO DAILY 2. Donepezil 5 mg PO QHS 3. Furosemide 60 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Phenytoin Sodium Extended 100 mg PO BID 6. Sertraline 100 mg PO DAILY 7. Pyridoxine 100 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Severe Aortic Stenosis s/p AVR ___ mm ___ Epic tissue valve. Coronary Artery Disease s/p CABG x 2 (SVG-PDA, SVG-OM) Hypertension Hyperlipidemia TBI/post-concussion syndrome ___ - s/p drain and plate place Macular degeneration Abdominal hernia Bilateral hallux rigidus Polynueropathy Polymyalgia Rheumatica Gait disturbance Carpal tunnel syndrome s/p CVA still with some mild left sided weakness Memory loss Seizures - remote DVT >> PE s/p IVC filter ___ years ago Hypothyroidism Prostate CA s/p XRT and hormonal therapy OSA Left shoulder pain s/p cortisone injections q 3 months Hx of remote falls Depression Discharge Condition: Alert and oriented x3, pleasantly confused, non-focal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage no edema Discharge Instructions: 1). Shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 2). NO lotions, cream, powder, or ointments to incisions 3). Daily weights: keep a log 4). No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours Followup Instructions: ___	[ "I350", "I69954", "D689", "F0390", "D62", "D696", "I2584", "I2510", "I10", "E785", "E039", "Z8546", "Z923", "G4733", "F329", "G40909", "M353", "Z86711", "Z86718", "G629", "H3530" ]	Allergies: triamterene / verapamil / hydrochlorothiazide Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: [MASKED] 1. Aortic valve replacement, 27 mm [MASKED] Epic tissue valve. 2. Coronary artery bypass grafting x2, reverse saphenous vein graft to the posterior descending artery and the marginal branch of the circumflex. History of Present Illness: Very nice [MASKED] year old gentleman previously seen at the time of his cardiac catheterization who has known aortic stenosis. Previously noted as moderate but is now severe echocardiogram. He notes significant fatigue and exertional dyspnea. He underwent a cardiac catheterization on [MASKED] which showed two vessel coronary artery disease, not amendable to percutaneous intervention. Given his symptoms and degree of aortic stenosis, he has been referred for higher risk surgical intervention. Past Medical History: Hypertension Hyperlipidemia TBI/post-concussion syndrome [MASKED] - s/p drain and plate place Macular degeneration Abdominal hernia Bilateral hallux rigidus Polynueropathy Polymyalgia Rheumatica Gait disturbance Carpal tunnel syndrome s/p CVA still with some mild left sided weakness Memory loss Seizures - remote DVT >> PE s/p IVC filter [MASKED] years ago Hypothyroidism Prostate CA s/p XRT and hormonal therapy OSA Left shoulder pain s/p cortisone injections q 3 months Hx of remote falls Depression Social History: [MASKED] Family History: Non-Contributory Physical Exam: Pulse: 62 Resp: 17 O2 sat: 97% RA B/P Right: 123/62 Left: Height: 72" Weight: 175 lbs 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] venous stasis changes Neuro: Grossly intact [x] Pulses: Femoral Right: cath site Left: 2+ DP Right: 1+ Left: 1+ [MASKED] Right: 1+ Left: 1+ Radial Right: cath site Left: 2+ Carotid Bruit Right: + rad murmur Left: + rad murmur =========================================================== DISCHARGE EXAM: Gen- NAD, A&Ox2, non-focal CV: RRR Lungs: no resp. distress, diminished at bases Abd: +BS, soft, non-tender, non-distended Ext: no CCE, palpable pulses sternal incision: c/d/I, no erythema or drainage Pertinent Results: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Moderate AS (area 1.0-1.2cm2) Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR [MASKED] normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. 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 simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). POSTBYPASS There is preserved biventricular systolic function/ There is a well seated, well functioning bioprosthesis in the aortic position. No AI is visualized. Limited exam due to poor windows. Chest Film [MASKED] Large left pleural effusion has increased. Right pleural effusion and right lower lobe and right middle lobe consolidations have increased. There are low lung volumes. Cardiomegaly cannot be assessed. There is no evident pneumothorax. Admission Labs: [MASKED]: WBC-15.3# RBC-2.47# Hgb-7.5# Hct-23.1# MCV-94 MCH-30.4 MCHC-32.5 RDW-14.5 RDWSD-49.2* Plt Ct-69* [MASKED] UreaN-16 Creat-0.6 Cl-105 HCO3-20* AnGap-17 [MASKED] ALT-30 AST-80* LD(LDH)-288* AlkPhos-62 Amylase-57 TotBili-1.4 [MASKED] Mg-2.1 Discharge Labs: [MASKED] 05:00AM BLOOD WBC-8.5 RBC-3.87* Hgb-11.6* Hct-35.3* MCV-91 MCH-30.0 MCHC-32.9 RDW-15.0 RDWSD-49.4* Plt [MASKED] [MASKED] 02:38AM BLOOD WBC-13.3* RBC-3.08# Hgb-9.4 Hct-27.1* MCV-88 MCH-30.5 MCHC-34.7 RDW-14.6 RDWSD-46.2 Plt Ct-91* [MASKED] 12:40PM BLOOD WBC-17.6* RBC-2.43* Hgb-7.4* Hct-22.3* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.4 RDWSD-48.7* Plt [MASKED] [MASKED] 03:13AM BLOOD [MASKED] PTT-29.2 [MASKED] [MASKED] 05:00AM BLOOD Glucose-103* UreaN-19 Creat-0.8 Na-136 K-4.4 Cl-99 HCO3-23 AnGap-18 [MASKED] 06:56AM BLOOD Glucose-123* UreaN-18 Creat-0.9 Na-134 K-4.0 Cl-97 HCO3-24 AnGap-17 [MASKED] 08:39PM BLOOD ALT-30 AST-80* LD(LDH)-288* AlkPhos-62 Amylase-57 TotBili-1.4 [MASKED] 05:00AM BLOOD Mg-2.0 Brief Hospital Course: The patient was brought to the Operating Room on [MASKED] where the patient underwent Aortic valve replacement, 27 mm [MASKED] [MASKED] Epic tissue valve. Coronary artery bypass grafting x2, reverse saphenous vein graft to the posterior descending artery and the marginal branch of the circumflex. The Cardiopulmonary Bypass time was 115 minutes. The Cross-Clamp time was 82 minutes. 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 hemodynamically stable, weaned from inotropic and vasopressor support. He had periods of brief delirium but overall remained oriented. Beta blocker were held secondary to his prolonged PR interval. He was transfused with 1 unit of PRBC for HCT of 22 to a HCT of 27. His platelet count trend down. HIT was negative and platelet count trended up. He tolerated initiation of low dose beta blocker. His seizure medication and dementia medication were restarted. He was gently diuresed toward his preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was seen by Occupational Therapy to evaluate and assist with his cognitive function. He remained oriented with brief periods of confusion. By the time of discharge on POD 6 the patient was ambulating, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [MASKED] in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dipyridamole-Aspirin 1 CAP PO DAILY 2. Donepezil 5 mg PO QHS 3. Furosemide 60 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. Phenytoin Sodium Extended 100 mg PO BID 6. Sertraline 100 mg PO DAILY 7. Pyridoxine 100 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN dry eyes Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Severe Aortic Stenosis s/p AVR [MASKED] mm [MASKED] Epic tissue valve. Coronary Artery Disease s/p CABG x 2 (SVG-PDA, SVG-OM) Hypertension Hyperlipidemia TBI/post-concussion syndrome [MASKED] - s/p drain and plate place Macular degeneration Abdominal hernia Bilateral hallux rigidus Polynueropathy Polymyalgia Rheumatica Gait disturbance Carpal tunnel syndrome s/p CVA still with some mild left sided weakness Memory loss Seizures - remote DVT >> PE s/p IVC filter [MASKED] years ago Hypothyroidism Prostate CA s/p XRT and hormonal therapy OSA Left shoulder pain s/p cortisone injections q 3 months Hx of remote falls Depression Discharge Condition: Alert and oriented x3, pleasantly confused, non-focal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage no edema Discharge Instructions: 1). Shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 2). NO lotions, cream, powder, or ointments to incisions 3). Daily weights: keep a log 4). No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours Followup Instructions: [MASKED]	[]	[ "D62", "D696", "I2510", "I10", "E785", "E039", "G4733", "F329", "Z86718" ]	[ "I350: Nonrheumatic aortic (valve) stenosis", "I69954: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side", "D689: Coagulation defect, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "D62: Acute posthemorrhagic anemia", "D696: Thrombocytopenia, unspecified", "I2584: Coronary atherosclerosis due to calcified coronary lesion", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z923: Personal history of irradiation", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F329: Major depressive disorder, single episode, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "M353: Polymyalgia rheumatica", "Z86711: Personal history of pulmonary embolism", "Z86718: Personal history of other venous thrombosis and embolism", "G629: Polyneuropathy, unspecified", "H3530: Unspecified macular degeneration" ]
10,047,824	20,377,673	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 don't know why I came to the hospital" Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old male with history of schizoaffective disorder, cannabis sue disorder, with prior psychiatric hospitalizations and suicide attempts, who was brought to the ___ ED from ___ due to overingestion of medications. It is unclear what medications the patient took. Suicide note was reportedly found at he scene. Patient was given naloxone x 8 doses at the scene and taken to ___, where he tested positive for fentanyl and maijuana. While there, he was intubated for airway protection and had witnessed tonic-clonic seizure for which he was given lorazepam 2mg IV and was loaded with levetiracetam; he also had CXR and NCHCT (both reportedly negative) and was transferred to ___ for further care. Once here, he was admitted to the ICU, where he was kept on propofol, and levetiracetam IV. Patient self-extubated early this morning and has since been receiving dexmedetomidine for agitation. The psychiatry consultation team was consulted to perform a safety assessment and to assist with medication management around ___ history of primary psychotic disorder and management of agitation while in the hospital. HISTORY OF PRESENT ILLNESS: Mr. ___ had difficulty participating in a full interview due to significant hoarseness (seems to be due to self-extubation while ET tube balloon was still inflated). As such, the interview was limited and focused around his presentation to the hospital. Mr. ___ reported not knowing why he is in the hospital and said that the last thing he remembers is lying on his bed at home and falling asleep on the day of presentation to ___ ___ (___). When asked to provide details of the events leading to that, he described being alone at home with his wife (their 2 children were with ___ father) and having an argument with his wife earlier that day (about people on TV). After that argument, patient and wife made up, then went shopping at the ___ store where they had a subsequent argument (about whether or not they should buy peanut butter) and police was called; they left the store prior to arrival of the police. Patient then described that they "drove around a bit" and then attempted to get a prescription filled at the pharmacy, but that was declined by the pharmacist. Throughout this description of events, the patient was noted to be circumstantial and somewhat difficult to follow, requiring multiple clarifying questions. When asked specifically whether he overdose on medications, he denied. When asked why he was so sedated as to require intubation and ICU admission, he reported being sedated from his medications (which he said he takes as prescribed) and from being "up for 72 hours straight[ ...] because the boys were sick" (referring to his twin boys). Patient reported being adherent with his medications and denied any recent problems with mood, anxiety, or psychosis. He described some intermittent delusional thoughts about his ___ not being his ___ and his family kidnapping him, for which he says he takes PRN haloperidol 5mg, with good effect. He said he last had these delusions about 3 weeks ago. Mr. ___ denied having attempted suicide prior to being brought to the hospital, and denied thoughts of wanting to die or harm himself. He denied ever having attempted suicide (which is inaccurate based on records from ___). Mr. ___ does not feel like he needs to be in the hospital and he does not understand the reason for admission, saying "yo can't keep me here between these 4 walls". He declined to discuss the reasons for his hospitalization with this writer: "I don't want to talk about it". REVIEW OF SYSTEMS: -Patient denies depressed mood, fatigue/loss of energy, anhedonia, thoughts of death/SI, sleep disturbance including insomnia or hypersomnia, loss of appetite/weight changes, poor concentration, psychomotor agitation or retardation. -Patient denies worry, rumination, intrusive thoughts, avoidance, phobias, panic. -Patient denies distractibility, erratic/risky behavior, grandiosity, flight of ideas, increased activity, decreased need for sleep, or talkativeness/pressured speech. -Patient denies auditory or visual hallucinations, or delusions of reference, paranoia, thought insertion/broadcasting/withdrawal. -General: Denies fever, chills, nightsweats, headache, focal numbness, focal weakness, changes in vision, changes in hearing, heat intolerance, cold intolerance, polyuria, polydipsia, SOB, CP, palpitations, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, blood in stools, dysuria, increased urinary frequency, rash, skin changes, joint pain, muscle pain, edema, bruising, bleeding. COLLATERAL: ___ Community Action Programs (___ ___, ___ Attempted to contact ___ ___ provider in order to determine when patietn last received his haldol decanoate dose. Call went to voicemail. Voice message was left twice with detailed callback information. __________________________________ Wife (at bedside, patient agreed to have wife speak to the psychiatry team in private) ___ wife reported that patient was very quiet and was crying frequently on the day of presentation ___ he was also making unusual statements, such as "I want you to be happy" and "I want you to take care of the boys". Wife said that this is not ___ baseline and she was not sure why he was acting this way, and she still does not know why ("he shut me out this time, he is unable to share with me") The afternoon of ___, wife was at home "cooking dinner for the boys" (referring to their twin ___ year-old boys). She described that she saw the patient go to their bedroom to sleep at around 6 ___ (which patient had done in the past). Some time after that, ___ phone started ringing (it was ___ father calling) and patient would not pick up, which made the wife concerned. She attempted to wake the patient up, but was unable to. She initially attributed this to his regular medications, but continued to "check on him" intermittently. Later that evening, she witnessed the patient having "convulsions" for several minutes at a time, at which point she called the ___ father who instructed her to call ___. Wife thinks that patient overdosed on medications, but she is unsure which ones because the patient keeps numerous empty medications bottles together with his regular medication bottles. Wife provided the EMS staff with the names of ___ medications as well as her own medications. Wife also reported finding a suicide note at home, written by the patient, which read as "I leave my baseball cards to the boys [...] good ___ trust anybody". Wife declined to elaborate further on the note ("it was a long personal thing", but confirmed that it was a suicide note. Wife also stated that statements such as "don't trust anybody" are not the ___ baseline. Wife is concerned about the patient and she thinks that he needs psychiatric treatment: "when we need treatment, we get treatment", stating that she also has a psychiatric condition. Wife is aware of one previous suicide attempt by patient during high school via Tylenol overdose. Both patient and wife requested that the medical and psychiatric teams not discuss with wife's mother ___ mother-in-law) about his care. They are concerned that the mother-in-law will use the information with DCF in order to gain custody of their children. Past Medical History: PAST PSYCHIATRIC HISTORY: -Patient is a ___ client -Prior diagnoses: Schizoaffective disorder -Hospitalizations: At ___ in ___ due to agitation, disorganization, in setting of medication non-adherence. Prior hospitalizations at ___ and ___ ___. -Psychiatrist: ___ NP at ___ Human Services ___ -___ ACCS worker (Jesus, ___ -___ for Haldol decanoate injections q2weeks: ___ Community Action Programs (___ Community Action Programs, ___ -Medication trials: Clozapine, Risperidone, Trileptal, Olanzapine, Haldol, Gabapentin, Sertraline, -___ trials: No -Suicide attempts: Denies. Per ___ records: " The patient reported two previous suicidal attempts, one by cutting and one by overdose on medication, all of them in the remote past." Wife reported that patient had SA by Tyleonol overdose in high school -Self-injurious behavior: Reported prior history of cutting, but none in ___ years ago -Harm to others: Deferred -Trauma: Deferred; No history of trauma per ___ records -Access to weapons: Denied explicitly any access to firearms MEDICATIONS [Including vitamins, herbs, supplements, OTC]: Confirmed with ___ Pharmacy: Haloperidol decanoate 100mg IM q2weks last filled on ___ Olanzapine 5mg PO qHS #90 filled ___ Olanzapine 15mg PO qHS #90 filled ___ Olanzapine 20mg PO qHS #90 filled ___ Sertraline 50mg PO qAM #90 filled on ___ Gabapentin 900mg PO TID filled ___ Ventolin 90mcg 2PUFFS q6h PRN for wheeze Advair 115/21mcg 2PUFF qAM + 2 PUFF qHS . Last PMP Review: ___ Gabapentin 300mg #270 for 30-day supply ___ Gabapentin 300mg #270 for 30-day supply ___ Gabapentin 300mg #270 for 30-day supply . PAST MEDICAL HISTORY: Denies -Denies history of head trauma, seizure. *PCP: Dr. ___ Social History: SUBSTANCE USE HISTORY: -Tobacco: 1 ppd -Alcohol: Denies; Denies history of alcohol withdrawal, DTs, seizures. -Marijuana: Reports smoking one blunt or 1 bowl ___ week (reported that he recently changed the source from which he obtains his marijuana); -Other Drugs: Denies . FORENSIC HISTORY: -Arrests, Convictions and Jail terms: Plead guilty to OUI x2 and "1 domestic;" did not spend any time incarcerated -Current status (pending charges, probation, parole): No open cases . SOCIAL HISTORY: ___ Family History: FAMILY PSYCHIATRIC HISTORY: "Not as far as I know, they don't tell me." Physical Exam: EXAM: ___ 1202 Temp: 98.2 PO BP: 132/81 HR: 95 RR: 20 O2 sat: 95% O2 delivery: Ra Physical Exam: GEN: no acute distress HEENT: Normocephalic, atraumatic. Moist mucous membranes. Anicteric sclera. CV: Regular rate, normal S1, S2. No murmurs/rubs/gallops. 2+ radial pulses. mild diaphoresis. RESP: Non-labored. Clear to auscultation bilaterally. No wheezes/rales/rhonchi. ABD: Soft, non-tender, non-distended. Truncal obesity. Positive bowel sounds. EXT: Warm and well perfused. No gross deformity. No peripheral edema. SKIN: No rashes or lesions noted. Neurological Exam: - Cranial nerves: II: PERRLA 4mm to 2mm, brisk bilaterally ___, IV, VI: extraocular movements intact. no nystagmus. V: facial sensation to touch equal in all 3 divisions bilaterally VII: face symmetric on eye closure and smile VIII: hearing normal bilaterally to rubbing fingers IX, X: palate elevates symmetrically XI: head turning and shoulder shrug intact XII: tongue midline. - Reflexes: 2+ and symmetrical biceps, brachioradialis, patellar - Motor: ___ biceps, triceps, iliopsoas, quadriceps, hamstrings. Normal bulk. - Sensation: intact and symmetric to light touch. - Gait and station: Good initiation. Narrow-based gait, normal stride and arm-swing. No ataxia noted. Normal coordination of finger to nose and heel to shin testing. Mild loss of balance while standing on one foot. No fall. - Abnormal movements: No tremor or abnormal movements appreciated. Cognition: - Wakefulness/alertness: Awake and alert - Attention: MOYB with 0 errors - Orientation: Oriented to person, time, place, situation - Memory: ___ registration, ___ recall (despite multiple choice), long-term grossly intact - Fund of knowledge: appropriate for education - Calculations: $2.25 = 9 quarters - Abstraction: train/bike = "move on wheels," watch/ruler = "numbers"; "never judge a book by its cover" = "you shouldn't take what's at surface level, sometimes you have to dig deeper" - Speech: fluent, spontaneous, clear. normal volume, rate, tone, and prosody. - Language: fluent ___ Mental Status: - Appearance: man appearing stated age, wearing hospital gown, in no apparent distress - Behavior: Sitting upright, appropriate eye contact. No psychomotor agitation or retardation - Attitude: Cooperative, engaged, forthcoming. - Mood: "I'm doing okay" - Affect: Mood-congruent, full range, appropriate to situation - Thought process: Linear, coherent, goal-oriented, no loose associations - Thought Content: asks appropriate questions about hospitalization and discharge. Safety: Denies SI/HI. Delusions: No evidence of paranoia, etc. Obsessions/Compulsions: No evidence based on current encounter Hallucinations: Denies AVH, not appearing to be attending to internal stimuli Insight / Judgment: fair / fair Pertinent Results: ___ 06:07AM BLOOD WBC-5.0 RBC-4.44 Hgb-13.8 Hct-41.1 MCV-93 MCH-31.1 MCHC-33.6 RDW-12.1 RDWSD-41.1 Plt ___ ___ 06:07AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-146 K-4.4 Cl-111* HCO3-23 AnGap-12 ___ 07:48AM BLOOD ALT-112* AST-53* LD(LDH)-278* AlkPhos-82 TotBili-0.4 ___ 07:09AM BLOOD ALT-94* AST-67* LD(___)-274* CK(CPK)-101 AlkPhos-77 TotBili-0.3 ___ 06:07AM BLOOD CK(CPK)-268 ___ 07:09AM BLOOD Albumin-4.5 Cholest-170 ___ 06:07AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1 ___ 07:09AM BLOOD VitB12-1206* Folate-10 ___ 07:09AM BLOOD %HbA1c-5.4 eAG-108 ___ 07:09AM BLOOD Triglyc-178* HDL-25* CHOL/HD-6.8 LDLcalc-109 ___ 07:09AM BLOOD TSH-2.4 ___ 07:09AM BLOOD Trep Ab-NEG Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. He was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. Patient deemed appropriate for monitored access to sharps. . 2. PSYCHIATRIC: On admission interview, patient continued to deny suicide attempt or intentional ingestion. He endorsed regular medication adherence and states that he is help-seeking when necessary, follows up with outpatient providers, and has not been hospitalized in several years. Despite this, it was concerning that his wife felt the patient was making unusual statements about her taking care of their children, found suicidal statements in his journal (including intended inheritance of personal belongings), and then was unable to rouse the patient from sleeping in the early evening necessitating EMS evaluation. When patient was initially seen by medical teams, he denied much of his past psychiatric and forensic history, though appeared to be more forthcoming during interview upon admission to inpatient psychiatric unit. . On exam, patient did not appear dysphoric or psychotic, but his story of taking his diet supplement at night instead of in the morning does not appear to match the severity of his medical admission, during which he had a witnessed generalized tonic-clonic seizure, aspirated with sequelae of aspiration pneumonia, had metabolic abnormalities including elevated CK, and required intubation and MICU admission. There was significant concern that the patient may have been minimizing his ingestion, and thus required further investigation and collateral information. Patient appeared well-compensated in his underlying schizoaffective disorder; he provided long-standing history of psychotic symptoms, including delusions involving imposters of his family members, auditory hallucinations, and rare visual hallucination. Last endorsed paranoia and imposter delusions 3 weeks prior. He did not appear dysphoric or psychotic, and remained linear, goal-directed, and future-oriented in his thought process, albeit concrete. . Interventions included: individual, group, and milieu therapy; psychoeducation on suicidal ideation and crisis resources; treatment of underlying mental illness, coping skills, engaging family supports, and outpatient provider ___. We restarted and maintained the patient on his home regimen, including olanzapine 40 mg PO QHS, sertraline 50mg po qday, and gabapentin 900mg po TID, and haloperidol 5mg po PRN. He received his Haldol decanoate 100mg IM on ___ while on the medicine floor, to be continued q2 weeks, next due ___. Patient denied all medication side effects. . He did not exhibit any dysphoric or psychotic symptoms during this admission, and was noted by OT to be less impatient/pressured during groups over time. . Regarding ___ ingestion, it was difficult to state what definitively occurred. There have been rare case reports of seizure and hepatotoxicity, including fatality, with older formulations of hydroxycut, and it was possible that there could have been a drug interaction with the ___ Zyprexa. The patient has thrown away the rest of his hydroxycut supply. Confounding this picture, patient tended to keep several empty prescription bottles, obscuring an accurate amount of what medications ___ could have ingested. . Toxicology screens were confounded by iatrogenic administration of fentanyl, lorazepam and midazolam for sedation during intubation. Reviewed OSH records from ___. On ___, patient received fentanyl at ___, lorazepam at ___ and midazolam on ___ at 0027. Serum toxicology drawn at ___, and resulted positive for fentanyl and cannabis, negative for benzodiazepines. Patiently subsequently tested positive for benzodiazepines upon transfer to ___. . Given some concerns by father that patient may be misusing his medications, could consider tapering down medications with abuse potential, ie. gabapentin. Notably, patient did not appear to seek additional doses of any medications or anxiolytics while on our service. On discharge, patient exhibited mood congruent euthymic affect with linear thought process and thought content absent for delusional beliefs. Patient did not appear to be internally preoccupied, nor did he report any perceptual disturbances. Patient continued to deny any suicidal ideation or thoughts/urges to engage in self-harm or harm of others. Voiced future oriented thought content and plan to remain engaged in outpatient treatment. . 3. SUBSTANCE USE DISORDERS: # Cannabis use Patient states he is smoking ___ bowls/blunts per week. Motivated to stop smoking due to effects on lung and inability to keep up with young children. Provided psychoeducation around cannabis use, including deleterious effects on depression, psychosis, cognition and respiratory health. Patient expressed understanding and had not realized some of the effects of cannabis previously, and was very concerned that he had tested positive for fentanyl, possibly attributing this to a new dealer (now presumed due to sedation from intubation). Referred to outpatient psychiatrist for continued discussion. . # Tobacco use disorder Patient endorsed 1 pack-day with roughly 20-pack year history. Discussed smoking cessation, and patient states he is motivated, has nicotine patches at home and is currently tapering patches. Initiated at nicotine 21mg TD patch daily, and titrated to 14mg at ___ request. Referred to PCP for further smoking cessation counseling. . 4. MEDICAL # Transaminitis: Patient noted to have normal LFTs on admission to medicine floor with down-trended CK. Upon admission to psychiatry, noted to have new low-grade hepatocellular pattern of LFT elevation, attributed to either drug interaction in ingestion or to drug-induced liver injury (perhaps to sedative or anesthetic) while hospitalized. Asymptomatic, history of HCV s/p treatment, no acute risk factors for hepatitis, negative ethanol on admission toxicology screen. Lab work remained stable/slightly down-trending. Referred to PCP for repeat LFTs after discharge. . # Aspiration pneumonia ___ aspiration in overdose: Diagnosed on medicine floor with fever, patchy bibasilar opacities on CXR, and sputum culture with H. influenzae. s/p IV ceftriaxone, transitioned to cefpodoxime Proxetil 400 mg PO Q12H for 5 day course. Stable on room air upon admission to Deac 4. Completed final day of cefpodoxime course (ended ___. . # Dysuria: Complained of burning with urination while on medicine floor, thought ___ irritation from catheter. UA with few bacteria and urine culture with <10K colony count. No further complaints while on psychiatry unit; no intervention provided. . # Asthma Substituted fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID for home Advair. Substituted ipratropium-Albuterol Neb 1 NEB Q6H:PRN wheeze for home Ventolin inhaler. Rarely required rescue inhaler for wheezing. . 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient intermittently attended groups, including coping skills and meditation. Generally pleasant and interactive in the milieu, often seen making personal phone calls to wife. #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT Primary team obtained direct collateral information from - Psychiatrist: ___, psychiatric NP, ___ - Psychiatry MHA: ___, ___ - ___ worker: ___, ___ - Wife: ___, ___ - Father: ___ ___ During these conversations, his wife stated that she now feels she misinterpreted the situation, and was seeking an explanation for why patient was convulsing. She described the preceding day as "normal" apart from a period of tearfulness and denied any arguments or police involvement, as well as active substance use. She denied ongoing safety concerns and is eager for his discharge, stating that the children miss him. His father stated that patient has been doing well for the past several years, and does not have any active concerns for his patient complained of depression around financial worries, without suicidal ideation; which ___ affirmed was consistent with his last clinic visit in late ___. There were concerns that patient and his wife could be motivated to conceal a suicide attempt to avoid ___ involvement; ___ was already involved during his medical admission. His father did not have any concerns about their parenting and believes he and his wife are a good team. . #) INTERVENTIONS - Medications: No changes to stable outpatient regimen. Haldol decanoate 100mg IM administered on ___ plan for continued q2week administration via ___. - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: He was offered a partial hospitalization, but declined due to long commute to nearest available option in ___. ___ is also open to considering a therapy referral. He will also have in-home daily ___ visits for 2 weeks post-discharge to review home safety and medication management. Social work on medicine and inpatient psychiatry floors discussed case with DCF. - Behavioral Interventions (e.g. encouraged DBT skills, ect): encouraged tobacco and cannabis cessation. . RISK ASSESSMENT: STATIC RISK FACTORS Static factors at time of admission and discharge include: history of suicide attempts, chronic mental illness, history of violence, male gender, Caucasian ethnicity, and unemployment. Patient plans to seek employment while maintaining SSDI. . MODIFIABLE RISK FACTORS Dynamic factors addressed during this hospitalization included: disorganized and unpredictable behavior, active cannabis use, and limited coping skills. Patient attended groups regularly to learn coping skills and meditation skills. We provided psychoeducation around cannabis use and patient agrees to cut back use. As far as his unpredictable behavior, patient maintains that this was not an impulsive attempt, and has an established safety planning including speaking with his wife, ___ worker, and psychiatric NP. If he is unable to reach any of these contacts, he goes to the hospital to seek further care. . PROTECTIVE RISK FACTORS Factors that may decrease this ___ harm risk include: children in the home, strong sense of responsibility to family, married relationship status, help-seeking behavior, life satisfaction, future-oriented viewpoint, strong social supports including ___ worker, ___, and wraparound supports, consistent outpatient ___, positive therapeutic relationship with outpatient providers, medication compliance, no access to lethal weapons, intact reality-testing ability, and cooperation with treatment team recommendations. . While patient will remain at a chronically elevated risk of self-harm given the above risk factors, he has strong social supports, and several close family members and outpatient providers who feel he has been doing well for the past couple of years, are comfortable with his discharge, and are not actively concerned for his safety. Given isolated case reports of hydroxycut toxicity, no acute stressor (chronic financial stressors), confounded toxicology screen, and continuous denial of suicide attempt, am inclined to rule ingestion as unintentional drug interaction. Finally, patient demonstrated preserved capacity to engage in a meaningful conversation about safety planning and what he would do in the event of worsening psychiatric symptoms or onset of suicidal ideation (e.g. contact providers, tell family members, call ___, or go to the emergency room). Overall, at time of discharge, patient did not require ongoing inpatient admission due to decompensated psychiatric symptoms; patient was no longer at acutely elevated risk of self-harm or harm to others. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Nicotine Patch 14 mg/day TD DAILY 3. OLANZapine 40 mg PO QHS 4. Haloperidol 5 mg PO TID:PRN agitation 5. Cefpodoxime Proxetil 400 mg PO Q12H 6. Haloperidol Decanoate (long acting) 100 mg IM EVERY 2 WEEKS (FR) psychotic symptoms 7. Advair HFA (fluticasone propion-salmeterol) 115-21 mcg/actuation inhalation BID 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 9. Sertraline 50 mg PO DAILY 10. Gabapentin 900 mg PO TID Discharge Medications: 1. Nicotine Patch 14 mg/day TD DAILY 2. Advair HFA (fluticasone propion-salmeterol) 115-21 mcg/actuation inhalation BID 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 4. Gabapentin 900 mg PO TID 5. Haloperidol Decanoate (long acting) 100 mg IM EVERY 2 WEEKS (FR) psychotic symptoms (last administered on ___ 6. Haloperidol 5 mg PO TID:PRN agitation 7. OLANZapine 40 mg PO QHS 8. Sertraline 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Schizoaffective Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. VS: ___ 0715 T 97.4, BP 129 / 84, HR 104, RR 17 96% O2 Sat on RA MENTAL STATUS: Appearance: no acute distress; well-developed, appears stated age, wearing casual clothing. Behavior: cooperative, forthcoming, pleasant. appropriate eye contact Mood and Affect: 'good' / mood-congruent, euthymic, reactive Thought process / associations: linear, goal-direct, coherent. concrete. No looseness of associations. Thought Content: no SI/HI. no AVH. not responding to internal stimuli. no delusions elicited. Judgment and Insight: fair / fair COGNITION: Wakefulness/alertness: Alert, oriented Attention: grossly intact Memory: long-term grossly intact Speech: fluent, spontaneous, clear. normal volume, rate, tone prosody. *Language: fluent ___, regional accent Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: ___	[ "F259", "F1290", "F17210", "J45909" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I don't know why I came to the hospital" Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with history of schizoaffective disorder, cannabis sue disorder, with prior psychiatric hospitalizations and suicide attempts, who was brought to the [MASKED] ED from [MASKED] due to overingestion of medications. It is unclear what medications the patient took. Suicide note was reportedly found at he scene. Patient was given naloxone x 8 doses at the scene and taken to [MASKED], where he tested positive for fentanyl and maijuana. While there, he was intubated for airway protection and had witnessed tonic-clonic seizure for which he was given lorazepam 2mg IV and was loaded with levetiracetam; he also had CXR and NCHCT (both reportedly negative) and was transferred to [MASKED] for further care. Once here, he was admitted to the ICU, where he was kept on propofol, and levetiracetam IV. Patient self-extubated early this morning and has since been receiving dexmedetomidine for agitation. The psychiatry consultation team was consulted to perform a safety assessment and to assist with medication management around [MASKED] history of primary psychotic disorder and management of agitation while in the hospital. HISTORY OF PRESENT ILLNESS: Mr. [MASKED] had difficulty participating in a full interview due to significant hoarseness (seems to be due to self-extubation while ET tube balloon was still inflated). As such, the interview was limited and focused around his presentation to the hospital. Mr. [MASKED] reported not knowing why he is in the hospital and said that the last thing he remembers is lying on his bed at home and falling asleep on the day of presentation to [MASKED] [MASKED] ([MASKED]). When asked to provide details of the events leading to that, he described being alone at home with his wife (their 2 children were with [MASKED] father) and having an argument with his wife earlier that day (about people on TV). After that argument, patient and wife made up, then went shopping at the [MASKED] store where they had a subsequent argument (about whether or not they should buy peanut butter) and police was called; they left the store prior to arrival of the police. Patient then described that they "drove around a bit" and then attempted to get a prescription filled at the pharmacy, but that was declined by the pharmacist. Throughout this description of events, the patient was noted to be circumstantial and somewhat difficult to follow, requiring multiple clarifying questions. When asked specifically whether he overdose on medications, he denied. When asked why he was so sedated as to require intubation and ICU admission, he reported being sedated from his medications (which he said he takes as prescribed) and from being "up for 72 hours straight[ ...] because the boys were sick" (referring to his twin boys). Patient reported being adherent with his medications and denied any recent problems with mood, anxiety, or psychosis. He described some intermittent delusional thoughts about his [MASKED] not being his [MASKED] and his family kidnapping him, for which he says he takes PRN haloperidol 5mg, with good effect. He said he last had these delusions about 3 weeks ago. Mr. [MASKED] denied having attempted suicide prior to being brought to the hospital, and denied thoughts of wanting to die or harm himself. He denied ever having attempted suicide (which is inaccurate based on records from [MASKED]). Mr. [MASKED] does not feel like he needs to be in the hospital and he does not understand the reason for admission, saying "yo can't keep me here between these 4 walls". He declined to discuss the reasons for his hospitalization with this writer: "I don't want to talk about it". REVIEW OF SYSTEMS: -Patient denies depressed mood, fatigue/loss of energy, anhedonia, thoughts of death/SI, sleep disturbance including insomnia or hypersomnia, loss of appetite/weight changes, poor concentration, psychomotor agitation or retardation. -Patient denies worry, rumination, intrusive thoughts, avoidance, phobias, panic. -Patient denies distractibility, erratic/risky behavior, grandiosity, flight of ideas, increased activity, decreased need for sleep, or talkativeness/pressured speech. -Patient denies auditory or visual hallucinations, or delusions of reference, paranoia, thought insertion/broadcasting/withdrawal. -General: Denies fever, chills, nightsweats, headache, focal numbness, focal weakness, changes in vision, changes in hearing, heat intolerance, cold intolerance, polyuria, polydipsia, SOB, CP, palpitations, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, blood in stools, dysuria, increased urinary frequency, rash, skin changes, joint pain, muscle pain, edema, bruising, bleeding. COLLATERAL: [MASKED] Community Action Programs ([MASKED] [MASKED], [MASKED] Attempted to contact [MASKED] [MASKED] provider in order to determine when patietn last received his haldol decanoate dose. Call went to voicemail. Voice message was left twice with detailed callback information. [MASKED] Wife (at bedside, patient agreed to have wife speak to the psychiatry team in private) [MASKED] wife reported that patient was very quiet and was crying frequently on the day of presentation [MASKED] he was also making unusual statements, such as "I want you to be happy" and "I want you to take care of the boys". Wife said that this is not [MASKED] baseline and she was not sure why he was acting this way, and she still does not know why ("he shut me out this time, he is unable to share with me") The afternoon of [MASKED], wife was at home "cooking dinner for the boys" (referring to their twin [MASKED] year-old boys). She described that she saw the patient go to their bedroom to sleep at around 6 [MASKED] (which patient had done in the past). Some time after that, [MASKED] phone started ringing (it was [MASKED] father calling) and patient would not pick up, which made the wife concerned. She attempted to wake the patient up, but was unable to. She initially attributed this to his regular medications, but continued to "check on him" intermittently. Later that evening, she witnessed the patient having "convulsions" for several minutes at a time, at which point she called the [MASKED] father who instructed her to call [MASKED]. Wife thinks that patient overdosed on medications, but she is unsure which ones because the patient keeps numerous empty medications bottles together with his regular medication bottles. Wife provided the EMS staff with the names of [MASKED] medications as well as her own medications. Wife also reported finding a suicide note at home, written by the patient, which read as "I leave my baseball cards to the boys [...] good [MASKED] trust anybody". Wife declined to elaborate further on the note ("it was a long personal thing", but confirmed that it was a suicide note. Wife also stated that statements such as "don't trust anybody" are not the [MASKED] baseline. Wife is concerned about the patient and she thinks that he needs psychiatric treatment: "when we need treatment, we get treatment", stating that she also has a psychiatric condition. Wife is aware of one previous suicide attempt by patient during high school via Tylenol overdose. Both patient and wife requested that the medical and psychiatric teams not discuss with wife's mother [MASKED] mother-in-law) about his care. They are concerned that the mother-in-law will use the information with DCF in order to gain custody of their children. Past Medical History: PAST PSYCHIATRIC HISTORY: -Patient is a [MASKED] client -Prior diagnoses: Schizoaffective disorder -Hospitalizations: At [MASKED] in [MASKED] due to agitation, disorganization, in setting of medication non-adherence. Prior hospitalizations at [MASKED] and [MASKED] [MASKED]. -Psychiatrist: [MASKED] NP at [MASKED] Human Services [MASKED] -[MASKED] ACCS worker (Jesus, [MASKED] -[MASKED] for Haldol decanoate injections q2weeks: [MASKED] Community Action Programs ([MASKED] Community Action Programs, [MASKED] -Medication trials: Clozapine, Risperidone, Trileptal, Olanzapine, Haldol, Gabapentin, Sertraline, -[MASKED] trials: No -Suicide attempts: Denies. Per [MASKED] records: " The patient reported two previous suicidal attempts, one by cutting and one by overdose on medication, all of them in the remote past." Wife reported that patient had SA by Tyleonol overdose in high school -Self-injurious behavior: Reported prior history of cutting, but none in [MASKED] years ago -Harm to others: Deferred -Trauma: Deferred; No history of trauma per [MASKED] records -Access to weapons: Denied explicitly any access to firearms MEDICATIONS [Including vitamins, herbs, supplements, OTC]: Confirmed with [MASKED] Pharmacy: Haloperidol decanoate 100mg IM q2weks last filled on [MASKED] Olanzapine 5mg PO qHS #90 filled [MASKED] Olanzapine 15mg PO qHS #90 filled [MASKED] Olanzapine 20mg PO qHS #90 filled [MASKED] Sertraline 50mg PO qAM #90 filled on [MASKED] Gabapentin 900mg PO TID filled [MASKED] Ventolin 90mcg 2PUFFS q6h PRN for wheeze Advair 115/21mcg 2PUFF qAM + 2 PUFF qHS . Last PMP Review: [MASKED] Gabapentin 300mg #270 for 30-day supply [MASKED] Gabapentin 300mg #270 for 30-day supply [MASKED] Gabapentin 300mg #270 for 30-day supply . PAST MEDICAL HISTORY: Denies -Denies history of head trauma, seizure. *PCP: Dr. [MASKED] Social History: SUBSTANCE USE HISTORY: -Tobacco: 1 ppd -Alcohol: Denies; Denies history of alcohol withdrawal, DTs, seizures. -Marijuana: Reports smoking one blunt or 1 bowl [MASKED] week (reported that he recently changed the source from which he obtains his marijuana); -Other Drugs: Denies . FORENSIC HISTORY: -Arrests, Convictions and Jail terms: Plead guilty to OUI x2 and "1 domestic;" did not spend any time incarcerated -Current status (pending charges, probation, parole): No open cases . SOCIAL HISTORY: [MASKED] Family History: FAMILY PSYCHIATRIC HISTORY: "Not as far as I know, they don't tell me." Physical Exam: EXAM: [MASKED] 1202 Temp: 98.2 PO BP: 132/81 HR: 95 RR: 20 O2 sat: 95% O2 delivery: Ra Physical Exam: GEN: no acute distress HEENT: Normocephalic, atraumatic. Moist mucous membranes. Anicteric sclera. CV: Regular rate, normal S1, S2. No murmurs/rubs/gallops. 2+ radial pulses. mild diaphoresis. RESP: Non-labored. Clear to auscultation bilaterally. No wheezes/rales/rhonchi. ABD: Soft, non-tender, non-distended. Truncal obesity. Positive bowel sounds. EXT: Warm and well perfused. No gross deformity. No peripheral edema. SKIN: No rashes or lesions noted. Neurological Exam: - Cranial nerves: II: PERRLA 4mm to 2mm, brisk bilaterally [MASKED], IV, VI: extraocular movements intact. no nystagmus. V: facial sensation to touch equal in all 3 divisions bilaterally VII: face symmetric on eye closure and smile VIII: hearing normal bilaterally to rubbing fingers IX, X: palate elevates symmetrically XI: head turning and shoulder shrug intact XII: tongue midline. - Reflexes: 2+ and symmetrical biceps, brachioradialis, patellar - Motor: [MASKED] biceps, triceps, iliopsoas, quadriceps, hamstrings. Normal bulk. - Sensation: intact and symmetric to light touch. - Gait and station: Good initiation. Narrow-based gait, normal stride and arm-swing. No ataxia noted. Normal coordination of finger to nose and heel to shin testing. Mild loss of balance while standing on one foot. No fall. - Abnormal movements: No tremor or abnormal movements appreciated. Cognition: - Wakefulness/alertness: Awake and alert - Attention: MOYB with 0 errors - Orientation: Oriented to person, time, place, situation - Memory: [MASKED] registration, [MASKED] recall (despite multiple choice), long-term grossly intact - Fund of knowledge: appropriate for education - Calculations: $2.25 = 9 quarters - Abstraction: train/bike = "move on wheels," watch/ruler = "numbers"; "never judge a book by its cover" = "you shouldn't take what's at surface level, sometimes you have to dig deeper" - Speech: fluent, spontaneous, clear. normal volume, rate, tone, and prosody. - Language: fluent [MASKED] Mental Status: - Appearance: man appearing stated age, wearing hospital gown, in no apparent distress - Behavior: Sitting upright, appropriate eye contact. No psychomotor agitation or retardation - Attitude: Cooperative, engaged, forthcoming. - Mood: "I'm doing okay" - Affect: Mood-congruent, full range, appropriate to situation - Thought process: Linear, coherent, goal-oriented, no loose associations - Thought Content: asks appropriate questions about hospitalization and discharge. Safety: Denies SI/HI. Delusions: No evidence of paranoia, etc. Obsessions/Compulsions: No evidence based on current encounter Hallucinations: Denies AVH, not appearing to be attending to internal stimuli Insight / Judgment: fair / fair Pertinent Results: [MASKED] 06:07AM BLOOD WBC-5.0 RBC-4.44 Hgb-13.8 Hct-41.1 MCV-93 MCH-31.1 MCHC-33.6 RDW-12.1 RDWSD-41.1 Plt [MASKED] [MASKED] 06:07AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-146 K-4.4 Cl-111* HCO3-23 AnGap-12 [MASKED] 07:48AM BLOOD ALT-112* AST-53* LD(LDH)-278* AlkPhos-82 TotBili-0.4 [MASKED] 07:09AM BLOOD ALT-94* AST-67* LD([MASKED])-274* CK(CPK)-101 AlkPhos-77 TotBili-0.3 [MASKED] 06:07AM BLOOD CK(CPK)-268 [MASKED] 07:09AM BLOOD Albumin-4.5 Cholest-170 [MASKED] 06:07AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1 [MASKED] 07:09AM BLOOD VitB12-1206* Folate-10 [MASKED] 07:09AM BLOOD %HbA1c-5.4 eAG-108 [MASKED] 07:09AM BLOOD Triglyc-178* HDL-25* CHOL/HD-6.8 LDLcalc-109 [MASKED] 07:09AM BLOOD TSH-2.4 [MASKED] 07:09AM BLOOD Trep Ab-NEG Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. He was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. Patient deemed appropriate for monitored access to sharps. . 2. PSYCHIATRIC: On admission interview, patient continued to deny suicide attempt or intentional ingestion. He endorsed regular medication adherence and states that he is help-seeking when necessary, follows up with outpatient providers, and has not been hospitalized in several years. Despite this, it was concerning that his wife felt the patient was making unusual statements about her taking care of their children, found suicidal statements in his journal (including intended inheritance of personal belongings), and then was unable to rouse the patient from sleeping in the early evening necessitating EMS evaluation. When patient was initially seen by medical teams, he denied much of his past psychiatric and forensic history, though appeared to be more forthcoming during interview upon admission to inpatient psychiatric unit. . On exam, patient did not appear dysphoric or psychotic, but his story of taking his diet supplement at night instead of in the morning does not appear to match the severity of his medical admission, during which he had a witnessed generalized tonic-clonic seizure, aspirated with sequelae of aspiration pneumonia, had metabolic abnormalities including elevated CK, and required intubation and MICU admission. There was significant concern that the patient may have been minimizing his ingestion, and thus required further investigation and collateral information. Patient appeared well-compensated in his underlying schizoaffective disorder; he provided long-standing history of psychotic symptoms, including delusions involving imposters of his family members, auditory hallucinations, and rare visual hallucination. Last endorsed paranoia and imposter delusions 3 weeks prior. He did not appear dysphoric or psychotic, and remained linear, goal-directed, and future-oriented in his thought process, albeit concrete. . Interventions included: individual, group, and milieu therapy; psychoeducation on suicidal ideation and crisis resources; treatment of underlying mental illness, coping skills, engaging family supports, and outpatient provider [MASKED]. We restarted and maintained the patient on his home regimen, including olanzapine 40 mg PO QHS, sertraline 50mg po qday, and gabapentin 900mg po TID, and haloperidol 5mg po PRN. He received his Haldol decanoate 100mg IM on [MASKED] while on the medicine floor, to be continued q2 weeks, next due [MASKED]. Patient denied all medication side effects. . He did not exhibit any dysphoric or psychotic symptoms during this admission, and was noted by OT to be less impatient/pressured during groups over time. . Regarding [MASKED] ingestion, it was difficult to state what definitively occurred. There have been rare case reports of seizure and hepatotoxicity, including fatality, with older formulations of hydroxycut, and it was possible that there could have been a drug interaction with the [MASKED] Zyprexa. The patient has thrown away the rest of his hydroxycut supply. Confounding this picture, patient tended to keep several empty prescription bottles, obscuring an accurate amount of what medications [MASKED] could have ingested. . Toxicology screens were confounded by iatrogenic administration of fentanyl, lorazepam and midazolam for sedation during intubation. Reviewed OSH records from [MASKED]. On [MASKED], patient received fentanyl at [MASKED], lorazepam at [MASKED] and midazolam on [MASKED] at 0027. Serum toxicology drawn at [MASKED], and resulted positive for fentanyl and cannabis, negative for benzodiazepines. Patiently subsequently tested positive for benzodiazepines upon transfer to [MASKED]. . Given some concerns by father that patient may be misusing his medications, could consider tapering down medications with abuse potential, ie. gabapentin. Notably, patient did not appear to seek additional doses of any medications or anxiolytics while on our service. On discharge, patient exhibited mood congruent euthymic affect with linear thought process and thought content absent for delusional beliefs. Patient did not appear to be internally preoccupied, nor did he report any perceptual disturbances. Patient continued to deny any suicidal ideation or thoughts/urges to engage in self-harm or harm of others. Voiced future oriented thought content and plan to remain engaged in outpatient treatment. . 3. SUBSTANCE USE DISORDERS: # Cannabis use Patient states he is smoking [MASKED] bowls/blunts per week. Motivated to stop smoking due to effects on lung and inability to keep up with young children. Provided psychoeducation around cannabis use, including deleterious effects on depression, psychosis, cognition and respiratory health. Patient expressed understanding and had not realized some of the effects of cannabis previously, and was very concerned that he had tested positive for fentanyl, possibly attributing this to a new dealer (now presumed due to sedation from intubation). Referred to outpatient psychiatrist for continued discussion. . # Tobacco use disorder Patient endorsed 1 pack-day with roughly 20-pack year history. Discussed smoking cessation, and patient states he is motivated, has nicotine patches at home and is currently tapering patches. Initiated at nicotine 21mg TD patch daily, and titrated to 14mg at [MASKED] request. Referred to PCP for further smoking cessation counseling. . 4. MEDICAL # Transaminitis: Patient noted to have normal LFTs on admission to medicine floor with down-trended CK. Upon admission to psychiatry, noted to have new low-grade hepatocellular pattern of LFT elevation, attributed to either drug interaction in ingestion or to drug-induced liver injury (perhaps to sedative or anesthetic) while hospitalized. Asymptomatic, history of HCV s/p treatment, no acute risk factors for hepatitis, negative ethanol on admission toxicology screen. Lab work remained stable/slightly down-trending. Referred to PCP for repeat LFTs after discharge. . # Aspiration pneumonia [MASKED] aspiration in overdose: Diagnosed on medicine floor with fever, patchy bibasilar opacities on CXR, and sputum culture with H. influenzae. s/p IV ceftriaxone, transitioned to cefpodoxime Proxetil 400 mg PO Q12H for 5 day course. Stable on room air upon admission to Deac 4. Completed final day of cefpodoxime course (ended [MASKED]. . # Dysuria: Complained of burning with urination while on medicine floor, thought [MASKED] irritation from catheter. UA with few bacteria and urine culture with <10K colony count. No further complaints while on psychiatry unit; no intervention provided. . # Asthma Substituted fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID for home Advair. Substituted ipratropium-Albuterol Neb 1 NEB Q6H:PRN wheeze for home Ventolin inhaler. Rarely required rescue inhaler for wheezing. . 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient intermittently attended groups, including coping skills and meditation. Generally pleasant and interactive in the milieu, often seen making personal phone calls to wife. #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT Primary team obtained direct collateral information from - Psychiatrist: [MASKED], psychiatric NP, [MASKED] - Psychiatry MHA: [MASKED], [MASKED] - [MASKED] worker: [MASKED], [MASKED] - Wife: [MASKED], [MASKED] - Father: [MASKED] [MASKED] During these conversations, his wife stated that she now feels she misinterpreted the situation, and was seeking an explanation for why patient was convulsing. She described the preceding day as "normal" apart from a period of tearfulness and denied any arguments or police involvement, as well as active substance use. She denied ongoing safety concerns and is eager for his discharge, stating that the children miss him. His father stated that patient has been doing well for the past several years, and does not have any active concerns for his patient complained of depression around financial worries, without suicidal ideation; which [MASKED] affirmed was consistent with his last clinic visit in late [MASKED]. There were concerns that patient and his wife could be motivated to conceal a suicide attempt to avoid [MASKED] involvement; [MASKED] was already involved during his medical admission. His father did not have any concerns about their parenting and believes he and his wife are a good team. . #) INTERVENTIONS - Medications: No changes to stable outpatient regimen. Haldol decanoate 100mg IM administered on [MASKED] plan for continued q2week administration via [MASKED]. - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: He was offered a partial hospitalization, but declined due to long commute to nearest available option in [MASKED]. [MASKED] is also open to considering a therapy referral. He will also have in-home daily [MASKED] visits for 2 weeks post-discharge to review home safety and medication management. Social work on medicine and inpatient psychiatry floors discussed case with DCF. - Behavioral Interventions (e.g. encouraged DBT skills, ect): encouraged tobacco and cannabis cessation. . RISK ASSESSMENT: STATIC RISK FACTORS Static factors at time of admission and discharge include: history of suicide attempts, chronic mental illness, history of violence, male gender, Caucasian ethnicity, and unemployment. Patient plans to seek employment while maintaining SSDI. . MODIFIABLE RISK FACTORS Dynamic factors addressed during this hospitalization included: disorganized and unpredictable behavior, active cannabis use, and limited coping skills. Patient attended groups regularly to learn coping skills and meditation skills. We provided psychoeducation around cannabis use and patient agrees to cut back use. As far as his unpredictable behavior, patient maintains that this was not an impulsive attempt, and has an established safety planning including speaking with his wife, [MASKED] worker, and psychiatric NP. If he is unable to reach any of these contacts, he goes to the hospital to seek further care. . PROTECTIVE RISK FACTORS Factors that may decrease this [MASKED] harm risk include: children in the home, strong sense of responsibility to family, married relationship status, help-seeking behavior, life satisfaction, future-oriented viewpoint, strong social supports including [MASKED] worker, [MASKED], and wraparound supports, consistent outpatient [MASKED], positive therapeutic relationship with outpatient providers, medication compliance, no access to lethal weapons, intact reality-testing ability, and cooperation with treatment team recommendations. . While patient will remain at a chronically elevated risk of self-harm given the above risk factors, he has strong social supports, and several close family members and outpatient providers who feel he has been doing well for the past couple of years, are comfortable with his discharge, and are not actively concerned for his safety. Given isolated case reports of hydroxycut toxicity, no acute stressor (chronic financial stressors), confounded toxicology screen, and continuous denial of suicide attempt, am inclined to rule ingestion as unintentional drug interaction. Finally, patient demonstrated preserved capacity to engage in a meaningful conversation about safety planning and what he would do in the event of worsening psychiatric symptoms or onset of suicidal ideation (e.g. contact providers, tell family members, call [MASKED], or go to the emergency room). Overall, at time of discharge, patient did not require ongoing inpatient admission due to decompensated psychiatric symptoms; patient was no longer at acutely elevated risk of self-harm or harm to others. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Nicotine Patch 14 mg/day TD DAILY 3. OLANZapine 40 mg PO QHS 4. Haloperidol 5 mg PO TID:PRN agitation 5. Cefpodoxime Proxetil 400 mg PO Q12H 6. Haloperidol Decanoate (long acting) 100 mg IM EVERY 2 WEEKS (FR) psychotic symptoms 7. Advair HFA (fluticasone propion-salmeterol) 115-21 mcg/actuation inhalation BID 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 9. Sertraline 50 mg PO DAILY 10. Gabapentin 900 mg PO TID Discharge Medications: 1. Nicotine Patch 14 mg/day TD DAILY 2. Advair HFA (fluticasone propion-salmeterol) 115-21 mcg/actuation inhalation BID 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 4. Gabapentin 900 mg PO TID 5. Haloperidol Decanoate (long acting) 100 mg IM EVERY 2 WEEKS (FR) psychotic symptoms (last administered on [MASKED] 6. Haloperidol 5 mg PO TID:PRN agitation 7. OLANZapine 40 mg PO QHS 8. Sertraline 50 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Schizoaffective Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. VS: [MASKED] 0715 T 97.4, BP 129 / 84, HR 104, RR 17 96% O2 Sat on RA MENTAL STATUS: Appearance: no acute distress; well-developed, appears stated age, wearing casual clothing. Behavior: cooperative, forthcoming, pleasant. appropriate eye contact Mood and Affect: 'good' / mood-congruent, euthymic, reactive Thought process / associations: linear, goal-direct, coherent. concrete. No looseness of associations. Thought Content: no SI/HI. no AVH. not responding to internal stimuli. no delusions elicited. Judgment and Insight: fair / fair COGNITION: Wakefulness/alertness: Alert, oriented Attention: grossly intact Memory: long-term grossly intact Speech: fluent, spontaneous, clear. normal volume, rate, tone prosody. *Language: fluent [MASKED], regional accent Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED]	[]	[ "F17210", "J45909" ]	[ "F259: Schizoaffective disorder, unspecified", "F1290: Cannabis use, unspecified, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "J45909: Unspecified asthma, uncomplicated" ]
10,047,824	26,390,509	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Overdose ?Suicide attempt Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ with hx schizophrenia, mood disorder, cluster B personality traits who presents to the ___ from ___ ___ with overdose. Unclear when he was last seen well yesterday evening. He reportedly then overdosed on his medications in a suicide attempt, with a suicide note found at scene. EMS documented to be at the field at ___. It was unclear what medications he took, but he had prescriptions for olanzapine, haloperidol, Neurontin, and Cogentin found at scene. Per ___ records - he also had access to his wife's medications including ___, lamictal, ziprasidone, propranolol. He was given 8x Narcan in the field and taken to ___, where he was somnolent with an intact gag reflex. Tox screen positive fentanyl and marijuana screen. While at ___ he was intubated for airway protection. Additionally he had witnessed tonic-clonic seizure activity. He was given 2mg Ativan, was loaded with 1g Keppra, given 2L IVF. A NCHCT and CXR were unremarkable. He was then transferred to ___ for further care. In the ___, Initial Vitals: T98.5, HR 105, BP 128/74, RR 22, 97% while intubated Exam: Intubated and sedated Pupils 3-4mm and reactive, head NC/AT Tachycardic CTA bilaterally Abdomen soft and nontender Skin warm and dry Labs: CBC: 7.3 > 14.7/43.1 < 187 BMP: Na 141, K 4.4, Cl 112, HCO3 20, BUN 15, Cr 1.0 Serum tox: negative Urine tox: + benzos Imaging: CXR - Appropriate positioning of endotracheal tube in the lower trachea. Patchy bibasilar opacities, left greater right, are favored to represent subsegmental atelectasis. However, in the proper clinical setting, pneumonia cannot be excluded. Consults: none - toxicology consult deferred as ___ attending is a toxicologist. Recommending supportive care - likely overdose on mostly sedative medications causing respiratory distress. Interventions: continued on propofol while intubated VS Prior to Transfer: HR 100, BP 125/69, RR 17, 98% intubated On arrival to the ICU - patient remains sedated and intubated. Past Medical History: Schizophrenia with auditory hallucinations Mood disorder Cluster B personality traits Prior SI attempt in high school Social History: ___ Family History: unable to obtain on admission Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T98.3, HR 142, BP 156/82, 15, 99% intubated GEN: intubated and sedated, OG tube in place to wall suction - rust-colored drainage EYES: PERRLA HENNT: NC/AT CV: RRR, no m/r/g RESP: CTAB GI: +BS, soft, NTND MSK: WWP, no ___ edema NEURO: sedated DISCHARGE PHYSICAL EXAM: ======================== VITALS: ___ 0755 Temp: 97.9 PO BP: 143/84 HR: 96 RR: 20 O2 sat: 96% O2 delivery: Ra GENERAL: Alert, NAD, sitting up in bed with sitter in the room. CARDIAC: RRR, no m/r/g LUNGS: CTAB, no wheezes, rhonchi or crackles EXTREMITIES: Warm, well perfused. NEUROLOGIC: AOx3 PSYCH: mood and affect appropriate, Pertinent Results: ADMISSION LABS: =============== ___ 02:00AM BLOOD WBC-7.3 RBC-4.58* Hgb-14.7 Hct-43.1 MCV-94 MCH-32.1* MCHC-34.1 RDW-12.6 RDWSD-43.1 Plt ___ ___ 02:00AM BLOOD Neuts-76.8* Lymphs-11.5* Monos-9.3 Eos-1.5 Baso-0.4 Im ___ AbsNeut-5.62 AbsLymp-0.84* AbsMono-0.68 AbsEos-0.11 AbsBaso-0.03 ___ 02:00AM BLOOD Glucose-85 UreaN-15 Creat-1.0 Na-141 K-4.4 Cl-112* HCO3-20* AnGap-9* ___ 02:00AM BLOOD ALT-<5 AST-<5 CK(CPK)-611* AlkPhos-61 TotBili-0.3 ___ 02:00AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.2 ___ 02:00AM BLOOD Triglyc-844* ___ 02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 05:26AM BLOOD ___ pO2-32* pCO2-46* pH-7.35 calTCO2-26 Base XS--1 ___ 05:26AM BLOOD Lactate-1.2 CXR ___ IMPRESSION: Appropriate positioning of endotracheal tube in the lower trachea. Patchy bibasilar opacities, left greater right, are favored to represent subsegmental atelectasis. However, in the proper clinical setting, pneumonia cannot be excluded. DISCHARGE LABS: =============== ___ 06:07AM BLOOD WBC-5.0 RBC-4.44* Hgb-13.8 Hct-41.1 MCV-93 MCH-31.1 MCHC-33.6 RDW-12.1 RDWSD-41.1 Plt ___ ___ 06:07AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-146 K-4.4 Cl-111* HCO3-23 AnGap-___ PMH schizophrenia, mood disorder, cluster B personality traits who presented to the ___ with possible suicide attempt by overdose of medications. He was intubated for airway protection and transferred to ___ MICU on ___, extubated and completed treatment for aspiration pneumonia. TRANSITIONAL ISSUES [ ] Continue cefpedoxime to complete 5 day course (___) LAST DOSE ___ at 8:00 pm [ ] Follow up with outpatient psychiatrist regarding restarting sertraline and gabatentin ACUTE ISSUES =============== #Aspiration pneumonia Patient was diagnosed with aspiration pneumonia due to fever, CXR with patchy bibasilar opacities and sputum culture growing H. Flu. An aspiration event most likely occurred in the setting of an overdose. He was started on IV Ceftriaxone, but as his clinical status improved, he was transitioned to oral cefpedoxime for a total course of 5 days. #Suicide attempt #Schizophrenia #Mood disorder #Cluster B personality trait Patient insists this was not a suicide attempt. However, collateral from patient's wife and past records from ___ revealed that patient has had prior suicide attempts which he denied, and has had recent changes in affect/behavior witnessed by wife. His wife described this episode as a suicide attempt, supported by the presence of a suicide note (which patient denied). Patient's wife expressed that the patient is not currently at his baseline (displayed isolative behaviors and frequent crying on the day of presentation and made a paranoid statement in his suicide note). Psychiatry evaluated patient during this admission and believe that patient is not psychiatrically cleared for discharge home and will require inpatient psych admission. Patient had a 1:1 sitter during the admission. Patient was continued on IM haloperidol decanoate (received on ___, and olanzapine was increased to 40 mg daily per psychiatry recommendations. #Agitation Agitation was managed with PRN Haldol and olanzapine 20mg QHS and ultimately dubsided. His QT interval was monitored with daily EKGs. Discontinued sertraline while inpatient given c/f QT prolongation. # Elevated CK (resolved) Was likely elevated in the setting of taking hydroxycut. Downtrended to normal limits at the time of discharge. #Tonic-clonic seizure (resolved) Witnessed at ___. While there received Keppra 1g, Ativan 2mg. Unclear if has history of epilepsy. ___ have been in setting of recent toxin ingestions, though again, patient reliably states he did not intentionally overdose or take anything new other than hydroxycut. IV Keppra was discontinued as EEG was without seizure activity. # Asthma (stable) Patient continued on Albuterol inhaler Q6 PRN and fluticasone-salmeterol diskus 250/50. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sertraline 50 mg PO DAILY 2. Gabapentin 300 mg PO TID 3. Haloperidol Dose is Unknown IM Q2 WEEKS 4. OLANZapine 40 mg PO QHS 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea, wheezing Discharge Medications: 1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 1 Day 2. Nicotine Patch 21 mg/day TD DAILY 3. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea, wheezing 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Haloperidol Decanoate (long acting) 100 mg IM EVERY 2 WEEKS (FR) 6. OLANZapine 40 mg PO QHS 7. HELD- Gabapentin 300 mg PO TID This medication was held. Do not restart Gabapentin until you see your outpatient psychiatrist 8. HELD- Sertraline 50 mg PO DAILY This medication was held. Do not restart Sertraline until you see your outpatient psychiatrist Discharge Disposition: Extended Care Discharge Diagnosis: Aspiration pneumonia Suicide attempt 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 transferred from ___ because you were intubated for protection of your airway and concern for an overdose, as well as to control an infection in your lung (pneumonia). What was done for me while I was in the hospital? You received antibiotics for your pneumonia. You were also evaluated by the psychiatry team, which felt that it would be safest for you to be transferred to an inpatient psychiatric unit where you can receive more intensive psychiatric care to help you recover and return home safely. Therefore, you were transferred after you were medically cleared at ___. We wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___	[ "T426X2A", "J690", "T433X2A", "T43592A", "T434X2A", "T43222A", "T443X2A", "T424X2A", "T447X2A", "F259", "F39", "F209", "Y929", "F6089", "D696", "F29", "R451", "R300", "F17200", "J984", "Z781" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Overdose ?Suicide attempt Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] with hx schizophrenia, mood disorder, cluster B personality traits who presents to the [MASKED] from [MASKED] [MASKED] with overdose. Unclear when he was last seen well yesterday evening. He reportedly then overdosed on his medications in a suicide attempt, with a suicide note found at scene. EMS documented to be at the field at [MASKED]. It was unclear what medications he took, but he had prescriptions for olanzapine, haloperidol, Neurontin, and Cogentin found at scene. Per [MASKED] records - he also had access to his wife's medications including [MASKED], lamictal, ziprasidone, propranolol. He was given 8x Narcan in the field and taken to [MASKED], where he was somnolent with an intact gag reflex. Tox screen positive fentanyl and marijuana screen. While at [MASKED] he was intubated for airway protection. Additionally he had witnessed tonic-clonic seizure activity. He was given 2mg Ativan, was loaded with 1g Keppra, given 2L IVF. A NCHCT and CXR were unremarkable. He was then transferred to [MASKED] for further care. In the [MASKED], Initial Vitals: T98.5, HR 105, BP 128/74, RR 22, 97% while intubated Exam: Intubated and sedated Pupils 3-4mm and reactive, head NC/AT Tachycardic CTA bilaterally Abdomen soft and nontender Skin warm and dry Labs: CBC: 7.3 > 14.7/43.1 < 187 BMP: Na 141, K 4.4, Cl 112, HCO3 20, BUN 15, Cr 1.0 Serum tox: negative Urine tox: + benzos Imaging: CXR - Appropriate positioning of endotracheal tube in the lower trachea. Patchy bibasilar opacities, left greater right, are favored to represent subsegmental atelectasis. However, in the proper clinical setting, pneumonia cannot be excluded. Consults: none - toxicology consult deferred as [MASKED] attending is a toxicologist. Recommending supportive care - likely overdose on mostly sedative medications causing respiratory distress. Interventions: continued on propofol while intubated VS Prior to Transfer: HR 100, BP 125/69, RR 17, 98% intubated On arrival to the ICU - patient remains sedated and intubated. Past Medical History: Schizophrenia with auditory hallucinations Mood disorder Cluster B personality traits Prior SI attempt in high school Social History: [MASKED] Family History: unable to obtain on admission Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T98.3, HR 142, BP 156/82, 15, 99% intubated GEN: intubated and sedated, OG tube in place to wall suction - rust-colored drainage EYES: PERRLA HENNT: NC/AT CV: RRR, no m/r/g RESP: CTAB GI: +BS, soft, NTND MSK: WWP, no [MASKED] edema NEURO: sedated DISCHARGE PHYSICAL EXAM: ======================== VITALS: [MASKED] 0755 Temp: 97.9 PO BP: 143/84 HR: 96 RR: 20 O2 sat: 96% O2 delivery: Ra GENERAL: Alert, NAD, sitting up in bed with sitter in the room. CARDIAC: RRR, no m/r/g LUNGS: CTAB, no wheezes, rhonchi or crackles EXTREMITIES: Warm, well perfused. NEUROLOGIC: AOx3 PSYCH: mood and affect appropriate, Pertinent Results: ADMISSION LABS: =============== [MASKED] 02:00AM BLOOD WBC-7.3 RBC-4.58* Hgb-14.7 Hct-43.1 MCV-94 MCH-32.1* MCHC-34.1 RDW-12.6 RDWSD-43.1 Plt [MASKED] [MASKED] 02:00AM BLOOD Neuts-76.8* Lymphs-11.5* Monos-9.3 Eos-1.5 Baso-0.4 Im [MASKED] AbsNeut-5.62 AbsLymp-0.84* AbsMono-0.68 AbsEos-0.11 AbsBaso-0.03 [MASKED] 02:00AM BLOOD Glucose-85 UreaN-15 Creat-1.0 Na-141 K-4.4 Cl-112* HCO3-20* AnGap-9* [MASKED] 02:00AM BLOOD ALT-<5 AST-<5 CK(CPK)-611* AlkPhos-61 TotBili-0.3 [MASKED] 02:00AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.2 [MASKED] 02:00AM BLOOD Triglyc-844* [MASKED] 02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 05:26AM BLOOD [MASKED] pO2-32* pCO2-46* pH-7.35 calTCO2-26 Base XS--1 [MASKED] 05:26AM BLOOD Lactate-1.2 CXR [MASKED] IMPRESSION: Appropriate positioning of endotracheal tube in the lower trachea. Patchy bibasilar opacities, left greater right, are favored to represent subsegmental atelectasis. However, in the proper clinical setting, pneumonia cannot be excluded. DISCHARGE LABS: =============== [MASKED] 06:07AM BLOOD WBC-5.0 RBC-4.44* Hgb-13.8 Hct-41.1 MCV-93 MCH-31.1 MCHC-33.6 RDW-12.1 RDWSD-41.1 Plt [MASKED] [MASKED] 06:07AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-146 K-4.4 Cl-111* HCO3-23 AnGap-[MASKED] PMH schizophrenia, mood disorder, cluster B personality traits who presented to the [MASKED] with possible suicide attempt by overdose of medications. He was intubated for airway protection and transferred to [MASKED] MICU on [MASKED], extubated and completed treatment for aspiration pneumonia. TRANSITIONAL ISSUES [ ] Continue cefpedoxime to complete 5 day course ([MASKED]) LAST DOSE [MASKED] at 8:00 pm [ ] Follow up with outpatient psychiatrist regarding restarting sertraline and gabatentin ACUTE ISSUES =============== #Aspiration pneumonia Patient was diagnosed with aspiration pneumonia due to fever, CXR with patchy bibasilar opacities and sputum culture growing H. Flu. An aspiration event most likely occurred in the setting of an overdose. He was started on IV Ceftriaxone, but as his clinical status improved, he was transitioned to oral cefpedoxime for a total course of 5 days. #Suicide attempt #Schizophrenia #Mood disorder #Cluster B personality trait Patient insists this was not a suicide attempt. However, collateral from patient's wife and past records from [MASKED] revealed that patient has had prior suicide attempts which he denied, and has had recent changes in affect/behavior witnessed by wife. His wife described this episode as a suicide attempt, supported by the presence of a suicide note (which patient denied). Patient's wife expressed that the patient is not currently at his baseline (displayed isolative behaviors and frequent crying on the day of presentation and made a paranoid statement in his suicide note). Psychiatry evaluated patient during this admission and believe that patient is not psychiatrically cleared for discharge home and will require inpatient psych admission. Patient had a 1:1 sitter during the admission. Patient was continued on IM haloperidol decanoate (received on [MASKED], and olanzapine was increased to 40 mg daily per psychiatry recommendations. #Agitation Agitation was managed with PRN Haldol and olanzapine 20mg QHS and ultimately dubsided. His QT interval was monitored with daily EKGs. Discontinued sertraline while inpatient given c/f QT prolongation. # Elevated CK (resolved) Was likely elevated in the setting of taking hydroxycut. Downtrended to normal limits at the time of discharge. #Tonic-clonic seizure (resolved) Witnessed at [MASKED]. While there received Keppra 1g, Ativan 2mg. Unclear if has history of epilepsy. [MASKED] have been in setting of recent toxin ingestions, though again, patient reliably states he did not intentionally overdose or take anything new other than hydroxycut. IV Keppra was discontinued as EEG was without seizure activity. # Asthma (stable) Patient continued on Albuterol inhaler Q6 PRN and fluticasone-salmeterol diskus 250/50. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sertraline 50 mg PO DAILY 2. Gabapentin 300 mg PO TID 3. Haloperidol Dose is Unknown IM Q2 WEEKS 4. OLANZapine 40 mg PO QHS 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN dyspnea, wheezing Discharge Medications: 1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 1 Day 2. Nicotine Patch 21 mg/day TD DAILY 3. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN dyspnea, wheezing 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Haloperidol Decanoate (long acting) 100 mg IM EVERY 2 WEEKS (FR) 6. OLANZapine 40 mg PO QHS 7. HELD- Gabapentin 300 mg PO TID This medication was held. Do not restart Gabapentin until you see your outpatient psychiatrist 8. HELD- Sertraline 50 mg PO DAILY This medication was held. Do not restart Sertraline until you see your outpatient psychiatrist Discharge Disposition: Extended Care Discharge Diagnosis: Aspiration pneumonia Suicide attempt 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 transferred from [MASKED] because you were intubated for protection of your airway and concern for an overdose, as well as to control an infection in your lung (pneumonia). What was done for me while I was in the hospital? You received antibiotics for your pneumonia. You were also evaluated by the psychiatry team, which felt that it would be safest for you to be transferred to an inpatient psychiatric unit where you can receive more intensive psychiatric care to help you recover and return home safely. Therefore, you were transferred after you were medically cleared at [MASKED]. We wish you the best. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "Y929", "D696" ]	[ "T426X2A: Poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm, initial encounter", "J690: Pneumonitis due to inhalation of food and vomit", "T433X2A: Poisoning by phenothiazine antipsychotics and neuroleptics, intentional self-harm, initial encounter", "T43592A: Poisoning by other antipsychotics and neuroleptics, intentional self-harm, initial encounter", "T434X2A: Poisoning by butyrophenone and thiothixene neuroleptics, intentional self-harm, initial encounter", "T43222A: Poisoning by selective serotonin reuptake inhibitors, intentional self-harm, initial encounter", "T443X2A: Poisoning by other parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics, intentional self-harm, initial encounter", "T424X2A: Poisoning by benzodiazepines, intentional self-harm, initial encounter", "T447X2A: Poisoning by beta-adrenoreceptor antagonists, intentional self-harm, initial encounter", "F259: Schizoaffective disorder, unspecified", "F39: Unspecified mood [affective] disorder", "F209: Schizophrenia, unspecified", "Y929: Unspecified place or not applicable", "F6089: Other specific personality disorders", "D696: Thrombocytopenia, unspecified", "F29: Unspecified psychosis not due to a substance or known physiological condition", "R451: Restlessness and agitation", "R300: Dysuria", "F17200: Nicotine dependence, unspecified, uncomplicated", "J984: Other disorders of lung", "Z781: Physical restraint status" ]
10,048,001	20,362,822	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with history of ___ disease c/b cirrhosis, esophageal varices and recurrent episodes of cholangitis and VRE bacteremia on suppressive medications presenting for low grade fever and dyspnea. Patient notes onset of dyspnea with dry cough on ___. Shortness of breath present while lying down or sitting up. No chest pain, pleuritic symptoms, lightheadedness/dizziness. No history of asthma or COPD but feels like he has been wheezing. Notes low grade fever 99.5 at home. Denies abdominal pain, chills, diarrhea, blood in stool or black stools. Has been eating and drinking well. No sick contacts. Of note, patient was recently admitted with concern for upper GI bleed form gastropathy with EGD only showing grade I varices and acute cholangitis with Enterococcus bacteremia treated with Daptomycin for 2 weeks. Patient had previously been on suppressive antibiotics with levofloxacin and cefpodoxime since ___ without infections. Given recurrent resistant bacterial infections and resistance profile of bacteria, prophylaxis regimen was changed to 1 month of cefpodoxime alternating with 1 month of Augmentin at recent ID visit. He was started on Augmentin on ___ at which point right arm PICC was also removed. He has started Augmentin on ___ as well though has previously taken this medication without issues. In the ED initial vitals: T 99.4 HR 82 BP 104/53 RR 20 100%RA -->94% 2L - Exam notable for: PULM: Mild end expiratory wheeze throughout, dry cough, no accessory mm. ABDOMINAL: Nontender, mildly distended, no rebound/guarding, no peritonitic signs - Labs notable for: WBC 5.3 Hgb 11.3/35.3 Plt 43 137/100/17 -----------<112 4.0/23/1.2 ATL 23, AST 48 AP 133 Tbili 2.2 Alb 3.1 Lipase 19 Trop <0.01 Lactate 2.6 Flu negative UA: negative - Imaging notable for: CXR: Low lung volumes with bibasilar atelectasis. abdominal U/s: No tappable pocket on abdominal u/s - Patient was given: 1L LR On the floor, patient appears to be in acute respiratory distress, sitting up at the side of the bed. Denies chest pain but confirms history above with worsening shortness of breath since ___. No recent travel or pain in the ___. Notes stable mild generalized abdominal pain that remains stable without other symptoms. Stat CTA obtained on the floor consistent with bilateral PE. REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS reviewed and negative. Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in ___ Social History: ___ Family History: ther is alive with heart disease. Father died at ___ of ?cancer. No family history of liver disease or polycystic kidney disease. Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== T 98.6 BP 125/72 HR 92 RR 24 Sat 95% 3L NC GENERAL: sitting up in acute respiratory distress with use of accessory muscles, tripoding, able to complete full sentences, coughing intermittently HEENT: EOMI, PERRL, anicteric sclera, MMM NECK: supple, no JVD HEART: tachycardic, regular rhythm, no murmurs, gallops, or rubs LUNGS: tachypneic, Diffuse wheezing bilaterally, no rhonchi or crackles, otherwise as above ABDOMEN: Mildly TTP diffusely, easily reducible umbilical hernia, +hepatomegaly, no rebound or peritoneal signs EXTREMITIES: no ___ edema, no calf tenderness, Right upper extremity without tenderness or swelling NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis DISCHARGE PHYSICAL EXAM: ======================== GENERAL: laying in bed comfortably, does not appear in respiratory distress. A&Ox3 HEENT: EOMI, PERRL, anicteric sclera, MMM NECK: supple, no JVD HEART: RRR LUNGS: CTAB, breathing comfortably ABDOMEN: Mildly distended but soft, nontender. EXTREMITIES: no ___ edema, no calf tenderness, Right upper extremity without tenderness or swelling. Bilateral upper extremities appear symmetrical. NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis Pertinent Results: ADMISSION LABS: =============== ___ 08:54PM URINE HOURS-RANDOM ___ 08:54PM URINE UHOLD-HOLD ___ 08:54PM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 08:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 07:50PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 06:39PM LACTATE-2.6* ___ 04:30PM GLUCOSE-112* UREA N-17 CREAT-1.2 SODIUM-137 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14 ___ 04:30PM estGFR-Using this ___ 04:30PM ALT(SGPT)-23 AST(SGOT)-48* ALK PHOS-133* TOT BILI-2.2* ___ 04:30PM LIPASE-19 ___ 04:30PM cTropnT-<0.01 proBNP-906* ___ 04:30PM ALBUMIN-3.1* ___ 04:30PM WBC-5.3 RBC-3.63* HGB-11.3* HCT-35.3* MCV-97 MCH-31.1 MCHC-32.0 RDW-19.7* RDWSD-69.0* ___ 04:30PM NEUTS-77.7* LYMPHS-7.4* MONOS-11.4 EOS-2.3 BASOS-0.4 IM ___ AbsNeut-4.08 AbsLymp-0.39* AbsMono-0.60 AbsEos-0.12 AbsBaso-0.02 ___ 04:30PM ___ PTT-31.1 ___ ___ 04:30PM PLT COUNT-43* PERTINENT STUDIES: ================== ___ Imaging CHEST (PA & LAT) Low lung volumes with bibasilar atelectasis. ___ Imaging CTA CHEST Large bilateral pulmonary emboli with evidence of right heart strain. No signs of associated pulmonary infarct. ___ Imaging BILAT LOWER EXT VEINS No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ Imaging UNILAT UP EXT VEINS US Nonocclusive thrombus within the right axillary vein and proximal to mid right basilic vein. ___ Imaging DUPLEX DOPP ABD/PEL 1. Heterogeneous hepatic parenchyma with patent paraumbilical vein and retrograde flow of the right portal vein into the left portal vein. No evidence of thrombosis. 2. Splenomegaly, measuring 19.6 cm, previously 18.5 cm. ___ Imaging CHEST (PORTABLE AP) Mild pulmonary edema, new. ___ TTE IMPRESSION: Preserved biventricular systolic function. Mild to moderate tricuspid regurgitation. Mild mitral regurgitation. Moderate to severe pulmonary hypertension. Very small pericardial effusion. DISCHARGE LABS: =============== ___ 06:17AM BLOOD WBC-2.5* RBC-3.04* Hgb-9.5* Hct-29.7* MCV-98 MCH-31.3 MCHC-32.0 RDW-20.5* RDWSD-73.1* Plt Ct-39* ___ 06:17AM BLOOD ___ PTT-36.2 ___ ___ 06:17AM BLOOD Glucose-84 UreaN-15 Creat-1.1 Na-145 K-4.2 Cl-110* HCO3-22 AnGap-13 ___ 06:17AM BLOOD ALT-19 AST-26 AlkPhos-108 TotBili-1.0 ___ 06:17AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.4 Mg-1.6 Iron-31* ___ 06:17AM BLOOD calTIBC-203* Ferritn-95 TRF-156* ___ 05:52AM BLOOD CMV IgG-NEG CMV IgM-NEG CMVI-There is n EBV IgG-POS* EBNA-POS* EBV IgM-NEG EBVI-Results in Brief Hospital Course: ___ male with past medical history notable for Caroli disease complicated by recurrent episodes of cholangitis and VRE bacteremia on suppressive regimen, resultant cirrhosis with esophageal varices and portal gastropathy, presented with low grade fevers and dyspnea. Found on CTA to have acute bilateral PE with signs of RV strain but otherwise hemodynamically stable. Patient was anticoagulated first on heparin drip and then transitioned to rivoraxaban. TRANSITIONAL ISSUES: ==================== [ ] Please obtain repeat echocardiogram in ___ weeks to monitor pulmonary artery pressures. TTE from this admission showed estimated PA pressures were 52 mmHg likely from PE. [ ] Pulmonary embolus presumed to be provoked in setting of PICC associated DVT. Would reevaluate after 6 months of therapy if anticoagulation needs to be continued indefinitely. [ ] Patient's transferrin saturation was 15% (iron 31, calTIBC 203, ferritin 95, transferrin 156). Please consider outpatient iron supplementation ACUTE ISSUES: ============ #Hypoxia #Acute Submassive PE Patient presented with dyspnea and CTA ___ demonstrated acute bilateral PE. Patient recently had PICC removed on ___ after finishing IV daptomycin course for recent admission for enterococcus bacteremia. Doppler of right upper extremity demonstrating DVT, lower extremity dopplers negative. In this setting, PE presumed to be provoked. Surface echocardiogram with significant pulmonary hypertension with PA systolic pressure of 52mmHg. Cardiac biomarkers checked and BNP elevated to 900's. Patient Initially required 2L NC for hypoxia and weaned to room air at rest and ambulation by discharge. During admission, patient was initially started on heparin drip and transitioned to rivaroxaban for anticipated 6 month course of anticoagulation. #Fever Fever to 101.3 noted on ___ in absence of other clinical symptoms; was on suppressive daily augmentin at this time per outpatient infectious disease for bacteremia. He was started on vancomycin/cefepime. After 48 hours of negative cultures and negative CXR and chest CT, patient was trialed off antibiotics and was afebrile without any localizing symptoms. Fever presumed to be in setting of clot burden. ___ Presented with creatinine to 1.2 from baseline 0.9; resolved by discharge. Thought to be prerenal. CHRONIC ISSUES: ============= #___ Syndrome complicated by Cirrhosis EGD in ___ demonstrated portal gastropathy and duodenal ectasia (cauterized). Due to concern for possible bleeding while on anticoagulation, home diuretics and beta blockade were held. At discharge these were restarted - Restarted nadolol 20mg qdaily at discharge - Restarted furosemide 40mg qdaily and amiloride 10mg qdaily at discharge. # CODE: confirmed DNR/DNI # CONTACT: Wife, ___, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 10 mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Magnesium Oxide 400 mg PO DAILY 6. Nadolol 20 mg PO DAILY 7. Ursodiol 600 mg PO BID 8. Lactulose 30 mL PO Q2H 9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 11. Loratadine 10 mg PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Sildenafil 50 mg PO DAILY:PRN sexual activity 14. rifAXIMin 550 mg PO BID 15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 2. Rivaroxaban 15 mg PO BID 3. aMILoride 10 mg PO DAILY 4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 6. Citalopram 20 mg PO DAILY 7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 8. Furosemide 40 mg PO DAILY 9. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. Loratadine 10 mg PO DAILY 12. Magnesium Oxide 400 mg PO DAILY 13. Nadolol 20 mg PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. rifAXIMin 550 mg PO BID 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Ursodiol 600 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS #Acute Pulmonary Embolism SECONDARY DIAGNOSIS ___ disease complicated by recurrent episodes of cholangitis and VRE bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for coming to ___ for your care. Please read the following directions carefully: Why was I admitted to the hospital? -You were admitted to the hospital because were having difficulty breathing -We found that you had blood clots in your lungs What was done for me while I was in the hospital? -You were placed on blood thinners to prevent the blood clots from getting worse What do I need to do when I leave the hospital? -Your primary care doctor can help arrange for short term disability -Please take your medications as listed below -Please keep your appointments as below We wish you the best with your care! -Your ___ care team. Followup Instructions: ___	[ "I2699", "N179", "Q445", "Z87891", "Z66", "F329" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old male with history of [MASKED] disease c/b cirrhosis, esophageal varices and recurrent episodes of cholangitis and VRE bacteremia on suppressive medications presenting for low grade fever and dyspnea. Patient notes onset of dyspnea with dry cough on [MASKED]. Shortness of breath present while lying down or sitting up. No chest pain, pleuritic symptoms, lightheadedness/dizziness. No history of asthma or COPD but feels like he has been wheezing. Notes low grade fever 99.5 at home. Denies abdominal pain, chills, diarrhea, blood in stool or black stools. Has been eating and drinking well. No sick contacts. Of note, patient was recently admitted with concern for upper GI bleed form gastropathy with EGD only showing grade I varices and acute cholangitis with Enterococcus bacteremia treated with Daptomycin for 2 weeks. Patient had previously been on suppressive antibiotics with levofloxacin and cefpodoxime since [MASKED] without infections. Given recurrent resistant bacterial infections and resistance profile of bacteria, prophylaxis regimen was changed to 1 month of cefpodoxime alternating with 1 month of Augmentin at recent ID visit. He was started on Augmentin on [MASKED] at which point right arm PICC was also removed. He has started Augmentin on [MASKED] as well though has previously taken this medication without issues. In the ED initial vitals: T 99.4 HR 82 BP 104/53 RR 20 100%RA -->94% 2L - Exam notable for: PULM: Mild end expiratory wheeze throughout, dry cough, no accessory mm. ABDOMINAL: Nontender, mildly distended, no rebound/guarding, no peritonitic signs - Labs notable for: WBC 5.3 Hgb 11.3/35.3 Plt 43 137/100/17 -----------<112 4.0/23/1.2 ATL 23, AST 48 AP 133 Tbili 2.2 Alb 3.1 Lipase 19 Trop <0.01 Lactate 2.6 Flu negative UA: negative - Imaging notable for: CXR: Low lung volumes with bibasilar atelectasis. abdominal U/s: No tappable pocket on abdominal u/s - Patient was given: 1L LR On the floor, patient appears to be in acute respiratory distress, sitting up at the side of the bed. Denies chest pain but confirms history above with worsening shortness of breath since [MASKED]. No recent travel or pain in the [MASKED]. Notes stable mild generalized abdominal pain that remains stable without other symptoms. Stat CTA obtained on the floor consistent with bilateral PE. REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS reviewed and negative. Past Medical History: -[MASKED] Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late [MASKED] -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in [MASKED] Social History: [MASKED] Family History: ther is alive with heart disease. Father died at [MASKED] of ?cancer. No family history of liver disease or polycystic kidney disease. Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== T 98.6 BP 125/72 HR 92 RR 24 Sat 95% 3L NC GENERAL: sitting up in acute respiratory distress with use of accessory muscles, tripoding, able to complete full sentences, coughing intermittently HEENT: EOMI, PERRL, anicteric sclera, MMM NECK: supple, no JVD HEART: tachycardic, regular rhythm, no murmurs, gallops, or rubs LUNGS: tachypneic, Diffuse wheezing bilaterally, no rhonchi or crackles, otherwise as above ABDOMEN: Mildly TTP diffusely, easily reducible umbilical hernia, +hepatomegaly, no rebound or peritoneal signs EXTREMITIES: no [MASKED] edema, no calf tenderness, Right upper extremity without tenderness or swelling NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis DISCHARGE PHYSICAL EXAM: ======================== GENERAL: laying in bed comfortably, does not appear in respiratory distress. A&Ox3 HEENT: EOMI, PERRL, anicteric sclera, MMM NECK: supple, no JVD HEART: RRR LUNGS: CTAB, breathing comfortably ABDOMEN: Mildly distended but soft, nontender. EXTREMITIES: no [MASKED] edema, no calf tenderness, Right upper extremity without tenderness or swelling. Bilateral upper extremities appear symmetrical. NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis Pertinent Results: ADMISSION LABS: =============== [MASKED] 08:54PM URINE HOURS-RANDOM [MASKED] 08:54PM URINE UHOLD-HOLD [MASKED] 08:54PM URINE COLOR-Yellow APPEAR-Hazy* SP [MASKED] [MASKED] 08:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 07:50PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 06:39PM LACTATE-2.6* [MASKED] 04:30PM GLUCOSE-112* UREA N-17 CREAT-1.2 SODIUM-137 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14 [MASKED] 04:30PM estGFR-Using this [MASKED] 04:30PM ALT(SGPT)-23 AST(SGOT)-48* ALK PHOS-133* TOT BILI-2.2* [MASKED] 04:30PM LIPASE-19 [MASKED] 04:30PM cTropnT-<0.01 proBNP-906* [MASKED] 04:30PM ALBUMIN-3.1* [MASKED] 04:30PM WBC-5.3 RBC-3.63* HGB-11.3* HCT-35.3* MCV-97 MCH-31.1 MCHC-32.0 RDW-19.7* RDWSD-69.0* [MASKED] 04:30PM NEUTS-77.7* LYMPHS-7.4* MONOS-11.4 EOS-2.3 BASOS-0.4 IM [MASKED] AbsNeut-4.08 AbsLymp-0.39* AbsMono-0.60 AbsEos-0.12 AbsBaso-0.02 [MASKED] 04:30PM [MASKED] PTT-31.1 [MASKED] [MASKED] 04:30PM PLT COUNT-43* PERTINENT STUDIES: ================== [MASKED] Imaging CHEST (PA & LAT) Low lung volumes with bibasilar atelectasis. [MASKED] Imaging CTA CHEST Large bilateral pulmonary emboli with evidence of right heart strain. No signs of associated pulmonary infarct. [MASKED] Imaging BILAT LOWER EXT VEINS No evidence of deep venous thrombosis in the right or left lower extremity veins. [MASKED] Imaging UNILAT UP EXT VEINS US Nonocclusive thrombus within the right axillary vein and proximal to mid right basilic vein. [MASKED] Imaging DUPLEX DOPP ABD/PEL 1. Heterogeneous hepatic parenchyma with patent paraumbilical vein and retrograde flow of the right portal vein into the left portal vein. No evidence of thrombosis. 2. Splenomegaly, measuring 19.6 cm, previously 18.5 cm. [MASKED] Imaging CHEST (PORTABLE AP) Mild pulmonary edema, new. [MASKED] TTE IMPRESSION: Preserved biventricular systolic function. Mild to moderate tricuspid regurgitation. Mild mitral regurgitation. Moderate to severe pulmonary hypertension. Very small pericardial effusion. DISCHARGE LABS: =============== [MASKED] 06:17AM BLOOD WBC-2.5* RBC-3.04* Hgb-9.5* Hct-29.7* MCV-98 MCH-31.3 MCHC-32.0 RDW-20.5* RDWSD-73.1* Plt Ct-39* [MASKED] 06:17AM BLOOD [MASKED] PTT-36.2 [MASKED] [MASKED] 06:17AM BLOOD Glucose-84 UreaN-15 Creat-1.1 Na-145 K-4.2 Cl-110* HCO3-22 AnGap-13 [MASKED] 06:17AM BLOOD ALT-19 AST-26 AlkPhos-108 TotBili-1.0 [MASKED] 06:17AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.4 Mg-1.6 Iron-31* [MASKED] 06:17AM BLOOD calTIBC-203* Ferritn-95 TRF-156* [MASKED] 05:52AM BLOOD CMV IgG-NEG CMV IgM-NEG CMVI-There is n EBV IgG-POS* EBNA-POS* EBV IgM-NEG EBVI-Results in Brief Hospital Course: [MASKED] male with past medical history notable for Caroli disease complicated by recurrent episodes of cholangitis and VRE bacteremia on suppressive regimen, resultant cirrhosis with esophageal varices and portal gastropathy, presented with low grade fevers and dyspnea. Found on CTA to have acute bilateral PE with signs of RV strain but otherwise hemodynamically stable. Patient was anticoagulated first on heparin drip and then transitioned to rivoraxaban. TRANSITIONAL ISSUES: ==================== [ ] Please obtain repeat echocardiogram in [MASKED] weeks to monitor pulmonary artery pressures. TTE from this admission showed estimated PA pressures were 52 mmHg likely from PE. [ ] Pulmonary embolus presumed to be provoked in setting of PICC associated DVT. Would reevaluate after 6 months of therapy if anticoagulation needs to be continued indefinitely. [ ] Patient's transferrin saturation was 15% (iron 31, calTIBC 203, ferritin 95, transferrin 156). Please consider outpatient iron supplementation ACUTE ISSUES: ============ #Hypoxia #Acute Submassive PE Patient presented with dyspnea and CTA [MASKED] demonstrated acute bilateral PE. Patient recently had PICC removed on [MASKED] after finishing IV daptomycin course for recent admission for enterococcus bacteremia. Doppler of right upper extremity demonstrating DVT, lower extremity dopplers negative. In this setting, PE presumed to be provoked. Surface echocardiogram with significant pulmonary hypertension with PA systolic pressure of 52mmHg. Cardiac biomarkers checked and BNP elevated to 900's. Patient Initially required 2L NC for hypoxia and weaned to room air at rest and ambulation by discharge. During admission, patient was initially started on heparin drip and transitioned to rivaroxaban for anticipated 6 month course of anticoagulation. #Fever Fever to 101.3 noted on [MASKED] in absence of other clinical symptoms; was on suppressive daily augmentin at this time per outpatient infectious disease for bacteremia. He was started on vancomycin/cefepime. After 48 hours of negative cultures and negative CXR and chest CT, patient was trialed off antibiotics and was afebrile without any localizing symptoms. Fever presumed to be in setting of clot burden. [MASKED] Presented with creatinine to 1.2 from baseline 0.9; resolved by discharge. Thought to be prerenal. CHRONIC ISSUES: ============= #[MASKED] Syndrome complicated by Cirrhosis EGD in [MASKED] demonstrated portal gastropathy and duodenal ectasia (cauterized). Due to concern for possible bleeding while on anticoagulation, home diuretics and beta blockade were held. At discharge these were restarted - Restarted nadolol 20mg qdaily at discharge - Restarted furosemide 40mg qdaily and amiloride 10mg qdaily at discharge. # CODE: confirmed DNR/DNI # CONTACT: Wife, [MASKED], [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 10 mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Magnesium Oxide 400 mg PO DAILY 6. Nadolol 20 mg PO DAILY 7. Ursodiol 600 mg PO BID 8. Lactulose 30 mL PO Q2H 9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 11. Loratadine 10 mg PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Sildenafil 50 mg PO DAILY:PRN sexual activity 14. rifAXIMin 550 mg PO BID 15. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 2. Rivaroxaban 15 mg PO BID 3. aMILoride 10 mg PO DAILY 4. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 6. Citalopram 20 mg PO DAILY 7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 8. Furosemide 40 mg PO DAILY 9. Lactulose 30 mL PO Q8H:PRN As needed to have [MASKED] Bowel Movements per day 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. Loratadine 10 mg PO DAILY 12. Magnesium Oxide 400 mg PO DAILY 13. Nadolol 20 mg PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. rifAXIMin 550 mg PO BID 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Ursodiol 600 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS #Acute Pulmonary Embolism SECONDARY DIAGNOSIS [MASKED] disease complicated by recurrent episodes of cholangitis and VRE bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], Thank you for coming to [MASKED] for your care. Please read the following directions carefully: Why was I admitted to the hospital? -You were admitted to the hospital because were having difficulty breathing -We found that you had blood clots in your lungs What was done for me while I was in the hospital? -You were placed on blood thinners to prevent the blood clots from getting worse What do I need to do when I leave the hospital? -Your primary care doctor can help arrange for short term disability -Please take your medications as listed below -Please keep your appointments as below We wish you the best with your care! -Your [MASKED] care team. Followup Instructions: [MASKED]	[]	[ "N179", "Z87891", "Z66", "F329" ]	[ "I2699: Other pulmonary embolism without acute cor pulmonale", "N179: Acute kidney failure, unspecified", "Q445: Other congenital malformations of bile ducts", "Z87891: Personal history of nicotine dependence", "Z66: Do not resuscitate", "F329: Major depressive disorder, single episode, unspecified" ]
10,048,001	22,128,147	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Midline placed ___ History of Present Illness: ___ M with PMH ___'s disease (communicating cavernous ectasia, or congenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on lovenox who presents with dyspnea on exertion and dry cough. Patient reports symptoms began on ___. He reports dyspnea with walking around living room. He reports SOB improved with seating. He reports exacerbation of dry cough with lying flat but does not have worsening shortness of breath with lying flat. Patient reports that SOB worsened with walking to bathroom overnight. He denies fevers, chills, chest pain, productive cough, palpitations, lightheadedness. He denies blood in stool or black stool. - In the ED, initial vitals were: T 98.9 HR 86 BP 100/59 RR 22 SPO2 99% RA - Exam was notable for: JVP elevated to the mandible at 45 degrees, with HJR. Ext warm with 2+ pitting edema. No crackles appreciated - Labs were notable for: 136 \| 103 \| 23 -------------- 188 AGap=13 3.9 \| 20 \| 1.2 WBC 4.4 HGB 10.3 PLT 40 ___: 16.0 PTT: 46.9 INR: 1.5 LFTs not elevated. Tbili: 2.4 Lactate 3.2 to 2.3 proBNP: 775 Trop-T: <0.01 UA wnl - Studies were notable for: - CTA chest : improvement in pulmonary arterial thrombus burden, with persistent though small nonocclusive thrombus seen within the distal left main pulmonary artery and basal segmental branches. No substantial clot burden in the right pulmonary artery. Persistent dilatation of the left main pulmonary artery to 2.8 cm, otherwise no CT evidence of right heart strain. No evidence of underlying pulmonary infarction. - The patient was given: Furosemide 40 mg, Ipratropium-Albuterol Neb 1 NEB On arrival to the floor, the patient reports dyspnea on exertion but no positional component with orthopnea or platypnea. No subjective fevers/chills, abdominal pain, n/v/d, blood in the stool, confusion. Reports his weight at home has been stable at 205 lb. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in ___ Social History: ___ Family History: Mother has heart disease. Father died at age ___ from cancer and there is no other liver disease in his family that is known. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 103.0 BP 99 / 62 HR 91 RR 18 SpO2 96 GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: JVP to jaw at 45 degrees CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: No rhonchi or rales. No increased work of breathing. expiratory wheezing noted bilaterally BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, mildly distended but no notable fluid wave, non-tender to deep palpation in all four quadrants. No ___ sign EXTREMITIES: No clubbing, cyanosis. 1+ edema in b/l calves. Pulses DP/Radial 2+ bilaterally. wwp SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. no asterixis. able to recite days of week backwards DISCHARGE EXAM: =============== PHYSICAL EXAM: ============== 24 HR Data (last updated ___ @ 707) Temp: 97.6 (Tm 98.7), BP: 109/72 (96-109/60-72), HR: 69 (64-92), RR: 17 (___), O2 sat: 95% (95-97), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. CARDIAC: RRR no m/r/g LUNGS: Bilateral wheezing ABDOMEN: Soft, NT, ND, +BS Pertinent Results: ADMISSION LABS: =============== ___ 01:40PM BLOOD WBC-4.4 RBC-3.27* Hgb-10.3* Hct-31.5* MCV-96 MCH-31.5 MCHC-32.7 RDW-18.9* RDWSD-67.6* Plt Ct-40* ___ 01:40PM BLOOD Neuts-77.4* Lymphs-7.8* Monos-13.9* Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.39 AbsLymp-0.34* AbsMono-0.61 AbsEos-0.01* AbsBaso-0.01 ___ 01:40PM BLOOD ___ PTT-46.9* ___ ___ 01:40PM BLOOD Glucose-188* UreaN-23* Creat-1.2 Na-136 K-3.9 Cl-103 HCO3-20* AnGap-13 ___ 01:40PM BLOOD ALT-17 AST-34 AlkPhos-97 TotBili-2.4* ___ 01:40PM BLOOD proBNP-775* ___:40PM BLOOD Albumin-3.3* Calcium-8.6 Phos-1.5* Mg-1.6 ___ 01:40PM BLOOD Lactate-3.2* IMAGING: ======== ___ Imaging CHEST (PA & LAT) IMPRESSION: No interval change in cardiac silhouette size, no evidence of substantial pulmonary vascular congestion or pulmonary edema. Overall slight improvement in lung aeration bilaterally. No focal consolidation. ___ Imaging CTA CHEST IMPRESSION: Overall improvement in pulmonary arterial thrombus burden, with persistent though smaller nonocclusive thrombus seen within the distal left main pulmonary artery and basal segmental branches. No substantial clot burden in the right pulmonary artery. Persistent dilatation of the left main pulmonary artery to 2.8 cm, otherwise no CT evidence of right heart strain. No evidence of underlying pulmonary infarction. ___ Imaging US ABD LIMIT, SINGLE OR FINDINGS: Targeted grayscale ultrasound images were obtained of the 4 quadrants of the abdomen, revealing no ascites. IMPRESSION: No ascites. ___ Cardiovascular Transthoracic Echo Report CONCLUSION: The left atrial volume index is normal. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 74 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Diastolic function could not be assessed. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE (images reviewed) of ___ , the estimated pulmonary artery systolic pressure is now lower. The right ventricular cavity size is smaller. ___ Imaging MRCP (MR ABD ___ IMPRESSION: 1. Cirrhosis with findings of portal hypertension, including marked splenomegaly and perigastric varices. Saccular dilatation of the intrahepatic bile ducts involving the right hepatic lobe, similar to prior exams, compatible with known ___'s syndrome. No suspicious hepatic lesion. No evidence of active cholangitis. DISCHARGE LABS: =============== ___ 07:00AM BLOOD WBC-2.4* RBC-2.93* Hgb-9.2* Hct-28.5* MCV-97 MCH-31.4 MCHC-32.3 RDW-18.4* RDWSD-66.0* Plt Ct-56* ___ 07:00AM BLOOD Glucose-88 UreaN-13 Creat-1.0 Na-144 K-3.9 Cl-107 HCO3-23 AnGap-14 ___ 07:00AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.5* Brief Hospital Course: ___ M with PMH ___'s disease (communicating cavernous ectasia, or congenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on lovenox who presents with dyspnea/ cough found to have fever to 103 with blood cultures growing enterococcus. TRANSITIONAL ISSUES: ==================== [ ] Please continue your IV antibiotics until ___ [ ] Please follow-up with your physicians as scheduled [ ] Please reach out to your infectious disease doctor about restarting your prophylactic antibiotics once you finish your IV course. [ ] Follow-up platelet levels and consider decreasing enoxaparin dose. ACUTE/ACTIVE ISSUES: ==================== # Fever # History of recurrent MDR cholangitis Fever to 103 upon arrival to floor. No localized sx except cough, SOB but with recurrent episodes of cholangitis due to biliary ductal dilation from Caroli's disease. History of MDR infections with VRE bacteremia and Carbapenem resistant E. coli. Alternates suppressive augmentin with cefpodoxime at home. MRCP showed no evidence of cholangitis and was unrevealing for a cause, thus it was felt that the source of the bacteremia was transient gut translocation. Blood cultures returned positive for enterococcous. He was initially treated with Dapto/Cefepime/flagyl and then transitioned to zosyn for a ___, end date ___. # Dyspnea on Exertion # Pulmonary Hypertension Patient presenting with DOE/dry cough with JVP elevation, ___ edema without e/o of pulm edema on exam or CXR overall concerning for R heart failure. Known RV strain iso PE with PASP 50, however patient on AC with lovenox and CTPE with improved clot burden. TTE showed improvement in right heart strain. Symptoms improved with diuresis. # ___ syndrome # Cirrhosis # Thrombocytopenia Childs class B cirrhosis; MELD-Na 31 on admission (largely driven by INR). History of hepatic encephalopathy on lactulose, varices on Nadolol. No hx of ascites but on Lasix. EGD last admission ___ with 3 cords of grade I varices in distal esophagus, nonbleeding, and portal hypertensive gastropathy. His home furosemide and nadolol were initially held in the setting of infection but were restarted prior to discharge. # Lactic acidosis Lactic 3.2 downtrended to 2.3 in ED without fluid. Concern for infection given fever and hx of recurrent cholangitis. Improved. CHRONIC/STABLE ISSUES: ====================== # Depression: Continued home citalopram 20mg daily > 30 minutes spent on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 2. aMILoride 10 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Loratadine 10 mg PO DAILY 7. Ursodiol 600 mg PO BID 8. Sildenafil 50 mg PO DAILY:PRN sexual activity 9. Nadolol 20 mg PO DAILY 10. Magnesium Oxide 400 mg PO DAILY 11. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 12. Pantoprazole 40 mg PO Q24H 13. Enoxaparin Sodium 100 mg SC Q12H 14. Furosemide 40 mg PO DAILY 15. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 16. Cefpodoxime Proxetil 200 mg PO Q12H Discharge Medications: 1. Acyclovir 400 mg PO Q8H RX acyclovir 400 mg 1 tablet(s) by mouth q8hr Disp #12 Tablet Refills:*0 2. Piperacillin-Tazobactam 4.5 g IV Q8H 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 4. aMILoride 10 mg PO DAILY 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 6. Citalopram 20 mg PO DAILY 7. Enoxaparin Sodium 100 mg SC Q12H 8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 9. Furosemide 40 mg PO DAILY 10. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Loratadine 10 mg PO DAILY 13. Magnesium Oxide 400 mg PO DAILY 14. Nadolol 20 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Ursodiol 600 mg PO BID 18. HELD- Cefpodoxime Proxetil 200 mg PO Q12H This medication was held. Do not restart Cefpodoxime Proxetil until you speak with your infectious disease doctor. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: Enterococcus Bactermia Volume Overload Secondary Diagnoses: Caroli syndrome Cirrhosis Thrombocytopenia 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 because you had a fever and we were worried tat you had an infection due to your liver disease. WHAT HAPPENED TO ME IN THE HOSPITAL? - While you were in the hospital we did some imaging which showed you did not have an infection in your biliary system. - Some blood tests showed that you had bacteria in your blood. 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: ___	[ "A4181", "I2699", "E872", "A048", "K766", "I8510", "I2720", "D6959", "K838", "K7460", "Z66", "Z1611", "K3189", "M8580", "F329", "Z7901", "Z86711", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Midline placed [MASKED] History of Present Illness: [MASKED] M with PMH [MASKED]'s disease (communicating cavernous ectasia, or congenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on lovenox who presents with dyspnea on exertion and dry cough. Patient reports symptoms began on [MASKED]. He reports dyspnea with walking around living room. He reports SOB improved with seating. He reports exacerbation of dry cough with lying flat but does not have worsening shortness of breath with lying flat. Patient reports that SOB worsened with walking to bathroom overnight. He denies fevers, chills, chest pain, productive cough, palpitations, lightheadedness. He denies blood in stool or black stool. - In the ED, initial vitals were: T 98.9 HR 86 BP 100/59 RR 22 SPO2 99% RA - Exam was notable for: JVP elevated to the mandible at 45 degrees, with HJR. Ext warm with 2+ pitting edema. No crackles appreciated - Labs were notable for: 136 \| 103 \| 23 -------------- 188 AGap=13 3.9 \| 20 \| 1.2 WBC 4.4 HGB 10.3 PLT 40 [MASKED]: 16.0 PTT: 46.9 INR: 1.5 LFTs not elevated. Tbili: 2.4 Lactate 3.2 to 2.3 proBNP: 775 Trop-T: <0.01 UA wnl - Studies were notable for: - CTA chest : improvement in pulmonary arterial thrombus burden, with persistent though small nonocclusive thrombus seen within the distal left main pulmonary artery and basal segmental branches. No substantial clot burden in the right pulmonary artery. Persistent dilatation of the left main pulmonary artery to 2.8 cm, otherwise no CT evidence of right heart strain. No evidence of underlying pulmonary infarction. - The patient was given: Furosemide 40 mg, Ipratropium-Albuterol Neb 1 NEB On arrival to the floor, the patient reports dyspnea on exertion but no positional component with orthopnea or platypnea. No subjective fevers/chills, abdominal pain, n/v/d, blood in the stool, confusion. Reports his weight at home has been stable at 205 lb. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: -[MASKED] Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late [MASKED] -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in [MASKED] Social History: [MASKED] Family History: Mother has heart disease. Father died at age [MASKED] from cancer and there is no other liver disease in his family that is known. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 103.0 BP 99 / 62 HR 91 RR 18 SpO2 96 GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: JVP to jaw at 45 degrees CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: No rhonchi or rales. No increased work of breathing. expiratory wheezing noted bilaterally BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, mildly distended but no notable fluid wave, non-tender to deep palpation in all four quadrants. No [MASKED] sign EXTREMITIES: No clubbing, cyanosis. 1+ edema in b/l calves. Pulses DP/Radial 2+ bilaterally. wwp SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. no asterixis. able to recite days of week backwards DISCHARGE EXAM: =============== PHYSICAL EXAM: ============== 24 HR Data (last updated [MASKED] @ 707) Temp: 97.6 (Tm 98.7), BP: 109/72 (96-109/60-72), HR: 69 (64-92), RR: 17 ([MASKED]), O2 sat: 95% (95-97), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. CARDIAC: RRR no m/r/g LUNGS: Bilateral wheezing ABDOMEN: Soft, NT, ND, +BS Pertinent Results: ADMISSION LABS: =============== [MASKED] 01:40PM BLOOD WBC-4.4 RBC-3.27* Hgb-10.3* Hct-31.5* MCV-96 MCH-31.5 MCHC-32.7 RDW-18.9* RDWSD-67.6* Plt Ct-40* [MASKED] 01:40PM BLOOD Neuts-77.4* Lymphs-7.8* Monos-13.9* Eos-0.2* Baso-0.2 Im [MASKED] AbsNeut-3.39 AbsLymp-0.34* AbsMono-0.61 AbsEos-0.01* AbsBaso-0.01 [MASKED] 01:40PM BLOOD [MASKED] PTT-46.9* [MASKED] [MASKED] 01:40PM BLOOD Glucose-188* UreaN-23* Creat-1.2 Na-136 K-3.9 Cl-103 HCO3-20* AnGap-13 [MASKED] 01:40PM BLOOD ALT-17 AST-34 AlkPhos-97 TotBili-2.4* [MASKED] 01:40PM BLOOD proBNP-775* [MASKED]:40PM BLOOD Albumin-3.3* Calcium-8.6 Phos-1.5* Mg-1.6 [MASKED] 01:40PM BLOOD Lactate-3.2* IMAGING: ======== [MASKED] Imaging CHEST (PA & LAT) IMPRESSION: No interval change in cardiac silhouette size, no evidence of substantial pulmonary vascular congestion or pulmonary edema. Overall slight improvement in lung aeration bilaterally. No focal consolidation. [MASKED] Imaging CTA CHEST IMPRESSION: Overall improvement in pulmonary arterial thrombus burden, with persistent though smaller nonocclusive thrombus seen within the distal left main pulmonary artery and basal segmental branches. No substantial clot burden in the right pulmonary artery. Persistent dilatation of the left main pulmonary artery to 2.8 cm, otherwise no CT evidence of right heart strain. No evidence of underlying pulmonary infarction. [MASKED] Imaging US ABD LIMIT, SINGLE OR FINDINGS: Targeted grayscale ultrasound images were obtained of the 4 quadrants of the abdomen, revealing no ascites. IMPRESSION: No ascites. [MASKED] Cardiovascular Transthoracic Echo Report CONCLUSION: The left atrial volume index is normal. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 74 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Diastolic function could not be assessed. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE (images reviewed) of [MASKED] , the estimated pulmonary artery systolic pressure is now lower. The right ventricular cavity size is smaller. [MASKED] Imaging MRCP (MR ABD [MASKED] IMPRESSION: 1. Cirrhosis with findings of portal hypertension, including marked splenomegaly and perigastric varices. Saccular dilatation of the intrahepatic bile ducts involving the right hepatic lobe, similar to prior exams, compatible with known [MASKED]'s syndrome. No suspicious hepatic lesion. No evidence of active cholangitis. DISCHARGE LABS: =============== [MASKED] 07:00AM BLOOD WBC-2.4* RBC-2.93* Hgb-9.2* Hct-28.5* MCV-97 MCH-31.4 MCHC-32.3 RDW-18.4* RDWSD-66.0* Plt Ct-56* [MASKED] 07:00AM BLOOD Glucose-88 UreaN-13 Creat-1.0 Na-144 K-3.9 Cl-107 HCO3-23 AnGap-14 [MASKED] 07:00AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.5* Brief Hospital Course: [MASKED] M with PMH [MASKED]'s disease (communicating cavernous ectasia, or congenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on lovenox who presents with dyspnea/ cough found to have fever to 103 with blood cultures growing enterococcus. TRANSITIONAL ISSUES: ==================== [ ] Please continue your IV antibiotics until [MASKED] [ ] Please follow-up with your physicians as scheduled [ ] Please reach out to your infectious disease doctor about restarting your prophylactic antibiotics once you finish your IV course. [ ] Follow-up platelet levels and consider decreasing enoxaparin dose. ACUTE/ACTIVE ISSUES: ==================== # Fever # History of recurrent MDR cholangitis Fever to 103 upon arrival to floor. No localized sx except cough, SOB but with recurrent episodes of cholangitis due to biliary ductal dilation from Caroli's disease. History of MDR infections with VRE bacteremia and Carbapenem resistant E. coli. Alternates suppressive augmentin with cefpodoxime at home. MRCP showed no evidence of cholangitis and was unrevealing for a cause, thus it was felt that the source of the bacteremia was transient gut translocation. Blood cultures returned positive for enterococcous. He was initially treated with Dapto/Cefepime/flagyl and then transitioned to zosyn for a [MASKED], end date [MASKED]. # Dyspnea on Exertion # Pulmonary Hypertension Patient presenting with DOE/dry cough with JVP elevation, [MASKED] edema without e/o of pulm edema on exam or CXR overall concerning for R heart failure. Known RV strain iso PE with PASP 50, however patient on AC with lovenox and CTPE with improved clot burden. TTE showed improvement in right heart strain. Symptoms improved with diuresis. # [MASKED] syndrome # Cirrhosis # Thrombocytopenia Childs class B cirrhosis; MELD-Na 31 on admission (largely driven by INR). History of hepatic encephalopathy on lactulose, varices on Nadolol. No hx of ascites but on Lasix. EGD last admission [MASKED] with 3 cords of grade I varices in distal esophagus, nonbleeding, and portal hypertensive gastropathy. His home furosemide and nadolol were initially held in the setting of infection but were restarted prior to discharge. # Lactic acidosis Lactic 3.2 downtrended to 2.3 in ED without fluid. Concern for infection given fever and hx of recurrent cholangitis. Improved. CHRONIC/STABLE ISSUES: ====================== # Depression: Continued home citalopram 20mg daily > 30 minutes spent on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 2. aMILoride 10 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Lactulose 30 mL PO Q8H:PRN As needed to have [MASKED] Bowel Movements per day 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Loratadine 10 mg PO DAILY 7. Ursodiol 600 mg PO BID 8. Sildenafil 50 mg PO DAILY:PRN sexual activity 9. Nadolol 20 mg PO DAILY 10. Magnesium Oxide 400 mg PO DAILY 11. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 12. Pantoprazole 40 mg PO Q24H 13. Enoxaparin Sodium 100 mg SC Q12H 14. Furosemide 40 mg PO DAILY 15. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 16. Cefpodoxime Proxetil 200 mg PO Q12H Discharge Medications: 1. Acyclovir 400 mg PO Q8H RX acyclovir 400 mg 1 tablet(s) by mouth q8hr Disp #12 Tablet Refills:*0 2. Piperacillin-Tazobactam 4.5 g IV Q8H 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 4. aMILoride 10 mg PO DAILY 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 6. Citalopram 20 mg PO DAILY 7. Enoxaparin Sodium 100 mg SC Q12H 8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 9. Furosemide 40 mg PO DAILY 10. Lactulose 30 mL PO Q8H:PRN As needed to have [MASKED] Bowel Movements per day 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Loratadine 10 mg PO DAILY 13. Magnesium Oxide 400 mg PO DAILY 14. Nadolol 20 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Ursodiol 600 mg PO BID 18. HELD- Cefpodoxime Proxetil 200 mg PO Q12H This medication was held. Do not restart Cefpodoxime Proxetil until you speak with your infectious disease doctor. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses: Enterococcus Bactermia Volume Overload Secondary Diagnoses: Caroli syndrome Cirrhosis Thrombocytopenia 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 because you had a fever and we were worried tat you had an infection due to your liver disease. WHAT HAPPENED TO ME IN THE HOSPITAL? - While you were in the hospital we did some imaging which showed you did not have an infection in your biliary system. - Some blood tests showed that you had bacteria in your blood. 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]	[]	[ "E872", "Z66", "F329", "Z7901", "Z87891" ]	[ "A4181: Sepsis due to Enterococcus", "I2699: Other pulmonary embolism without acute cor pulmonale", "E872: Acidosis", "A048: Other specified bacterial intestinal infections", "K766: Portal hypertension", "I8510: Secondary esophageal varices without bleeding", "I2720: Pulmonary hypertension, unspecified", "D6959: Other secondary thrombocytopenia", "K838: Other specified diseases of biliary tract", "K7460: Unspecified cirrhosis of liver", "Z66: Do not resuscitate", "Z1611: Resistance to penicillins", "K3189: Other diseases of stomach and duodenum", "M8580: Other specified disorders of bone density and structure, unspecified site", "F329: Major depressive disorder, single episode, unspecified", "Z7901: Long term (current) use of anticoagulants", "Z86711: Personal history of pulmonary embolism", "Z87891: Personal history of nicotine dependence" ]
10,048,001	24,319,281	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Confusion, upper GI bleeding Major Surgical or Invasive Procedure: EGD ___: APC to vascular ectasia in the duodenum PICC line placement ___ History of Present Illness: Mr. ___ is a ___ year old man with a history of Caroli disease and well compensated cirrhosis who presents from ___ with confusion, abdominal pain and vomiting. He was just on vacation in ___ and approximately 3d ago his wife noticed that he wasn't acting like himself, was confused, and asking repetitive questions. He had diarrhea for one week, some of which was black of dark red. He also had some abomdinal pain that was not significantly different from normal, but did have some nausea and vomiting with bright red blood in the emesis. He has a history of cholangitis and typically has fevers and chills, which he hasn't had. He presented to the ___ ED. At ___ had WBc 13.8, INR 1.4, T bili 2.4, AST/ALT 143/123, Lactate 2.1, BNP 582, TropT 0.39. CTA without PE. CTAP with distended gallbladder with pericholecystic fluid and stone at gallbladder neck. A blood culture grew gram positive organisms in short chains. On arrival to the floor, he reports still feeling somewhat confused. He has not had further nausea/vomiting. He is very thirsty. EMERGENCY DEPARTMENT COURSE Initial vital signs were notable for: - T 96.9, HR 86, BP 129/71, RR 16, O2 95% RA Exam notable for: - Benign abdomen Labs were notable for: - ALT 108 - AP 246 - T bili 2.3 - AST 115 - Cr 1.3, BUN 43 - Lactate 2.3 Patient was given: - Zosyn - Protonix - Urosodiol 600mg - Lasix 40mg PO - Nadolol 20mg - Amliloride 10mg - Vancomycin Consults: - Hepatology ================= REVIEW OF SYSTEMS ================= Complete ROS obtained and is otherwise negative. Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Inguinal hernia repair in ___ -Depression -Osteopenia per patient -Seasonal allergies -Bee allergy Social History: ___ Family History: Mother is alive with heart disease. Father died at ___ of ?cancer. No family history of liver disease or polycystic kidney disease. Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== VITALS: T 98.9, BP 127/77, HR 78, RR 22, ___ GENERAL: Tired appearing, lying in bed, arousable to voice HEENT: Pupils equal and reactive, mild scleral icterus, dry mucous membranes, CARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4 LUNGS: Poor air movement, bibasilar rales, diminished lung sounds bilaterally BACK: No CVA tenderness ABDOMEN: Soft, mildly tender to palpation diffusely, worse in LUQ. Umbilical hernia soft and reducible. EXTREMITIES: 2+ pitting edema to upper shins SKIN: Scattered superficial abrasions throughout abdomen NEUROLOGIC: A+Ox3, though slow to identify date. Mild asterixis. CNII-XII normal. ======================= DISCHARGE PHYSICAL EXAM ======================= General: Elderly gentleman, sitting up in chair HEENT: Sclera anicteric, mucous membranes moist Lungs: vesicular breath sounds bilaterally CV: Regular rate and rhythm, no murmurs Abdomen: obese, distended, no tenderness to palpation, reducible umbilical hernia Ext: Warm, well perfused, ___ bilateral pitting edema of lower extremities up to knees. Patient had removed compression stockings just prior to exam. Neuro: Alert, cranial nerves grossly intact Pertinent Results: ======================= ADMISSION LAB RESULTS ======================= ___ 04:13AM BLOOD WBC-12.5* RBC-3.55* Hgb-10.7* Hct-32.6* MCV-92 MCH-30.1 MCHC-32.8 RDW-18.6* RDWSD-56.5* Plt Ct-82* ___ 04:13AM BLOOD Neuts-87* Bands-1 Lymphs-4* Monos-2* Eos-0* ___ Myelos-6* NRBC-0.2* AbsNeut-11.00* AbsLymp-0.50* AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00* ___ 04:13AM BLOOD ___ PTT-28.2 ___ ___ 04:13AM BLOOD Glucose-115* UreaN-43* Creat-1.3* Na-138 K-8.2* Cl-108 HCO3-20* AnGap-10 ___ 04:13AM BLOOD ALT-113* AST-175* AlkPhos-217* TotBili-2.1* ___ 04:13AM BLOOD Lipase-39 ___ 04:13AM BLOOD Albumin-2.6* ====================== DISCHARGE LAB RESULTS ====================== ___ 07:34AM BLOOD WBC-3.2* RBC-2.97* Hgb-9.1* Hct-29.1* MCV-98 MCH-30.6 MCHC-31.3* RDW-21.2* RDWSD-75.1* Plt Ct-72* ___ 07:34AM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-142 K-4.6 Cl-109* HCO3-24 AnGap-9* ___ 07:34AM BLOOD ALT-27 AST-28 LD(LDH)-236 AlkPhos-130 TotBili-1.7* =============== MICRO DATA =============== ________________________________________________________ ___ 12:46 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:42 am BLOOD CULTURE #2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 8:51 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 5:03 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECALIS. Identification and susceptibility testing performed on culture # ___ (___). Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS. __________________________________________________________ ___ 7:20 am BLOOD CULTURE 2 OF 2. FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECALIS. Identification and susceptibility testing performed on culture # ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. __________________________________________________________ ___ 7:00 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin MIC = 1.0 MCG/ML. Daptomycin test result performed by Etest. TETRACYCLINE Susceptibility testing requested per ___ (___) (___). TETRACYCLINE IS NOT INTENDED FOR THE PRIMARY TREATMENT OF BLOOD STREAM INFECTIONS. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS \| AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- 2 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ @2149 ON ___. ===================== IMAGING AND REPORTS ===================== RUQ ULTRASOUND ___ IMPRESSION: 1. No biliary dilation or gallstones. Distended gallbladder without wall thickening, as seen previously. MRCP could further evaluate for cholangitis and the gallbladder distention. 2. Cirrhotic liver with stable splenomegaly and redemonstrated patent paraumbilical vein. Patent portal vein. CHEST X-RAY ___ IMPRESSION: Low lung volumes with mild pulmonary edema and trace left pleural effusion. Persistent bibasilar atelectasis. MRCP ___ IMPRESSION: 1. No MR evidence of acute cholangitis. Apparent 4 mm central filling defect in the distal CBD likely represents a flow void, without definite evidence of choledocholithiasis. 2. Well distended gallbladder without signs of acute cholecystitis, may be due to fasting state. 3. Overall stable saccular dilation of predominantly right-sided intrahepatic bile ducts, together with cirrhotic liver morphology and portal hypertension, consistent with known ___ syndrome. TRANSTHORACIC ECHO ___ IMPRESSION: No 2D echocardiographic evidence for endocarditis. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior TTE (images not available for review) of ___ , the estimated pulmonary artery systolic pressure is now increased. Tricuspid regurgitation is more prominent. UPPER ENDOSCOPY ___ 1. One cord of grade I varices in the distal esophagus. Not bleeding. 2. Diffuse congestion, petechiae and mosaic mucosal pattern of the stomach with contact bleeding in the fundus and body. Compatible with PHG. 3. Single small non bleeding localized angioectasia seen in the second part of the duodenum. Angioectasia was ablated completely. APC was successfully applied for hemostasis. Brief Hospital Course: Mr. ___ is a ___ year old man with a history of Caroli disease, cirrhosis, known esophageal varices who developed confusion and upper GI bleeding while on vacation in ___. He was treated for acute cholangitis, upper GI bleed likely from portal hypertensive gastropathy, and hepatic encephalopathy. He was discharged on his home medications with the addition of lactulose and daptomycin. He will follow up with PCP, infectious disease and hepatology for further management. ACUTE PROBLEMS: =============== # Acute cholangitis # Enterococcus faecalis bacteremia Patient has history of recurrent cholangitis due to intrahepatic biliary ductal dilation from ___'s disease. He has been on maintenance outpatient antibiotics and hasn't had any infections since about ___. Patient developed nausea, hematemesis and bloody bowel movement while on vacation with his wife in ___. ___. The episodes were self-limited, and they presented to nearest ER on return to ___ (which was ___. He was transferred to ___. Here, MRCP did not show any specific changes in biliary ducts. However, given that his disease is intra-hepatic, imaging may not be sensitive enough to identify changes. His blood cultures grew Enterococcus faecalis, and his initial broad antibiotic coverage was adjusted to Daptomycin with input from infectious disease team. He underwent placement of PICC line on ___ and was discharged with plan to follow up with ID. Routine TTE for bacteremia was normal. # Upper GI bleed Patient has history of bleeding esophageal varices that were previously banded. Most recent EGD was in ___ and showed grade I varices in the esophagus. Due to report of hematemesis and dark stool several days prior to admission, patient underwent EGD. This showed portal hypertensive gastropathy with bleeding on contact as well as small duodenal vascular ectasia that was treated with APC. There was no evidence of variceal bleeding on this exam. Colonoscopy was not done but should be pursued outpatient given that upper endoscopy findings were relatively underwhelming. He likely developed bleeding secondary to bacteremia from a biliary source. He was maintained on PPI and will follow up with hepatology at discharge, at which time colonoscopy should be discussed. # Acute decompensated cirrhosis: hepatic encephalopathy, volume overload, UGIB # ___'s disease Admission MELD-NA of 18. Patient has ___'s disease and subsequent liver cirrhosis for about ___ years. On this admission, his cirrhosis was decompensated by hepatic encephalopathy, volume overload and portal hypertensive gastropathy with GI bleeding. He likely developed bacteremia from cholangitis, which subsequently precipitated both GI bleed and hepatic encephalopathy. Patient was started on lactulose due to encephalopathy. Wife reported that over the last several weeks patient was showing signs of forgetfulness and confusion, and then developed altered sleep pattern while on vacation. This likely occurred in the setting of infection and GI bleeding. Patient will be discharged on lactulose titrated to ___ bowel movements daily (has not previously been on lactulose). GI bleeding was addressed as above. Underwent APC this admission, no varices. He was restarted on home nadolol at discharge. Home diuretics were initially held due to acute kidney injury. After EGD, he underwent IV diuresis due to worsening lower extremity edema and dyspnea. This improved and he was restarted on home diuretics at discharge. He was continued on home ursodiol. He will follow up with liver clinic (Dr. ___. # Acute kidney injury Baseline creatinine is about 1. On initial presentation to ___ it was elevated to 1.4. It improved with fluid and albumin for volume resuscitation. He likely was volume depleted after vomiting and diarrhea. Discharge creatinine was 0.9. CHRONIC PROBLEMS: ================ # Depression - Continue home citalopram ============================== TRANSITIONAL ISSUES ============================== [] Patient will be receiving Daptomycin once a day at the ___ at ___. ___ and ___, he will get it at their ___. The rest of the days of the week, he will need to go to the ___, located in the emergency room at ___. #CODE: Full, limited trial of life sustaining measures, confirmed #CONTACT: Wife, ___, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 10 mg PO DAILY 2. Cefpodoxime Proxetil 200 mg PO Q12H 3. LevoFLOXacin 500 mg PO Q24H 4. Citalopram 20 mg PO DAILY 5. Nadolol 20 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Ursodiol 600 mg PO BID 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Magnesium Oxide 400 mg PO DAILY 10. Sildenafil 50 mg PO DAILY:PRN sexual activity 11. Furosemide 40 mg PO DAILY 12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 13. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 14. Loratadine 10 mg PO DAILY Discharge Medications: 1. Daptomycin 850 mg IV Q24H 2. Lactulose 30 mL PO Q2H RX lactulose 20 gram/30 mL 30 ml by mouth once a day Disp #1 Bottle Refills:0 3. rifAXIMin 550 mg PO BID RX rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 4. aMILoride 10 mg PO DAILY 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 6. Citalopram 20 mg PO DAILY 7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 8. Furosemide 40 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Loratadine 10 mg PO DAILY 11. Magnesium Oxide 400 mg PO DAILY 12. Nadolol 20 mg PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Sildenafil 50 mg PO DAILY:PRN sexual activity 15. Ursodiol 600 mg PO BID 16. HELD- Cefpodoxime Proxetil 200 mg PO Q12H This medication was held. Do not restart Cefpodoxime Proxetil until discussion with infectious disease team 17. HELD- LevoFLOXacin 500 mg PO Q24H This medication was held. Do not restart LevoFLOXacin until discussion with the infectious disease team Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Acute cholangitis -Enterococcus bacteremia -Acute decompensated liver cirrhosis SECONDARY: -Hepatic encephalopathy -Upper GI bleed -Acute kidney injury Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital for confusion, bleeding and concern for cholangitis. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You had an imaging study of your abdomen that did show some possibility of cholangitis. - Your blood cultures grew bacteria called Enterococcus. This was treated with IV antibiotics. - You had an endoscopy done which showed changes in your stomach due to your liver disease. You had a chemical treatment done to prevent from bleeding. No banding was done. - You had a PICC line placed so that you could get IV antibiotics at home. WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. - You are scheduled to get antibiotics at the ___ ___. ___ and ___, you will get it at their infusion center. The rest of the days of the week, you will need to go to the ___, located in the emergency room at ___ ___. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "K8309", "K31811", "I8510", "K766", "R7881", "N179", "K920", "K921", "K3189", "B952", "Z1624", "K7290", "F329", "M8580", "J302", "Z87891", "E8770", "N189", "R0683", "K219", "D6959" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Confusion, upper GI bleeding Major Surgical or Invasive Procedure: EGD [MASKED]: APC to vascular ectasia in the duodenum PICC line placement [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with a history of Caroli disease and well compensated cirrhosis who presents from [MASKED] with confusion, abdominal pain and vomiting. He was just on vacation in [MASKED] and approximately 3d ago his wife noticed that he wasn't acting like himself, was confused, and asking repetitive questions. He had diarrhea for one week, some of which was black of dark red. He also had some abomdinal pain that was not significantly different from normal, but did have some nausea and vomiting with bright red blood in the emesis. He has a history of cholangitis and typically has fevers and chills, which he hasn't had. He presented to the [MASKED] ED. At [MASKED] had WBc 13.8, INR 1.4, T bili 2.4, AST/ALT 143/123, Lactate 2.1, BNP 582, TropT 0.39. CTA without PE. CTAP with distended gallbladder with pericholecystic fluid and stone at gallbladder neck. A blood culture grew gram positive organisms in short chains. On arrival to the floor, he reports still feeling somewhat confused. He has not had further nausea/vomiting. He is very thirsty. EMERGENCY DEPARTMENT COURSE Initial vital signs were notable for: - T 96.9, HR 86, BP 129/71, RR 16, O2 95% RA Exam notable for: - Benign abdomen Labs were notable for: - ALT 108 - AP 246 - T bili 2.3 - AST 115 - Cr 1.3, BUN 43 - Lactate 2.3 Patient was given: - Zosyn - Protonix - Urosodiol 600mg - Lasix 40mg PO - Nadolol 20mg - Amliloride 10mg - Vancomycin Consults: - Hepatology ================= REVIEW OF SYSTEMS ================= Complete ROS obtained and is otherwise negative. Past Medical History: -[MASKED] Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late [MASKED] -Cirrhosis -Inguinal hernia repair in [MASKED] -Depression -Osteopenia per patient -Seasonal allergies -Bee allergy Social History: [MASKED] Family History: Mother is alive with heart disease. Father died at [MASKED] of ?cancer. No family history of liver disease or polycystic kidney disease. Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== VITALS: T 98.9, BP 127/77, HR 78, RR 22, [MASKED] GENERAL: Tired appearing, lying in bed, arousable to voice HEENT: Pupils equal and reactive, mild scleral icterus, dry mucous membranes, CARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4 LUNGS: Poor air movement, bibasilar rales, diminished lung sounds bilaterally BACK: No CVA tenderness ABDOMEN: Soft, mildly tender to palpation diffusely, worse in LUQ. Umbilical hernia soft and reducible. EXTREMITIES: 2+ pitting edema to upper shins SKIN: Scattered superficial abrasions throughout abdomen NEUROLOGIC: A+Ox3, though slow to identify date. Mild asterixis. CNII-XII normal. ======================= DISCHARGE PHYSICAL EXAM ======================= General: Elderly gentleman, sitting up in chair HEENT: Sclera anicteric, mucous membranes moist Lungs: vesicular breath sounds bilaterally CV: Regular rate and rhythm, no murmurs Abdomen: obese, distended, no tenderness to palpation, reducible umbilical hernia Ext: Warm, well perfused, [MASKED] bilateral pitting edema of lower extremities up to knees. Patient had removed compression stockings just prior to exam. Neuro: Alert, cranial nerves grossly intact Pertinent Results: ======================= ADMISSION LAB RESULTS ======================= [MASKED] 04:13AM BLOOD WBC-12.5* RBC-3.55* Hgb-10.7* Hct-32.6* MCV-92 MCH-30.1 MCHC-32.8 RDW-18.6* RDWSD-56.5* Plt Ct-82* [MASKED] 04:13AM BLOOD Neuts-87* Bands-1 Lymphs-4* Monos-2* Eos-0* [MASKED] Myelos-6* NRBC-0.2* AbsNeut-11.00* AbsLymp-0.50* AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00* [MASKED] 04:13AM BLOOD [MASKED] PTT-28.2 [MASKED] [MASKED] 04:13AM BLOOD Glucose-115* UreaN-43* Creat-1.3* Na-138 K-8.2* Cl-108 HCO3-20* AnGap-10 [MASKED] 04:13AM BLOOD ALT-113* AST-175* AlkPhos-217* TotBili-2.1* [MASKED] 04:13AM BLOOD Lipase-39 [MASKED] 04:13AM BLOOD Albumin-2.6* ====================== DISCHARGE LAB RESULTS ====================== [MASKED] 07:34AM BLOOD WBC-3.2* RBC-2.97* Hgb-9.1* Hct-29.1* MCV-98 MCH-30.6 MCHC-31.3* RDW-21.2* RDWSD-75.1* Plt Ct-72* [MASKED] 07:34AM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-142 K-4.6 Cl-109* HCO3-24 AnGap-9* [MASKED] 07:34AM BLOOD ALT-27 AST-28 LD(LDH)-236 AlkPhos-130 TotBili-1.7* =============== MICRO DATA =============== [MASKED] [MASKED] 12:46 pm BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 10:42 am BLOOD CULTURE #2. FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 8:51 am BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 5:03 am BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: ENTEROCOCCUS FAECALIS. Identification and susceptibility testing performed on culture # [MASKED] ([MASKED]). Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS. [MASKED] [MASKED] 7:20 am BLOOD CULTURE 2 OF 2. FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: ENTEROCOCCUS FAECALIS. Identification and susceptibility testing performed on culture # [MASKED] [MASKED]. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. [MASKED] [MASKED] 7:00 am BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin MIC = 1.0 MCG/ML. Daptomycin test result performed by Etest. TETRACYCLINE Susceptibility testing requested per [MASKED] ([MASKED]) ([MASKED]). TETRACYCLINE IS NOT INTENDED FOR THE PRIMARY TREATMENT OF BLOOD STREAM INFECTIONS. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS FAECALIS \| AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- 2 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by [MASKED] @2149 ON [MASKED]. ===================== IMAGING AND REPORTS ===================== RUQ ULTRASOUND [MASKED] IMPRESSION: 1. No biliary dilation or gallstones. Distended gallbladder without wall thickening, as seen previously. MRCP could further evaluate for cholangitis and the gallbladder distention. 2. Cirrhotic liver with stable splenomegaly and redemonstrated patent paraumbilical vein. Patent portal vein. CHEST X-RAY [MASKED] IMPRESSION: Low lung volumes with mild pulmonary edema and trace left pleural effusion. Persistent bibasilar atelectasis. MRCP [MASKED] IMPRESSION: 1. No MR evidence of acute cholangitis. Apparent 4 mm central filling defect in the distal CBD likely represents a flow void, without definite evidence of choledocholithiasis. 2. Well distended gallbladder without signs of acute cholecystitis, may be due to fasting state. 3. Overall stable saccular dilation of predominantly right-sided intrahepatic bile ducts, together with cirrhotic liver morphology and portal hypertension, consistent with known [MASKED] syndrome. TRANSTHORACIC ECHO [MASKED] IMPRESSION: No 2D echocardiographic evidence for endocarditis. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global biventricular systolic function. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior TTE (images not available for review) of [MASKED] , the estimated pulmonary artery systolic pressure is now increased. Tricuspid regurgitation is more prominent. UPPER ENDOSCOPY [MASKED] 1. One cord of grade I varices in the distal esophagus. Not bleeding. 2. Diffuse congestion, petechiae and mosaic mucosal pattern of the stomach with contact bleeding in the fundus and body. Compatible with PHG. 3. Single small non bleeding localized angioectasia seen in the second part of the duodenum. Angioectasia was ablated completely. APC was successfully applied for hemostasis. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with a history of Caroli disease, cirrhosis, known esophageal varices who developed confusion and upper GI bleeding while on vacation in [MASKED]. He was treated for acute cholangitis, upper GI bleed likely from portal hypertensive gastropathy, and hepatic encephalopathy. He was discharged on his home medications with the addition of lactulose and daptomycin. He will follow up with PCP, infectious disease and hepatology for further management. ACUTE PROBLEMS: =============== # Acute cholangitis # Enterococcus faecalis bacteremia Patient has history of recurrent cholangitis due to intrahepatic biliary ductal dilation from [MASKED]'s disease. He has been on maintenance outpatient antibiotics and hasn't had any infections since about [MASKED]. Patient developed nausea, hematemesis and bloody bowel movement while on vacation with his wife in [MASKED]. [MASKED]. The episodes were self-limited, and they presented to nearest ER on return to [MASKED] (which was [MASKED]. He was transferred to [MASKED]. Here, MRCP did not show any specific changes in biliary ducts. However, given that his disease is intra-hepatic, imaging may not be sensitive enough to identify changes. His blood cultures grew Enterococcus faecalis, and his initial broad antibiotic coverage was adjusted to Daptomycin with input from infectious disease team. He underwent placement of PICC line on [MASKED] and was discharged with plan to follow up with ID. Routine TTE for bacteremia was normal. # Upper GI bleed Patient has history of bleeding esophageal varices that were previously banded. Most recent EGD was in [MASKED] and showed grade I varices in the esophagus. Due to report of hematemesis and dark stool several days prior to admission, patient underwent EGD. This showed portal hypertensive gastropathy with bleeding on contact as well as small duodenal vascular ectasia that was treated with APC. There was no evidence of variceal bleeding on this exam. Colonoscopy was not done but should be pursued outpatient given that upper endoscopy findings were relatively underwhelming. He likely developed bleeding secondary to bacteremia from a biliary source. He was maintained on PPI and will follow up with hepatology at discharge, at which time colonoscopy should be discussed. # Acute decompensated cirrhosis: hepatic encephalopathy, volume overload, UGIB # [MASKED]'s disease Admission MELD-NA of 18. Patient has [MASKED]'s disease and subsequent liver cirrhosis for about [MASKED] years. On this admission, his cirrhosis was decompensated by hepatic encephalopathy, volume overload and portal hypertensive gastropathy with GI bleeding. He likely developed bacteremia from cholangitis, which subsequently precipitated both GI bleed and hepatic encephalopathy. Patient was started on lactulose due to encephalopathy. Wife reported that over the last several weeks patient was showing signs of forgetfulness and confusion, and then developed altered sleep pattern while on vacation. This likely occurred in the setting of infection and GI bleeding. Patient will be discharged on lactulose titrated to [MASKED] bowel movements daily (has not previously been on lactulose). GI bleeding was addressed as above. Underwent APC this admission, no varices. He was restarted on home nadolol at discharge. Home diuretics were initially held due to acute kidney injury. After EGD, he underwent IV diuresis due to worsening lower extremity edema and dyspnea. This improved and he was restarted on home diuretics at discharge. He was continued on home ursodiol. He will follow up with liver clinic (Dr. [MASKED]. # Acute kidney injury Baseline creatinine is about 1. On initial presentation to [MASKED] it was elevated to 1.4. It improved with fluid and albumin for volume resuscitation. He likely was volume depleted after vomiting and diarrhea. Discharge creatinine was 0.9. CHRONIC PROBLEMS: ================ # Depression - Continue home citalopram ============================== TRANSITIONAL ISSUES ============================== [] Patient will be receiving Daptomycin once a day at the [MASKED] at [MASKED]. [MASKED] and [MASKED], he will get it at their [MASKED]. The rest of the days of the week, he will need to go to the [MASKED], located in the emergency room at [MASKED]. #CODE: Full, limited trial of life sustaining measures, confirmed #CONTACT: Wife, [MASKED], [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 10 mg PO DAILY 2. Cefpodoxime Proxetil 200 mg PO Q12H 3. LevoFLOXacin 500 mg PO Q24H 4. Citalopram 20 mg PO DAILY 5. Nadolol 20 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Ursodiol 600 mg PO BID 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Magnesium Oxide 400 mg PO DAILY 10. Sildenafil 50 mg PO DAILY:PRN sexual activity 11. Furosemide 40 mg PO DAILY 12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 13. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 14. Loratadine 10 mg PO DAILY Discharge Medications: 1. Daptomycin 850 mg IV Q24H 2. Lactulose 30 mL PO Q2H RX lactulose 20 gram/30 mL 30 ml by mouth once a day Disp #1 Bottle Refills:0 3. rifAXIMin 550 mg PO BID RX rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 4. aMILoride 10 mg PO DAILY 5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 6. Citalopram 20 mg PO DAILY 7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 8. Furosemide 40 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Loratadine 10 mg PO DAILY 11. Magnesium Oxide 400 mg PO DAILY 12. Nadolol 20 mg PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Sildenafil 50 mg PO DAILY:PRN sexual activity 15. Ursodiol 600 mg PO BID 16. HELD- Cefpodoxime Proxetil 200 mg PO Q12H This medication was held. Do not restart Cefpodoxime Proxetil until discussion with infectious disease team 17. HELD- LevoFLOXacin 500 mg PO Q24H This medication was held. Do not restart LevoFLOXacin until discussion with the infectious disease team Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Acute cholangitis -Enterococcus bacteremia -Acute decompensated liver cirrhosis SECONDARY: -Hepatic encephalopathy -Upper GI bleed -Acute kidney injury Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital for confusion, bleeding and concern for cholangitis. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You had an imaging study of your abdomen that did show some possibility of cholangitis. - Your blood cultures grew bacteria called Enterococcus. This was treated with IV antibiotics. - You had an endoscopy done which showed changes in your stomach due to your liver disease. You had a chemical treatment done to prevent from bleeding. No banding was done. - You had a PICC line placed so that you could get IV antibiotics at home. WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. - You are scheduled to get antibiotics at the [MASKED] [MASKED]. [MASKED] and [MASKED], you will get it at their infusion center. The rest of the days of the week, you will need to go to the [MASKED], located in the emergency room at [MASKED] [MASKED]. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "N179", "F329", "Z87891", "N189", "K219" ]	[ "K8309: Other cholangitis", "K31811: Angiodysplasia of stomach and duodenum with bleeding", "I8510: Secondary esophageal varices without bleeding", "K766: Portal hypertension", "R7881: Bacteremia", "N179: Acute kidney failure, unspecified", "K920: Hematemesis", "K921: Melena", "K3189: Other diseases of stomach and duodenum", "B952: Enterococcus as the cause of diseases classified elsewhere", "Z1624: Resistance to multiple antibiotics", "K7290: Hepatic failure, unspecified without coma", "F329: Major depressive disorder, single episode, unspecified", "M8580: Other specified disorders of bone density and structure, unspecified site", "J302: Other seasonal allergic rhinitis", "Z87891: Personal history of nicotine dependence", "E8770: Fluid overload, unspecified", "N189: Chronic kidney disease, unspecified", "R0683: Snoring", "K219: Gastro-esophageal reflux disease without esophagitis", "D6959: Other secondary thrombocytopenia" ]
10,048,001	26,430,797	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hypotension ugib Major Surgical or Invasive Procedure: EGD, colonoscopy ___ History of Present Illness: ___ with ___'s disease (communicating cavernous ectasia, or congenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on anticoagulation now with hematemesis, fever, headache after fall. Pt was in his usual state of health until ___ (the day prior to admission) morning, when he woke up around ___ to go to the bathroom. He reports that his feet got tangled in the covers and he tripped getting out of bed - falling, and hitting the left side of his head on the wooden radiator cover. He had immediate pain, but went to the bathroom and then went back to bed. Wife reports that he slept more than usual on the day on ___. ___ evening, he felt feverish and reports taking his temperature, which was ___. Went to bed and slept normally. The morning of admission, he woke up and "felt weak." Carried a load of laundry downstairs and put laundry in the washing machine, at which point he became very nauseated. Dry heaved ___ times before vomiting a moderate amount of dark red blood with small clots. Shortly thereafter, he had a bowel movement, which he reports was black and soft. Several hours later, he had bright red blood per rectum. Called his PCP, who recommended that he come in to be evaluated. Of note, the patient was recently admitted on ___ for confusion and melena - treated for hepatic encephalopathy; found to have Enterococcus faecalis bacteremia and acute cholangitis. Underwent MRCP without any specific changes in biliary ducts. EGD showed portal hypertensive gastropathy with bleeding on contact as well as small duodenal vascular ectasia that was treated with APC. Completed two week course of daptomycin for cholangitis and was started on Augmentin for suppressive therapy. Patient had previously been on suppressive antibiotics (alternating between levofloxacin and cefpodoxime) since ___ without infections. Given recurrent resistant bacterial infections and resistance profile of bacteria, prophylaxis regimen was changed to 1 month of cefpodoxime alternating with 1 month of Augmentin at recent ID visit. He was started on Augmentin on ___ at which point right arm PICC was also removed. He was again admitted on ___ for hypoxia and found to have an acute submassive PE. At that time the patient recently had PICC removed on ___ after finishing IV daptomycin course for recent admission for enterococcus bacteremia. Doppler of right upper extremity demonstrating DVT, lower extremity dopplers negative. In this setting, PE presumed to be provoked. Discharged on rivaroxaban for anticipated 6 month course of anticoagulation. In the ED, Initial Vitals: T 97.5, HR 75, BP 90/48, RR1 8, O2 100% Exam: Unremarkable (including neuro exam), aside from guiaic positive stool. Labs: CBC: WBC 8.8 Hgb 9.8, Hct 29.8 Plt 58, LFT: ALT 59 ASt 140 AP 142 T bili 2.8 ALb 2.8 BMP Na 135 K 4.4 Cl 101 Bicarb 18 BUn 45 Cr 1.2 Lactate 3.7 Imaging: CXR: Low lung volumes with mild bibasilar atelectasis. Liver US: 1. Cirrhotic liver morphology with saccular intrahepatic biliary ductal dilatation in the right hepatic lobe consistent with patient's known ___'s syndrome. The portal veins are patent with redemonstration of reversed flow in the right portal vein. 2. Sludge within a distended gallbladder without evidence of acute cholecystitis. 3. Redemonstration of marked splenomegaly and patent umbilical vein. CT Head w/out contrast: No acute intracranial abnormality. No acute fracture. Consults: Hepatology: no need for urgent scope, admit for monitoring and management of GI bleed Interventions: -Patient had 2 PIV placed, he recieved 1 U PRBC and 1 L fluid -Patient recieved 1 gram CTX IV, octreotide IV and pantoprazole 40mg IV VS Prior to Transfer: HR 66, BP 88/51, RR 20, SpO2 97% 2L NC On arrival to the MICU, he reports feeling "okay." Wants to know when he'll be able to eat. He denies lightheadedness, dizziness, shortness of breath, chest pain, abd pain, nausea. Had one episode of BRBPR in ED, but none since and no further vomiting. Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in ___ Social History: ___ Family History: Mother has heart disease. Father died at age ___ from cancer and there is no other liver disease in his family that is known. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: BP 96/60, HR 73, RR 26, SpO2 95%/RA GEN: tired-appearing man, sitting up in bed, NAD HEENT: mildly icteric sclera, PERRL. OP clear, dry MM. NECK: supple, no LAD. CV: RRR, S1+S2, no M/R/G RESP: CTAB, no W/R/C GI: non-distended, soft, non-tender MSK: WWP, no edema SKIN: bronzed skin, no skin lesions or breakdown NEURO: alert, oriented. No asterixis. PSYCH: pleasant, euthymic DISCHARGE PHYSICAL EXAM: ======================= VITALS: 24 HR Data (last updated ___ @ 1212) Temp: 97.9 (Tm 98.2), BP: 115/70 (99-122/61-75), HR: 80 (78-90), RR: 18, O2 sat: 95% (92-96), O2 delivery: Ra, Wt: 218.69 lb/99.2 kg GENERAL: Alert and interactive, in no acute distress. HEENT: Sclera anicteric and without injection. Moist mucous membranes CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. Pertinent Results: ADMISSION LABS: ==================== ___ 02:56PM WBC-8.8 RBC-3.13 HGB-9.8* HCT-29.8* MCV-95 MCH-31.3 MCHC-32.9 RDW-19.2* RDWSD-67.0* ___ 02:56PM ___ PTT-39.3* ___ ___ 02:56PM ALT(SGPT)-59* AST(SGOT)-140* ALK PHOS-142* TOT BILI-2.8* ___ 02:56PM LIPASE-17 ___ 02:56PM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-2.1* MAGNESIUM-1.9 ___ 02:56PM GLUCOSE-128* UREA N-45* CREAT-1.2 SODIUM-135 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-18* ANION GAP-16 ___ 03:10PM LACTATE-3.7* RELEVANT IMAGING: ==================== ___ EGD: portal hypertensive gastropathy, 3 grade I varices ___ ___: internal hemorrhoids without stigmata of bleeding ___ CT head w/o con: no acute intracranial process ___ TTE: CONCLUSION: The left atrial volume index is SEVERELY increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The right atrial pressure could not be estimated. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 75 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). Mildly dilated right ventricular cavity with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE (images reviewed) of ___ , right ventricle is now dilated. Estimated pulmonary artery pressures are similar. Trivial aortic regurgitation is present. DISCHARGE LABS: ================= ___ 06:34AM BLOOD WBC-2.5* RBC-2.99* Hgb-9.3* Hct-29.4* MCV-98 MCH-31.1 MCHC-31.6* RDW-19.9* RDWSD-71.3* Plt Ct-50* ___ 06:34AM BLOOD ___ PTT-34.1 ___ ___:34AM BLOOD Glucose-90 UreaN-15 Creat-0.9 Na-143 K-4.3 Cl-109* HCO3-20* AnGap-14 ___ 06:34AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6 MICRO: ====== ___ 6:08 am URINE Source: ___. *FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 3:05 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. Brief Hospital Course: PATIENT SUMMARY: ==================== ___ with ___'s disease (communicating cavernous ectasia, orcongenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on rivaroxaban, who presented with hematemesis, fever, and headache after fall. He remained hemodynamically stable while in house, with stable hemoglobin levels. His anticoagulation was switched to Lovenox (from rivaroxaban). TRANSITIONAL ISSUES: ==================== #GI Bleed #Acute Blood Loss Anemia: [] H/H check on ___: no active bleeding identified on ___ this admission, f/u H/H after starting lovenox for PE treatment on ___. #Cirrhosis [] Electrolyte check on ___: Lasix restarted at discharge, f/u K Mg Cr. [] F/u BP: home nadolol held in setting of GI bleed and hypotension, restarted nadolol for esophageal varices at discharge. BP 110s-120s/70s on day of discharge. #PE: [] AC switched to Lovenox, to be continued through ___, then discontinued. [] Consider TTE after completion of anticoagulation course, as RV was newly dilated on TTE ___. #CODE STATUS: DNR/DNI - if there was a treatable/fixable problem that would require temporary intubation, patient would be okay with intubation in that setting. #EMERGENCY CONTACT: Wife, ___, ___ ACTIVE/ACUTE ISSUES: ==================== # GI bleed # GAVE # Hypotension Patient presented with hematemesis x1, melena x1, BRBPR x2 - consistent with either very brisk UGIB or both UGIB and LGIB. Initially intermittently hypotensive in the ICU, blood pressure responsive to IV albumin and blood transfusions. Suspect that his hypotension was secondary to initial blood loss in combination with vasoplegia from underlying liver disease. Hemoglobin remained stable throughout admission and EGD and colonoscopy showed no identifiable source of bleeding, only showed his baseline GAVE. No other acute findings. Source of the GI bleed could be a small bowel source/AVMs vs. GAVE associated oozing. He was treated with IV pantoprazole 40mg BID, octreotide drip x72 hours, and ceftriaxone prophylaxis in setting of acute bleed (___). Transitioned back to home PPI at discharge. # ___ Baseline creatinine 0.9-1.2. Creatinine initially at baseline, but increased to 1.8 in setting of hypotension and bleed. Most likely pre-renal injury, resolved after volume resuscitation. # Coagulopathy Has some degree of coagulopathy at baseline in setting of cirrhosis, but presented with INR 4.9. Unknown etiology of this elevation, could have been mild elevation from rivaroxaban in combination with recent daptomycin and Augmentin causing some vitamin K malabsorption. Received IV vitamin K 10mg in the ED with normalization of INR. # PE # Catheter associated UE DVT Patient diagnosed with upper extremity DVT and submassive PE in ___. Planned for six months of anticoagulation for provoked thrombosis (through mid ___. Had been on rivaroxaban BID (loading dose) as an outpatient prior to admission. Rivaroxaban held during this admission in setting of GI bleed. After negative EGD/colonoscopy, patient was started on heparin gtt with stable Hgb. Vascular medicine was consulted for assistance with ongoing management of AC, recommended avoiding DOACs. He was transitioned from heparin gtt to lovenox BID (more rapid reversal than warfarin in event of recurrent bleeding) on ___. ___ TTE demonstrated dilated R ventricle, similar pulmonary artery pressures to most recent TTE on ___, no evidence of R heart failure. # Transaminitis Mild transaminitis, likely due to hypotension. Improving at time of discharge. # Fall Sounds mechanical in nature, per patient. No bleeding prior to fall, does not sound syncopal. CT head with no evidence of intracranial pathology or skull trauma. ___ was consulted, felt that there were no acute ___ needs. # ___ syndrome # Cirrhosis # Thrombocytopenia Childs class B cirrhosis; MELD-Na 31 on admission (largely driven by INR). History of hepatic encephalopathy, although none this admission. ___ EGD with one cord grade I varices, gastropathy, duodenal vascular ectasia status post APC, history of esophageal banding. EGD this admission with 3 cords of grade I varices in distal esophagus, nonbleeding, and portal hypertensive gastropathy. No tappable ascites pocket in the ED, no history of SBP. Continued home lactulose. Held nadolol and furosemide given recent GIB, restarted at time of discharge. CHRONIC ISSUES: ==================== # History of recurrent cholangitis Recurrent episodes of cholangitis due to biliary ductal dilation from ___'s disease. US on admission without evidence of cholangitis. History of CRE. Continued prophylactic Augmentin 850mg BID, ursodiol 600 mg BID. # Depression: continued citalopram 20mg daily Medications on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 10 mg PO DAILY 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 3. Citalopram 20 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Loratadine 10 mg PO DAILY 7. Nadolol 20 mg PO DAILY 8. Ursodiol 600 mg PO BID 9. rifAXIMin 550 mg PO BID 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 11. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 13. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 14. Magnesium Oxide 400 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Rivaroxaban 15 mg PO BID Discharge Medications: 1. Acyclovir 400 mg PO Q8H Duration: 5 Days RX acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #9 Tablet Refills:0 2. Enoxaparin Sodium 100 mg SC Q12H RX enoxaparin 100 mg/mL 1 ml SC every twelve (12) hours Disp #60 Syringe Refills:*0 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 4. aMILoride 10 mg PO DAILY 5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 6. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 7. Citalopram 20 mg PO DAILY 8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 9. Furosemide 40 mg PO DAILY 10. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel Movements per day 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Loratadine 10 mg PO DAILY 13. Magnesium Oxide 400 mg PO DAILY 14. Nadolol 20 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Ursodiol 600 mg PO BID 18.Outpatient Lab Work ICD-___ Please check CBC and chem ___ Fax results to Dr. ___ at ___ and Dr. ___ at ___ Discharge Disposition: Home Discharge Diagnosis: Primary: GI Bleed Secondary: ___ disease Childs class B cirrhosis Pulmonary embolism Catheter-associated upper extremity DVT Coagulopathy Thrombocytopenia ___ Fall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure being a part of your care at ___! WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had a fall at home, fever, headache, and had blood in vomit and stool. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You were found to have very low blood pressure. You were admitted to the ICU and given medications and blood transfusions to support your blood pressure and replace blood loss. - You were given medication to stop the bleeding. - You had an EGD and colonoscopy which did not identify any active sites of bleeding. - Your blood counts were monitored and remained stable. - Your home medication rivaroxaban was discontinued and you were started on enoxaparin (lovenox) to treat your pulmonary embolism and deep vein thrombosis (blood clots). WHAT SHOULD YOU DO WHEN YOU LEAVE? - You should get blood work checked on ___. - You should follow up with your PCP, ___, and Infectious Disease doctors in outpatient ___ as listed below. - Please seek medical attention immediately if you feel dizzy/lightheaded, notice bloody or black stools, or have any other symptoms that concern you. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "K31811", "D62", "N179", "D684", "I2782", "T82868A", "I82721", "K766", "Q445", "T82818A", "I8510", "Z66", "K7460", "T360X5A", "T368X5A", "W01190A", "Y92003", "K3189", "F329", "M8580", "J302", "D696", "K648", "Z7901", "Z87891", "E8809", "D72819", "E8770" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: hypotension ugib Major Surgical or Invasive Procedure: EGD, colonoscopy [MASKED] History of Present Illness: [MASKED] with [MASKED]'s disease (communicating cavernous ectasia, or congenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on anticoagulation now with hematemesis, fever, headache after fall. Pt was in his usual state of health until [MASKED] (the day prior to admission) morning, when he woke up around [MASKED] to go to the bathroom. He reports that his feet got tangled in the covers and he tripped getting out of bed - falling, and hitting the left side of his head on the wooden radiator cover. He had immediate pain, but went to the bathroom and then went back to bed. Wife reports that he slept more than usual on the day on [MASKED]. [MASKED] evening, he felt feverish and reports taking his temperature, which was [MASKED]. Went to bed and slept normally. The morning of admission, he woke up and "felt weak." Carried a load of laundry downstairs and put laundry in the washing machine, at which point he became very nauseated. Dry heaved [MASKED] times before vomiting a moderate amount of dark red blood with small clots. Shortly thereafter, he had a bowel movement, which he reports was black and soft. Several hours later, he had bright red blood per rectum. Called his PCP, who recommended that he come in to be evaluated. Of note, the patient was recently admitted on [MASKED] for confusion and melena - treated for hepatic encephalopathy; found to have Enterococcus faecalis bacteremia and acute cholangitis. Underwent MRCP without any specific changes in biliary ducts. EGD showed portal hypertensive gastropathy with bleeding on contact as well as small duodenal vascular ectasia that was treated with APC. Completed two week course of daptomycin for cholangitis and was started on Augmentin for suppressive therapy. Patient had previously been on suppressive antibiotics (alternating between levofloxacin and cefpodoxime) since [MASKED] without infections. Given recurrent resistant bacterial infections and resistance profile of bacteria, prophylaxis regimen was changed to 1 month of cefpodoxime alternating with 1 month of Augmentin at recent ID visit. He was started on Augmentin on [MASKED] at which point right arm PICC was also removed. He was again admitted on [MASKED] for hypoxia and found to have an acute submassive PE. At that time the patient recently had PICC removed on [MASKED] after finishing IV daptomycin course for recent admission for enterococcus bacteremia. Doppler of right upper extremity demonstrating DVT, lower extremity dopplers negative. In this setting, PE presumed to be provoked. Discharged on rivaroxaban for anticipated 6 month course of anticoagulation. In the ED, Initial Vitals: T 97.5, HR 75, BP 90/48, RR1 8, O2 100% Exam: Unremarkable (including neuro exam), aside from guiaic positive stool. Labs: CBC: WBC 8.8 Hgb 9.8, Hct 29.8 Plt 58, LFT: ALT 59 ASt 140 AP 142 T bili 2.8 ALb 2.8 BMP Na 135 K 4.4 Cl 101 Bicarb 18 BUn 45 Cr 1.2 Lactate 3.7 Imaging: CXR: Low lung volumes with mild bibasilar atelectasis. Liver US: 1. Cirrhotic liver morphology with saccular intrahepatic biliary ductal dilatation in the right hepatic lobe consistent with patient's known [MASKED]'s syndrome. The portal veins are patent with redemonstration of reversed flow in the right portal vein. 2. Sludge within a distended gallbladder without evidence of acute cholecystitis. 3. Redemonstration of marked splenomegaly and patent umbilical vein. CT Head w/out contrast: No acute intracranial abnormality. No acute fracture. Consults: Hepatology: no need for urgent scope, admit for monitoring and management of GI bleed Interventions: -Patient had 2 PIV placed, he recieved 1 U PRBC and 1 L fluid -Patient recieved 1 gram CTX IV, octreotide IV and pantoprazole 40mg IV VS Prior to Transfer: HR 66, BP 88/51, RR 20, SpO2 97% 2L NC On arrival to the MICU, he reports feeling "okay." Wants to know when he'll be able to eat. He denies lightheadedness, dizziness, shortness of breath, chest pain, abd pain, nausea. Had one episode of BRBPR in ED, but none since and no further vomiting. Past Medical History: -[MASKED] Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late [MASKED] -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in [MASKED] Social History: [MASKED] Family History: Mother has heart disease. Father died at age [MASKED] from cancer and there is no other liver disease in his family that is known. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: BP 96/60, HR 73, RR 26, SpO2 95%/RA GEN: tired-appearing man, sitting up in bed, NAD HEENT: mildly icteric sclera, PERRL. OP clear, dry MM. NECK: supple, no LAD. CV: RRR, S1+S2, no M/R/G RESP: CTAB, no W/R/C GI: non-distended, soft, non-tender MSK: WWP, no edema SKIN: bronzed skin, no skin lesions or breakdown NEURO: alert, oriented. No asterixis. PSYCH: pleasant, euthymic DISCHARGE PHYSICAL EXAM: ======================= VITALS: 24 HR Data (last updated [MASKED] @ 1212) Temp: 97.9 (Tm 98.2), BP: 115/70 (99-122/61-75), HR: 80 (78-90), RR: 18, O2 sat: 95% (92-96), O2 delivery: Ra, Wt: 218.69 lb/99.2 kg GENERAL: Alert and interactive, in no acute distress. HEENT: Sclera anicteric and without injection. Moist mucous membranes CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. Pertinent Results: ADMISSION LABS: ==================== [MASKED] 02:56PM WBC-8.8 RBC-3.13 HGB-9.8* HCT-29.8* MCV-95 MCH-31.3 MCHC-32.9 RDW-19.2* RDWSD-67.0* [MASKED] 02:56PM [MASKED] PTT-39.3* [MASKED] [MASKED] 02:56PM ALT(SGPT)-59* AST(SGOT)-140* ALK PHOS-142* TOT BILI-2.8* [MASKED] 02:56PM LIPASE-17 [MASKED] 02:56PM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-2.1* MAGNESIUM-1.9 [MASKED] 02:56PM GLUCOSE-128* UREA N-45* CREAT-1.2 SODIUM-135 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-18* ANION GAP-16 [MASKED] 03:10PM LACTATE-3.7* RELEVANT IMAGING: ==================== [MASKED] EGD: portal hypertensive gastropathy, 3 grade I varices [MASKED] [MASKED]: internal hemorrhoids without stigmata of bleeding [MASKED] CT head w/o con: no acute intracranial process [MASKED] TTE: CONCLUSION: The left atrial volume index is SEVERELY increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The right atrial pressure could not be estimated. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 75 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). Mildly dilated right ventricular cavity with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior TTE (images reviewed) of [MASKED] , right ventricle is now dilated. Estimated pulmonary artery pressures are similar. Trivial aortic regurgitation is present. DISCHARGE LABS: ================= [MASKED] 06:34AM BLOOD WBC-2.5* RBC-2.99* Hgb-9.3* Hct-29.4* MCV-98 MCH-31.1 MCHC-31.6* RDW-19.9* RDWSD-71.3* Plt Ct-50* [MASKED] 06:34AM BLOOD [MASKED] PTT-34.1 [MASKED] [MASKED]:34AM BLOOD Glucose-90 UreaN-15 Creat-0.9 Na-143 K-4.3 Cl-109* HCO3-20* AnGap-14 [MASKED] 06:34AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6 MICRO: ====== [MASKED] 6:08 am URINE Source: [MASKED]. *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 3:05 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. Brief Hospital Course: PATIENT SUMMARY: ==================== [MASKED] with [MASKED]'s disease (communicating cavernous ectasia, orcongenital cystic dilatation of the intrahepatic biliary tree) cirrhosis, recurrent cholangitis and sepsis, recent PE with RV strain on rivaroxaban, who presented with hematemesis, fever, and headache after fall. He remained hemodynamically stable while in house, with stable hemoglobin levels. His anticoagulation was switched to Lovenox (from rivaroxaban). TRANSITIONAL ISSUES: ==================== #GI Bleed #Acute Blood Loss Anemia: [] H/H check on [MASKED]: no active bleeding identified on [MASKED] this admission, f/u H/H after starting lovenox for PE treatment on [MASKED]. #Cirrhosis [] Electrolyte check on [MASKED]: Lasix restarted at discharge, f/u K Mg Cr. [] F/u BP: home nadolol held in setting of GI bleed and hypotension, restarted nadolol for esophageal varices at discharge. BP 110s-120s/70s on day of discharge. #PE: [] AC switched to Lovenox, to be continued through [MASKED], then discontinued. [] Consider TTE after completion of anticoagulation course, as RV was newly dilated on TTE [MASKED]. #CODE STATUS: DNR/DNI - if there was a treatable/fixable problem that would require temporary intubation, patient would be okay with intubation in that setting. #EMERGENCY CONTACT: Wife, [MASKED], [MASKED] ACTIVE/ACUTE ISSUES: ==================== # GI bleed # GAVE # Hypotension Patient presented with hematemesis x1, melena x1, BRBPR x2 - consistent with either very brisk UGIB or both UGIB and LGIB. Initially intermittently hypotensive in the ICU, blood pressure responsive to IV albumin and blood transfusions. Suspect that his hypotension was secondary to initial blood loss in combination with vasoplegia from underlying liver disease. Hemoglobin remained stable throughout admission and EGD and colonoscopy showed no identifiable source of bleeding, only showed his baseline GAVE. No other acute findings. Source of the GI bleed could be a small bowel source/AVMs vs. GAVE associated oozing. He was treated with IV pantoprazole 40mg BID, octreotide drip x72 hours, and ceftriaxone prophylaxis in setting of acute bleed ([MASKED]). Transitioned back to home PPI at discharge. # [MASKED] Baseline creatinine 0.9-1.2. Creatinine initially at baseline, but increased to 1.8 in setting of hypotension and bleed. Most likely pre-renal injury, resolved after volume resuscitation. # Coagulopathy Has some degree of coagulopathy at baseline in setting of cirrhosis, but presented with INR 4.9. Unknown etiology of this elevation, could have been mild elevation from rivaroxaban in combination with recent daptomycin and Augmentin causing some vitamin K malabsorption. Received IV vitamin K 10mg in the ED with normalization of INR. # PE # Catheter associated UE DVT Patient diagnosed with upper extremity DVT and submassive PE in [MASKED]. Planned for six months of anticoagulation for provoked thrombosis (through mid [MASKED]. Had been on rivaroxaban BID (loading dose) as an outpatient prior to admission. Rivaroxaban held during this admission in setting of GI bleed. After negative EGD/colonoscopy, patient was started on heparin gtt with stable Hgb. Vascular medicine was consulted for assistance with ongoing management of AC, recommended avoiding DOACs. He was transitioned from heparin gtt to lovenox BID (more rapid reversal than warfarin in event of recurrent bleeding) on [MASKED]. [MASKED] TTE demonstrated dilated R ventricle, similar pulmonary artery pressures to most recent TTE on [MASKED], no evidence of R heart failure. # Transaminitis Mild transaminitis, likely due to hypotension. Improving at time of discharge. # Fall Sounds mechanical in nature, per patient. No bleeding prior to fall, does not sound syncopal. CT head with no evidence of intracranial pathology or skull trauma. [MASKED] was consulted, felt that there were no acute [MASKED] needs. # [MASKED] syndrome # Cirrhosis # Thrombocytopenia Childs class B cirrhosis; MELD-Na 31 on admission (largely driven by INR). History of hepatic encephalopathy, although none this admission. [MASKED] EGD with one cord grade I varices, gastropathy, duodenal vascular ectasia status post APC, history of esophageal banding. EGD this admission with 3 cords of grade I varices in distal esophagus, nonbleeding, and portal hypertensive gastropathy. No tappable ascites pocket in the ED, no history of SBP. Continued home lactulose. Held nadolol and furosemide given recent GIB, restarted at time of discharge. CHRONIC ISSUES: ==================== # History of recurrent cholangitis Recurrent episodes of cholangitis due to biliary ductal dilation from [MASKED]'s disease. US on admission without evidence of cholangitis. History of CRE. Continued prophylactic Augmentin 850mg BID, ursodiol 600 mg BID. # Depression: continued citalopram 20mg daily Medications on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride 10 mg PO DAILY 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 3. Citalopram 20 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Loratadine 10 mg PO DAILY 7. Nadolol 20 mg PO DAILY 8. Ursodiol 600 mg PO BID 9. rifAXIMin 550 mg PO BID 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 11. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction 13. Lactulose 30 mL PO Q8H:PRN As needed to have [MASKED] Bowel Movements per day 14. Magnesium Oxide 400 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Rivaroxaban 15 mg PO BID Discharge Medications: 1. Acyclovir 400 mg PO Q8H Duration: 5 Days RX acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp #9 Tablet Refills:0 2. Enoxaparin Sodium 100 mg SC Q12H RX enoxaparin 100 mg/mL 1 ml SC every twelve (12) hours Disp #60 Syringe Refills:*0 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 4. aMILoride 10 mg PO DAILY 5. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 6. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral DAILY 7. Citalopram 20 mg PO DAILY 8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction Duration: 1 Dose 9. Furosemide 40 mg PO DAILY 10. Lactulose 30 mL PO Q8H:PRN As needed to have [MASKED] Bowel Movements per day 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Loratadine 10 mg PO DAILY 13. Magnesium Oxide 400 mg PO DAILY 14. Nadolol 20 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Sildenafil 50 mg PO DAILY:PRN sexual activity 17. Ursodiol 600 mg PO BID 18.Outpatient Lab Work ICD-[MASKED] Please check CBC and chem [MASKED] Fax results to Dr. [MASKED] at [MASKED] and Dr. [MASKED] at [MASKED] Discharge Disposition: Home Discharge Diagnosis: Primary: GI Bleed Secondary: [MASKED] disease Childs class B cirrhosis Pulmonary embolism Catheter-associated upper extremity DVT Coagulopathy Thrombocytopenia [MASKED] Fall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure being a part of your care at [MASKED]! WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had a fall at home, fever, headache, and had blood in vomit and stool. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You were found to have very low blood pressure. You were admitted to the ICU and given medications and blood transfusions to support your blood pressure and replace blood loss. - You were given medication to stop the bleeding. - You had an EGD and colonoscopy which did not identify any active sites of bleeding. - Your blood counts were monitored and remained stable. - Your home medication rivaroxaban was discontinued and you were started on enoxaparin (lovenox) to treat your pulmonary embolism and deep vein thrombosis (blood clots). WHAT SHOULD YOU DO WHEN YOU LEAVE? - You should get blood work checked on [MASKED]. - You should follow up with your PCP, [MASKED], and Infectious Disease doctors in outpatient [MASKED] as listed below. - Please seek medical attention immediately if you feel dizzy/lightheaded, notice bloody or black stools, or have any other symptoms that concern you. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "D62", "N179", "Z66", "F329", "D696", "Z7901", "Z87891" ]	[ "K31811: Angiodysplasia of stomach and duodenum with bleeding", "D62: Acute posthemorrhagic anemia", "N179: Acute kidney failure, unspecified", "D684: Acquired coagulation factor deficiency", "I2782: Chronic pulmonary embolism", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "I82721: Chronic embolism and thrombosis of deep veins of right upper extremity", "K766: Portal hypertension", "Q445: Other congenital malformations of bile ducts", "T82818A: Embolism due to vascular prosthetic devices, implants and grafts, initial encounter", "I8510: Secondary esophageal varices without bleeding", "Z66: Do not resuscitate", "K7460: Unspecified cirrhosis of liver", "T360X5A: Adverse effect of penicillins, initial encounter", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "W01190A: Fall on same level from slipping, tripping and stumbling with subsequent striking against furniture, initial encounter", "Y92003: Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "K3189: Other diseases of stomach and duodenum", "F329: Major depressive disorder, single episode, unspecified", "M8580: Other specified disorders of bone density and structure, unspecified site", "J302: Other seasonal allergic rhinitis", "D696: Thrombocytopenia, unspecified", "K648: Other hemorrhoids", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "D72819: Decreased white blood cell count, unspecified", "E8770: Fluid overload, unspecified" ]
10,048,001	28,046,191	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: ___ line placement ___ attach Pertinent Results: ADMISSION LABS: =============== ___ 09:02PM BLOOD WBC-3.8* RBC-3.31* Hgb-9.6* Hct-29.7* MCV-90 MCH-29.0 MCHC-32.3 RDW-19.2* RDWSD-62.5* Plt Ct-65* ___ 09:02PM BLOOD Neuts-73* Bands-3 Lymphs-7* Monos-15* Eos-1 Baso-0 ___ Metas-1* Myelos-0 Other-0 AbsNeut-2.89 AbsLymp-0.27* AbsMono-0.57 AbsEos-0.04 AbsBaso-0.00* ___ 09:08PM BLOOD ___ PTT-38.7* ___ ___ 09:02PM BLOOD Glucose-163* UreaN-24* Creat-1.5* Na-138 K-4.6 Cl-103 HCO3-21* AnGap-14 ___ 09:02PM BLOOD ALT-22 AST-37 AlkPhos-204* TotBili-1.0 ___ 05:16AM BLOOD Calcium-8.2* Phos-2.0* Mg-1.6 ___ 09:02PM BLOOD Albumin-3.2* ___ 01:42AM BLOOD Lactate-2.1* ___ 03:37AM BLOOD Lactate-2.1* DISCHARGE LABS: ================ no labs on day of discharge IMAGING: ========= RUQUS ___: 1. Cirrhotic liver morphology without concerning focal lesion. Saccular intrahepatic biliary ductal dilatation in the right hepatic lobe appears similar to prior, consistent with known ___ disease. No localizing source of infection. 2. Unremarkable gallbladder. 3. Marked splenomegaly and patent portal and umbilical veins. PET ___: FINDINGS: HEAD/NECK: No abnormal FDG uptake noted in the head or neck. CHEST: No abnormal FDG uptake noted in the chest. There is redemonstration of a1.0 cm epicardial lymph node demonstrating an SUV max 2.8 (CT ___, PET 140). ABDOMEN/PELVIS: Increased FDG uptake noted diffusely throughout the liver, which may represent an inflammatory process. Additionally, there are two foci of increased FDG uptake within the prostate, demonstrating an SUV max of 5.6, suggestive of prostatitis (CT ___, PET 265).There are multiple intrahepatic biliary cystic lesions in the right lobe of the liver, compatible with known ___ disease. Nodular hepatic contour is due to known cirrhosis. Redemonstration of a 1.3 cm periportal lymph node demonstrating SUV max of 4.4 (CT ___, PET 169). Persistent splenomegaly measuring up to 20.4 cm. MUSCULOSKELETAL: No abnormal FDG uptake. Physiologic uptake is seen in the brain, myocardium, salivary glands, GI and GU tracts, and spleen. IMPRESSION: 1. Foci of increased FDG uptake within the prostate suggestive of prostatitis; consider as possible source of bacteremia. 2. Diffuse increased FDG uptake throughout the liver may be due to inflammatory process, possibly secondary to ___ disease. TTE ___: The inferior vena cava diameter is normal. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is >=60%. The right ventricle has normal free wall motion. The aortic valve leaflets (3) appear structurally normal. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. 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. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. No masses/vegetations are seen on the pulmonic valve. There is mild pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. There is a central jet of mild to moderate [___] tricuspid regurgitation. There is SEVERE pulmonary artery systolic hypertension. The end-diastolic PR velocity is elevated suggesting pulmonary artery diastolic hypertension. IMPRESSION: No 2D echocardiographic evidence for endocarditis. Severe pulmonary artery systolic hypertension. Compared with the prior TTE (images reviewed) of ___ , slightly more tricuspid regurgitation and slightly higher pulmonary pressure but overall no major change. PROSTATE ULTRASOUND ___: Prostate measures 5.2cm x 4.1cm x 5.5cm. This corresponds to a calculated volume of 61 cm3. The predicted PSA is 7.3. There is enlargement of the central gland consistent with BPH. There is no evidence of prostatic or periprostatic fluid collection. Seminal vesicles are symmetric and appear within normal limits. IMPRESSION: Enlarged prostate consistent with BPH. No discrete fluid collections identified to suggest abscess.d TTE ___: There is no evidence for a right-to-left shunt with agitated saline at rest and with maneuvers. The left ventricle has a normal cavity size. Overall left ventricular systolic function is normal. Mildly dilated right ventricular cavity with depressed free wall motion. IMPRESSION: No right-to-left shunt identified. PFT ___: IMPRESSION MECHANICS: The FVC is moderately reduced. The reduction in FEV1 is moderately severe. The FEV1/FVC ratio is normal. FLOW-VOLUME LOOP: Moderately reduced flows and volume. LUNG VOLUMES: The TLC is moderately reduced. The FRC and RV are mildly reduced. The RV/TLC ratio is elevated. DLCO: The diffusion capacity corrected for hemoglobin is mildly reduced. Impression: Results are consistent with a moderate restrictive ventilatory defect and mild gas exchange defect. There are no prior studies avaialble for comparison. MRCP ___: IMPRESSION: 1. Stable saccular dilatation of the right sided intrahepatic bile ducts consistent with history of ___ disease. No cholangitis or intrahepatic abscess noted. No suspicious enhancing masses or lesions to suggest cholangiocarcinoma. The liver demonstrates a cirrhotic morphology with stigmata of portal hypertension in the form of splenomegaly. Patent portal vein and its branches. No ascites. 2. Small right pleural effusion. Stress Echo ___: CONCLUSION: Fair functional exercise capacity for age and gender. Non-specific ECG changes with no symptoms to achieved treadmill stress. No 2D echocardiographic evidence of inducible ischemia to achieved workload. No Doppler evidence for a change in left ventricular filling pressure with exercise. Mild mitral regurgitation at rest. Moderately increased pulmonary artery systolic pressure at rest with a moderate increase after exercise. Normal resting blood pressure with a normal blood pressure and a blunted heart rate response to achieved workload. V/Q Scan ___: IMPRESSION: Very low likelihood of pulmonary embolization. MICROBIOLOGY: ============= Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. TETRACYCLINE Susceptibility testing requested per ___ ___ ___. TETRACYCLINE IS NOT APPROPRIATE FOR PRIMARY THERAPY OF BLOODSTREAM INFECTIONS.. ORGANISMS THAT ARE SUSCEPTIBLE TO TETRACYCLINE ARE CONSIDERED SUSCEPTIBLE TO MINOCYCLINE AND DOXYCYCLINE. Daptomycin MIC OF 2 MCG/ML : test result performed by Etest. . HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. . LINEZOLID :ADDED ON PER ___ ON ___, 12:30PM. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ <=0.5 S Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ (___) AT 1515 ON ___. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin MIC = 4 MCG/ML test result performed by Etest. TETRACYCLINE REQUESTED BY ___ (___) ___. TETRACYCLINE IS NOT APPROPRIATE FOR PRIMARY THERAPY OF BLOODSTREAM INFECTIONS.. ORGANISMS THAT ARE SUSCEPTIBLE TO TETRACYCLINE ARE CONSIDERED SUSCEPTIBLE TO MINOCYCLINE AND DOXYCYCLINE.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S PENICILLIN G---------- =>___ R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ AT 0422 ON ___. Brief Hospital Course: BRIEF HOSPITAL SUMMARY: ======================= ___ year old male with hx of ___ disease complicated by cirrhosis, history of varices, hepatic encephalopathy, and pulmonary HTN, Pulmonary embolism from DVT on lovenox, with recent admission for ampicillin-resistant enterococcus bacteremia (IV ABX finished___)presented with 3 days of lethargy, weakness, and fevers found to have recurrent E. Faecium Bacteremia. The patient was started on dapto/ceftaroline and once the sensitivities resulted was narrowed to daptomycin. He had breakthrough fevers and positive blood cultures growing GPC therefore daptomycin was discontinued and linezolid PO started. Due to his recurrent bacteremia and history of cholecytitis he underwent a tagged WBC scan, that unfortunately did not reveal any source of infection. A TTE was negative for vegetatons. Its presumed that his liver disease is the culprit for these frequent infections. The patient will be on a 6 week course of linezolid from his last negative culture date (___) with an end date of ___, with tentative plans to begin a suppressive antibiotic regimen with minocycline. The patient will see infectious disease as an outpatient.His Picc line was also removed and the culture has no growth to date. Removal of the picc resulted in an upper extremity DVT, and consequently was started on ___ with plans for a third month outpatient course. Of note, the patient has a history of for a submassive PE ___ PICC-associated DVT. While he was being treated for this bacteremia, his transplant work up was progressed. Please see the transition issues below for a list of his outstanding work up. TRANSITIONAL ISSUES: ==================== # CODE: Full code, presumed # CONTACT: ___ (wife) ___ MED CHANGES/ADDITONS: [] ___ has been on nadolol since ___ and had 3 grade I varices in ___ --> holding nadolol on dc since he has not been getting it. ___ need EGD again as outpatient. [] linezolid six week course for bacteremia (ending ___, ___. Will f/u with ID as outpatient. Plan for starting suppressive abx regimen thereafter. [] Patient with one episode of paroxysmal afib. Please consider zio patch as outpatient to determine need for anticoagulation (since 6-month lovenox treatment for PE has finished). [] First dose Hep B given ___. Will need to complete course. [] CA ___ elevated 10,425 (___). Repeat CA ___ after antibiotics; may need ERCP with brushings if remains elevated. [] mumps non immune (holding immunization since actively infected and leukopenic right now), requires MMR Vaccine [] needs sleep study as outpatient per pulmonary to workup for pulmonary hypertension [] Repeat 6 minute walk test as outpatient [] Consider transitioning to from ___ to DOAC (Childs ___ A) for ease of use in provoked DVT tx [] PSA elevated this admission and is undergoing liver transplant workup, will need to follow up with urology outpatient. [] Will need weekly CBC for monitoring of cytopenias on Linezolid, to be monitored by ___ clinic. [] Will eventually need suppressive minocycline therapy for Caroli disease related infections, after completing linezolid ACTIVE ISSUES ============= # Enterococcus Bacteremia, ampicillin-resistant # Fever, Lethargy, weakness Long history of multiple hospitalizations for E. Faecium bacteremia which was previously pan-sensitive but was noted to be newly ampicillin-resistant at his last admission and was treated with daptomycin (since developed neutropenia on vancomycin) and finished course ___. After one day, he developed lethargy, weakness, and fevers. Blood cultures grew enterococcus faecium with increasing resistance to daptomycin. Search for source has been unrevealing besides prostatitis (including PET, repeat MRCPs, TTEs, tagged WBC study ) and most likely source is ascending cholangitis from underlying liver disease. He is undergoing liver transplant workup as there is no intervention to prevent recurrent infection, and his infections are becoming increasing more resistant to antibiotics. Setting up outpatient antibiotics had been very difficult due to the high cost of antibiotics, insurance will not cover home infusion, and ___ will not allow him to come twice a day for infusions. He will be discharged on PO linezolid for a total of six weeks and will follow up in infectious disease clinic. #Liver transplant work-up Discussed that underlying ___ syndrome is likely cause of recurrent bacteremia. Only definitive treatment would be liver transplant which he has not yet been evaluated for but ___ B class supports he should be. Discussed deceased and living donor transplant but he stated he would not feel comfortable asking anyone in his family to donate their liver for him at the current moment. #Elevated CA ___ CA ___ ___ (___), with previous CA ___. Concerning for cholangiocarcinoma. Back in ___, alk phos was normal and 67. Now alk phos has been elevated. ERCP would be reasonable to assess for cholangiocarcinoma, but may be risky since patient is frequently bacteremic, and CA ___ be elevated in thesetting of the ongoing, active disease in the bile ducts. MRCP ___ was without evidence of cholangiocarcinoma. Repeat CA ___ after antibiotics; may need ERCP with brushings if remains elevated. #Elevated PSA PSA 19.4. Checked as part of liver transplant work-up. Per OSH records, PSA 1.64 on ___. DRE with enlarged prostate and no focal nodules. PET CT with two foci on the prostate concerning for prostatitis. Prostate ultrasound with evidence of BPH. The patient will follow up with urology as an outpatient to determine need for prostate biopsy. #New-onset paroxysmal afib New-onset paroxysmal afib to 190s upon arrival to the floor. Unclear etiology, could be related to infection in setting of bacteremia. His home nadolol was discontinued, and he was started on metoprolol 12.5mg twice daily that was later discontinued when he became bacteremic again. He returned to normal sinus rhythm. CHADSVASC 1. Please consider zio patch as outpatient to determine need for anticoagulation (since 6-month lovenox treatment for PE has finished). #Pulmonary HTN Patient is asymptomatic and not hypoxic or platypneic to suggest hepatopulmonary syndrome. No ascites for hepatic hydrothorax. Most recent TTE ___ with PASP 61, slightly increased from previous TTE ___. TTE with bubble study without evidence of shunt. V/Q scan with low likelihood of PE. A right heart cath demonstrated elevated right heart filling pressure and mild pulmonary hypertension. The mild elevation of pulmonary artery pressures was thought to, to some degree, be attributable to the high cardiac output. #Cirrhosis ___ syndrome ___ B. Meld-Na 9 today. Well-compensated when not actively infected. - VARICES: EGD ___ with grade I varices in distal esophagus. Also PHGP noted in stomach. History of banded varices per patient. Discontinued nadolol and briefly on metoprolol for afib. Will be discharged without B-blocker therapy, as there is no clear indication. - ASCITES: continued home diuretics given lower extremity swelling - COAGULOPATHY: no evidence of bleeding. - HE: A&Ox3, holding home lactulose. On rifaximin. - HRS: previously with ___, now resolved - CIRRHOSIS: likely secondary to ___. Vaccinated against hepatitis A. non-immune to hepatitis B. First dose Hep B given ___. - Continue ursodiol #Acute kidney injury- Resolved Cr elevated to 1.5 --> 1.3 upon admission, which was 0.8 previously upon discharge from last admission. s/p 2L with improvement in Cr, and thus likely pre-renal. #Pulmonary embolism Hospitalized recently in ___ for a submassive PE ___ PICC-associated DVT, originally started on Xarelto but had hematemesis, BRBPR, hypotension requiring a MICU admission. Now on Lovenox, which he is tolerating well. No chest pain, shortness of breath, hypoxia, or e/o bleeding. Finished ___. V/Q scan with low likelihood of PE. Discontinued home LMWH 100 mg SC BID, but later it was restarted for a RUE DVT. Consider transition to DOAC as outpatient for ease of use. #Depression: - Continued home citalopram 20 mg daily #GERD - Continued home pantoprazole #Glaucoma - Continued home latanoprost Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Enoxaparin Sodium 100 mg SC Q12H 3. Lactulose 30 mL PO Q8H:PRN encephalopathy 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Pantoprazole 40 mg PO Q24H 6. Ursodiol 600 mg PO BID 7. Daptomycin 600 mg IV Q24H 8. Furosemide 40 mg PO DAILY 9. Magnesium Oxide 400 mg PO DAILY 10. Nadolol 20 mg PO DAILY 11. aMILoride 5 mg PO DAILY 12. rifAXIMin 550 mg PO BID Discharge Medications: 1. Linezolid ___ mg PO Q12H RX linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 2. Spironolactone 100 mg PO DAILY RX spironolactone 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. aMILoride 5 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Enoxaparin Sodium 100 mg SC Q12H RX enoxaparin 100 mg/mL 100mg twice a day Disp #5 Syringe Refills:*1 6. Furosemide 40 mg PO DAILY 7. Lactulose 30 mL PO Q8H:PRN encephalopathy 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Magnesium Oxide 400 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. rifAXIMin 550 mg PO BID 12. Ursodiol 600 mg PO BID 13.Outpatient Lab Work ICD code: ___ LABS TO CHECK: Weekly CBC with differential ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Ampicillin-resistant enterococcus bacteremia Cirrhosis secondary to ___ disease Provoked DVT from ___ Elevated PSA SECONDARY DIAGNOSIS: ==================== New-onset paroxysmal atrial fibrillation Pulmonary Hypertension Pulmonary embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you had a blood infection. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were treated with antibiotics for your blood infection. - You were also started the work-up for a liver transplant. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - 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: ___	[ "K8309", "D61811", "Q445", "N179", "I8510", "R7881", "Z1611", "D684", "I82621", "T82868A", "K7469", "Z87891", "I2720", "F329", "K219", "H409", "Z86718", "Z86711", "I480", "Z7902", "D6959", "R9720", "N400", "R197", "N419", "K648", "E876", "M7052", "Y848", "Y92230", "T368X5A", "Y929" ]	Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: [MASKED] line placement [MASKED] attach Pertinent Results: ADMISSION LABS: =============== [MASKED] 09:02PM BLOOD WBC-3.8* RBC-3.31* Hgb-9.6* Hct-29.7* MCV-90 MCH-29.0 MCHC-32.3 RDW-19.2* RDWSD-62.5* Plt Ct-65* [MASKED] 09:02PM BLOOD Neuts-73* Bands-3 Lymphs-7* Monos-15* Eos-1 Baso-0 [MASKED] Metas-1* Myelos-0 Other-0 AbsNeut-2.89 AbsLymp-0.27* AbsMono-0.57 AbsEos-0.04 AbsBaso-0.00* [MASKED] 09:08PM BLOOD [MASKED] PTT-38.7* [MASKED] [MASKED] 09:02PM BLOOD Glucose-163* UreaN-24* Creat-1.5* Na-138 K-4.6 Cl-103 HCO3-21* AnGap-14 [MASKED] 09:02PM BLOOD ALT-22 AST-37 AlkPhos-204* TotBili-1.0 [MASKED] 05:16AM BLOOD Calcium-8.2* Phos-2.0* Mg-1.6 [MASKED] 09:02PM BLOOD Albumin-3.2* [MASKED] 01:42AM BLOOD Lactate-2.1* [MASKED] 03:37AM BLOOD Lactate-2.1* DISCHARGE LABS: ================ no labs on day of discharge IMAGING: ========= RUQUS [MASKED]: 1. Cirrhotic liver morphology without concerning focal lesion. Saccular intrahepatic biliary ductal dilatation in the right hepatic lobe appears similar to prior, consistent with known [MASKED] disease. No localizing source of infection. 2. Unremarkable gallbladder. 3. Marked splenomegaly and patent portal and umbilical veins. PET [MASKED]: FINDINGS: HEAD/NECK: No abnormal FDG uptake noted in the head or neck. CHEST: No abnormal FDG uptake noted in the chest. There is redemonstration of a1.0 cm epicardial lymph node demonstrating an SUV max 2.8 (CT [MASKED], PET 140). ABDOMEN/PELVIS: Increased FDG uptake noted diffusely throughout the liver, which may represent an inflammatory process. Additionally, there are two foci of increased FDG uptake within the prostate, demonstrating an SUV max of 5.6, suggestive of prostatitis (CT [MASKED], PET 265).There are multiple intrahepatic biliary cystic lesions in the right lobe of the liver, compatible with known [MASKED] disease. Nodular hepatic contour is due to known cirrhosis. Redemonstration of a 1.3 cm periportal lymph node demonstrating SUV max of 4.4 (CT [MASKED], PET 169). Persistent splenomegaly measuring up to 20.4 cm. MUSCULOSKELETAL: No abnormal FDG uptake. Physiologic uptake is seen in the brain, myocardium, salivary glands, GI and GU tracts, and spleen. IMPRESSION: 1. Foci of increased FDG uptake within the prostate suggestive of prostatitis; consider as possible source of bacteremia. 2. Diffuse increased FDG uptake throughout the liver may be due to inflammatory process, possibly secondary to [MASKED] disease. TTE [MASKED]: The inferior vena cava diameter is normal. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is >=60%. The right ventricle has normal free wall motion. The aortic valve leaflets (3) appear structurally normal. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. 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. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. No masses/vegetations are seen on the pulmonic valve. There is mild pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. There is a central jet of mild to moderate [[MASKED]] tricuspid regurgitation. There is SEVERE pulmonary artery systolic hypertension. The end-diastolic PR velocity is elevated suggesting pulmonary artery diastolic hypertension. IMPRESSION: No 2D echocardiographic evidence for endocarditis. Severe pulmonary artery systolic hypertension. Compared with the prior TTE (images reviewed) of [MASKED] , slightly more tricuspid regurgitation and slightly higher pulmonary pressure but overall no major change. PROSTATE ULTRASOUND [MASKED]: Prostate measures 5.2cm x 4.1cm x 5.5cm. This corresponds to a calculated volume of 61 cm3. The predicted PSA is 7.3. There is enlargement of the central gland consistent with BPH. There is no evidence of prostatic or periprostatic fluid collection. Seminal vesicles are symmetric and appear within normal limits. IMPRESSION: Enlarged prostate consistent with BPH. No discrete fluid collections identified to suggest abscess.d TTE [MASKED]: There is no evidence for a right-to-left shunt with agitated saline at rest and with maneuvers. The left ventricle has a normal cavity size. Overall left ventricular systolic function is normal. Mildly dilated right ventricular cavity with depressed free wall motion. IMPRESSION: No right-to-left shunt identified. PFT [MASKED]: IMPRESSION MECHANICS: The FVC is moderately reduced. The reduction in FEV1 is moderately severe. The FEV1/FVC ratio is normal. FLOW-VOLUME LOOP: Moderately reduced flows and volume. LUNG VOLUMES: The TLC is moderately reduced. The FRC and RV are mildly reduced. The RV/TLC ratio is elevated. DLCO: The diffusion capacity corrected for hemoglobin is mildly reduced. Impression: Results are consistent with a moderate restrictive ventilatory defect and mild gas exchange defect. There are no prior studies avaialble for comparison. MRCP [MASKED]: IMPRESSION: 1. Stable saccular dilatation of the right sided intrahepatic bile ducts consistent with history of [MASKED] disease. No cholangitis or intrahepatic abscess noted. No suspicious enhancing masses or lesions to suggest cholangiocarcinoma. The liver demonstrates a cirrhotic morphology with stigmata of portal hypertension in the form of splenomegaly. Patent portal vein and its branches. No ascites. 2. Small right pleural effusion. Stress Echo [MASKED]: CONCLUSION: Fair functional exercise capacity for age and gender. Non-specific ECG changes with no symptoms to achieved treadmill stress. No 2D echocardiographic evidence of inducible ischemia to achieved workload. No Doppler evidence for a change in left ventricular filling pressure with exercise. Mild mitral regurgitation at rest. Moderately increased pulmonary artery systolic pressure at rest with a moderate increase after exercise. Normal resting blood pressure with a normal blood pressure and a blunted heart rate response to achieved workload. V/Q Scan [MASKED]: IMPRESSION: Very low likelihood of pulmonary embolization. MICROBIOLOGY: ============= Blood Culture, Routine (Final [MASKED]: ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. TETRACYCLINE Susceptibility testing requested per [MASKED] [MASKED] [MASKED]. TETRACYCLINE IS NOT APPROPRIATE FOR PRIMARY THERAPY OF BLOODSTREAM INFECTIONS.. ORGANISMS THAT ARE SUSCEPTIBLE TO TETRACYCLINE ARE CONSIDERED SUSCEPTIBLE TO MINOCYCLINE AND DOXYCYCLINE. Daptomycin MIC OF 2 MCG/ML : test result performed by Etest. . HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. . LINEZOLID :ADDED ON PER [MASKED] ON [MASKED], 12:30PM. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ <=0.5 S Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by [MASKED] ([MASKED]) AT 1515 ON [MASKED]. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Blood Culture, Routine (Final [MASKED]: ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin MIC = 4 MCG/ML test result performed by Etest. TETRACYCLINE REQUESTED BY [MASKED] ([MASKED]) [MASKED]. TETRACYCLINE IS NOT APPROPRIATE FOR PRIMARY THERAPY OF BLOODSTREAM INFECTIONS.. ORGANISMS THAT ARE SUSCEPTIBLE TO TETRACYCLINE ARE CONSIDERED SUSCEPTIBLE TO MINOCYCLINE AND DOXYCYCLINE.. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S PENICILLIN G---------- =>[MASKED] R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by [MASKED] AT 0422 ON [MASKED]. Brief Hospital Course: BRIEF HOSPITAL SUMMARY: ======================= [MASKED] year old male with hx of [MASKED] disease complicated by cirrhosis, history of varices, hepatic encephalopathy, and pulmonary HTN, Pulmonary embolism from DVT on lovenox, with recent admission for ampicillin-resistant enterococcus bacteremia (IV ABX finished )presented with 3 days of lethargy, weakness, and fevers found to have recurrent E. Faecium Bacteremia. The patient was started on dapto/ceftaroline and once the sensitivities resulted was narrowed to daptomycin. He had breakthrough fevers and positive blood cultures growing GPC therefore daptomycin was discontinued and linezolid PO started. Due to his recurrent bacteremia and history of cholecytitis he underwent a tagged WBC scan, that unfortunately did not reveal any source of infection. A TTE was negative for vegetatons. Its presumed that his liver disease is the culprit for these frequent infections. The patient will be on a 6 week course of linezolid from his last negative culture date ([MASKED]) with an end date of [MASKED], with tentative plans to begin a suppressive antibiotic regimen with minocycline. The patient will see infectious disease as an outpatient.His Picc line was also removed and the culture has no growth to date. Removal of the picc resulted in an upper extremity DVT, and consequently was started on [MASKED] with plans for a third month outpatient course. Of note, the patient has a history of for a submassive PE [MASKED] PICC-associated DVT. While he was being treated for this bacteremia, his transplant work up was progressed. Please see the transition issues below for a list of his outstanding work up. TRANSITIONAL ISSUES: ==================== # CODE: Full code, presumed # CONTACT: [MASKED] (wife) [MASKED] MED CHANGES/ADDITONS: [] [MASKED] has been on nadolol since [MASKED] and had 3 grade I varices in [MASKED] --> holding nadolol on dc since he has not been getting it. [MASKED] need EGD again as outpatient. [] linezolid six week course for bacteremia (ending [MASKED], [MASKED]. Will f/u with ID as outpatient. Plan for starting suppressive abx regimen thereafter. [] Patient with one episode of paroxysmal afib. Please consider zio patch as outpatient to determine need for anticoagulation (since 6-month lovenox treatment for PE has finished). [] First dose Hep B given [MASKED]. Will need to complete course. [] CA [MASKED] elevated 10,425 ([MASKED]). Repeat CA [MASKED] after antibiotics; may need ERCP with brushings if remains elevated. [] mumps non immune (holding immunization since actively infected and leukopenic right now), requires MMR Vaccine [] needs sleep study as outpatient per pulmonary to workup for pulmonary hypertension [] Repeat 6 minute walk test as outpatient [] Consider transitioning to from [MASKED] to DOAC (Childs [MASKED] A) for ease of use in provoked DVT tx [] PSA elevated this admission and is undergoing liver transplant workup, will need to follow up with urology outpatient. [] Will need weekly CBC for monitoring of cytopenias on Linezolid, to be monitored by [MASKED] clinic. [] Will eventually need suppressive minocycline therapy for Caroli disease related infections, after completing linezolid ACTIVE ISSUES ============= # Enterococcus Bacteremia, ampicillin-resistant # Fever, Lethargy, weakness Long history of multiple hospitalizations for E. Faecium bacteremia which was previously pan-sensitive but was noted to be newly ampicillin-resistant at his last admission and was treated with daptomycin (since developed neutropenia on vancomycin) and finished course [MASKED]. After one day, he developed lethargy, weakness, and fevers. Blood cultures grew enterococcus faecium with increasing resistance to daptomycin. Search for source has been unrevealing besides prostatitis (including PET, repeat MRCPs, TTEs, tagged WBC study ) and most likely source is ascending cholangitis from underlying liver disease. He is undergoing liver transplant workup as there is no intervention to prevent recurrent infection, and his infections are becoming increasing more resistant to antibiotics. Setting up outpatient antibiotics had been very difficult due to the high cost of antibiotics, insurance will not cover home infusion, and [MASKED] will not allow him to come twice a day for infusions. He will be discharged on PO linezolid for a total of six weeks and will follow up in infectious disease clinic. #Liver transplant work-up Discussed that underlying [MASKED] syndrome is likely cause of recurrent bacteremia. Only definitive treatment would be liver transplant which he has not yet been evaluated for but [MASKED] B class supports he should be. Discussed deceased and living donor transplant but he stated he would not feel comfortable asking anyone in his family to donate their liver for him at the current moment. #Elevated CA [MASKED] CA [MASKED] [MASKED] ([MASKED]), with previous CA [MASKED]. Concerning for cholangiocarcinoma. Back in [MASKED], alk phos was normal and 67. Now alk phos has been elevated. ERCP would be reasonable to assess for cholangiocarcinoma, but may be risky since patient is frequently bacteremic, and CA [MASKED] be elevated in thesetting of the ongoing, active disease in the bile ducts. MRCP [MASKED] was without evidence of cholangiocarcinoma. Repeat CA [MASKED] after antibiotics; may need ERCP with brushings if remains elevated. #Elevated PSA PSA 19.4. Checked as part of liver transplant work-up. Per OSH records, PSA 1.64 on [MASKED]. DRE with enlarged prostate and no focal nodules. PET CT with two foci on the prostate concerning for prostatitis. Prostate ultrasound with evidence of BPH. The patient will follow up with urology as an outpatient to determine need for prostate biopsy. #New-onset paroxysmal afib New-onset paroxysmal afib to 190s upon arrival to the floor. Unclear etiology, could be related to infection in setting of bacteremia. His home nadolol was discontinued, and he was started on metoprolol 12.5mg twice daily that was later discontinued when he became bacteremic again. He returned to normal sinus rhythm. CHADSVASC 1. Please consider zio patch as outpatient to determine need for anticoagulation (since 6-month lovenox treatment for PE has finished). #Pulmonary HTN Patient is asymptomatic and not hypoxic or platypneic to suggest hepatopulmonary syndrome. No ascites for hepatic hydrothorax. Most recent TTE [MASKED] with PASP 61, slightly increased from previous TTE [MASKED]. TTE with bubble study without evidence of shunt. V/Q scan with low likelihood of PE. A right heart cath demonstrated elevated right heart filling pressure and mild pulmonary hypertension. The mild elevation of pulmonary artery pressures was thought to, to some degree, be attributable to the high cardiac output. #Cirrhosis [MASKED] syndrome [MASKED] B. Meld-Na 9 today. Well-compensated when not actively infected. - VARICES: EGD [MASKED] with grade I varices in distal esophagus. Also PHGP noted in stomach. History of banded varices per patient. Discontinued nadolol and briefly on metoprolol for afib. Will be discharged without B-blocker therapy, as there is no clear indication. - ASCITES: continued home diuretics given lower extremity swelling - COAGULOPATHY: no evidence of bleeding. - HE: A&Ox3, holding home lactulose. On rifaximin. - HRS: previously with [MASKED], now resolved - CIRRHOSIS: likely secondary to [MASKED]. Vaccinated against hepatitis A. non-immune to hepatitis B. First dose Hep B given [MASKED]. - Continue ursodiol #Acute kidney injury- Resolved Cr elevated to 1.5 --> 1.3 upon admission, which was 0.8 previously upon discharge from last admission. s/p 2L with improvement in Cr, and thus likely pre-renal. #Pulmonary embolism Hospitalized recently in [MASKED] for a submassive PE [MASKED] PICC-associated DVT, originally started on Xarelto but had hematemesis, BRBPR, hypotension requiring a MICU admission. Now on Lovenox, which he is tolerating well. No chest pain, shortness of breath, hypoxia, or e/o bleeding. Finished [MASKED]. V/Q scan with low likelihood of PE. Discontinued home LMWH 100 mg SC BID, but later it was restarted for a RUE DVT. Consider transition to DOAC as outpatient for ease of use. #Depression: - Continued home citalopram 20 mg daily #GERD - Continued home pantoprazole #Glaucoma - Continued home latanoprost Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Enoxaparin Sodium 100 mg SC Q12H 3. Lactulose 30 mL PO Q8H:PRN encephalopathy 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Pantoprazole 40 mg PO Q24H 6. Ursodiol 600 mg PO BID 7. Daptomycin 600 mg IV Q24H 8. Furosemide 40 mg PO DAILY 9. Magnesium Oxide 400 mg PO DAILY 10. Nadolol 20 mg PO DAILY 11. aMILoride 5 mg PO DAILY 12. rifAXIMin 550 mg PO BID Discharge Medications: 1. Linezolid [MASKED] mg PO Q12H RX linezolid [MASKED] mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 2. Spironolactone 100 mg PO DAILY RX spironolactone 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. aMILoride 5 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Enoxaparin Sodium 100 mg SC Q12H RX enoxaparin 100 mg/mL 100mg twice a day Disp #5 Syringe Refills:*1 6. Furosemide 40 mg PO DAILY 7. Lactulose 30 mL PO Q8H:PRN encephalopathy 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Magnesium Oxide 400 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. rifAXIMin 550 mg PO BID 12. Ursodiol 600 mg PO BID 13.Outpatient Lab Work ICD code: [MASKED] LABS TO CHECK: Weekly CBC with differential ALL LAB RESULTS SHOULD BE SENT TO: ATTN: [MASKED] CLINIC - FAX: [MASKED] Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Ampicillin-resistant enterococcus bacteremia Cirrhosis secondary to [MASKED] disease Provoked DVT from [MASKED] Elevated PSA SECONDARY DIAGNOSIS: ==================== New-onset paroxysmal atrial fibrillation Pulmonary Hypertension Pulmonary embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital because you had a blood infection. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were treated with antibiotics for your blood infection. - You were also started the work-up for a liver transplant. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - 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]	[]	[ "N179", "Z87891", "F329", "K219", "Z86718", "I480", "Z7902", "N400", "Y92230", "Y929" ]	[ "K8309: Other cholangitis", "D61811: Other drug-induced pancytopenia", "Q445: Other congenital malformations of bile ducts", "N179: Acute kidney failure, unspecified", "I8510: Secondary esophageal varices without bleeding", "R7881: Bacteremia", "Z1611: Resistance to penicillins", "D684: Acquired coagulation factor deficiency", "I82621: Acute embolism and thrombosis of deep veins of right upper extremity", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "K7469: Other cirrhosis of liver", "Z87891: Personal history of nicotine dependence", "I2720: Pulmonary hypertension, unspecified", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "H409: Unspecified glaucoma", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "I480: Paroxysmal atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "D6959: Other secondary thrombocytopenia", "R9720: Elevated prostate specific antigen [PSA]", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "R197: Diarrhea, unspecified", "N419: Inflammatory disease of prostate, unspecified", "K648: Other hemorrhoids", "E876: Hypokalemia", "M7052: Other bursitis of knee, left knee", "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", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "Y929: Unspecified place or not applicable" ]
10,048,001	28,243,528	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ syndrome complicated by gram positive bacteremia Major Surgical or Invasive Procedure: TEE ___: No discrete vegetation or abscess seen. Mild mitral regurgitation. History of Present Illness: ___ yo M PMHx ___'s disease c/b cirrhosis with hx varices, HE, recurrent cholangitis and E. faecalis bacteremia, recent PE with RV strain on LMWH presented to ED with fevers that started ___ night and dry cough that started on ___ found to have GPCs in blood. The patient reports a 2 day history of fevers at home as well as a dry cough that started ___. He otherwise reports some mild nausea and chronic diarrhea ___ lactulose but otherwise no abdominal pain, chest pain, vomiting, headache, black/bloody stools. He takes suppressive Augmentin since his last infection in ___ and reports no missed doses. The patient has multiple hospitalizations for bacteremia and cholangitis, most recently in ___. He is on chronic suppression with Augmentin. He has also been hospitalized recently in ___ for a submassive PE ___ PICC-associated DVT, originally started on apixaban but had hematemesis, BRBPR, hypotension requiring a MICU admission. Now on Lovenox. He has a history of CRE E. Coli in ___ and reportedly VRE bacteremia per documentation review although not in ___ records. His recent E. faecalis species have been pan-sensitive. Regarding his cirrhosis, he has a history of HE on lactulose and grade I varices on nadolol as of his most recent EGD in ___. No clear history of ascites although he does take amiloride and furosemide as home medications. In the ED: - Initial vital signs were notable for: Temp 98.4, HR 81, BP 136/74, RR 16 satting 99% on RA Past Medical History: -___ Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late ___ -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in ___ Social History: ___ Family History: Mother has heart disease. Father died at age ___ from cancer and there is no other liver disease in his family that is known. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 1835) Temp: 100.2 (Tm 100.2), BP: 116/67, HR: 95, RR: 18, O2 sat: 95%, O2 delivery: RA GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. EOMI. Sclera anicteric. ENT: MMM. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Mild wheezes throughout. No rhonchi or rales. No increased work of breathing. ABDOMEN: Soft, Non-distended, non-tender to deep palpation in all four quadrants. No organomegaly. MSK: No CVA tenderness. No clubbing, cyanosis, or edema. Pulses DP/Radial 3+ bounding bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3. CN2-12 grossly intact. Able to say days of the week backwards. No asterixis. PSYCH: appropriate mood and affect DISCHARGE PHYSICAL EXAM: ============== 24 HR Data (last updated ___ @ 741) Temp: 98.2 (Tm 99.3), BP: 128/79 (118-129/72-79), HR: 93 (91-99), RR: 20 (___), O2 sat: 94% (93-95), O2 delivery: Ra, Wt: 218.3 lb/99.02 kg GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. Sclera anicteric. ENT: MMM. JVP elevated CARDIAC: Regular rhythm, normal rate. RESP: decreased breath sounds on R side. No increased work of breathing. ABDOMEN: Soft, Non-distended, non-tender to deep palpation in all four quadrants. +umbilical hernia MSK: No CVA tenderness. Trace peripheral edema. SKIN: Warm. No rash. NEUROLOGIC: AOx3. moving all extremities. Pertinent Results: ADMISSION LABS: =================== ___ 12:52PM BLOOD WBC-2.4* RBC-3.30* Hgb-9.3* Hct-30.4* MCV-92 MCH-28.2 MCHC-30.6* RDW-17.3* RDWSD-58.5* Plt Ct-60* ___ 12:52PM BLOOD Neuts-69.5 Lymphs-13.2* Monos-15.7* Eos-0.8* Baso-0.4 Im ___ AbsNeut-1.68 AbsLymp-0.32* AbsMono-0.38 AbsEos-0.02* AbsBaso-0.01 ___ 02:37PM BLOOD ___ PTT-41.2* ___ ___ 12:52PM BLOOD Glucose-135* UreaN-16 Creat-1.0 Na-138 K-4.7 Cl-106 HCO3-20* AnGap-12 ___ 07:49AM BLOOD ALT-14 AST-20 AlkPhos-149* TotBili-0.5 DirBili-0.2 IndBili-0.3 ___ 12:52PM BLOOD Albumin-3.5 Calcium-8.7 Phos-2.4* Mg-1.9 ___ 07:36AM BLOOD CRP-101.7* ___ 01:20PM BLOOD Lactate-1.5 DISCHARGE LABS: ================== ___ 06:06AM BLOOD WBC-2.3* RBC-2.82* Hgb-7.9* Hct-25.9* MCV-92 MCH-28.0 MCHC-30.5* RDW-17.5* RDWSD-58.8* Plt Ct-49* ___ 06:06AM BLOOD Neuts-70.6 Lymphs-17.1* Monos-10.1 Eos-0.9* Baso-0.4 Im ___ AbsNeut-1.61 AbsLymp-0.39* AbsMono-0.23 AbsEos-0.02* AbsBaso-0.01 ___ 06:06AM BLOOD Glucose-97 UreaN-11 Creat-0.8 Na-145 K-4.3 Cl-111* HCO3-24 AnGap-10 ___ 06:06AM BLOOD ALT-14 AST-20 AlkPhos-142* TotBili-0.6 ___ 06:06AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.7 MICROBIOLOGY DATA: ====================== FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin MIC OF 2 MCG/ML test result performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S PENICILLIN G---------- =>64 R VANCOMYCIN------------ <=0.5 S Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ ___ AT 8:40AM. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ___ 11:14 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. Identification and susceptibility testing performed on culture # ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ___ 11:14 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. Identification and susceptibility testing performed on culture # ___ ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. TTE CONCLUSION: There is no spontaneous echo contrast or thrombus in the body of the left atrium/left atrial appendage. The left atrial appendage ejection velocity is normal. No spontaneous echo contrast or thrombus is seen in the body of the right atrium/right atrial appendage. There is no evidence for an atrial septal defect by 2D/color Doppler. Overall left ventricular systolic function is normal. The right ventricle has normal free wall motion. There are no aortic arch atheroma with no atheroma in the descending aorta to 30 cm 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 [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is trivial tricuspid regurgitation. There is no pericardial effusion. IMPRESSION: No discrete vegetation or abscess seen. Mild mitral regurgitation. Brief Hospital Course: BRIEF HOSPITAL COURSE: ==================== ___ yo M PMHx Caroli's disease c/b cirrhosis with hx varices, HE, recurrent cholangitis and E. faecalis bacteremia, recent PE with RV strain on LMWH admitted for fevers that started ___ night and dry cough, found to have ampicillin-resistant enterococcus. He was treated with IV Vanc 1000mg q12 hours. TRANSITIONAL ISSUES: ================== [ ] TTE showing mod-severe pulm hypertension (PAp 58; given concern for this contributing to DOE, was referred to cardiology to follow up outpatient. TTE will need to be repeated in future [ ] Midline placed for IV abx for gram positive bacteremia, will be followed by ___ Infectious Disease clinic, with projected end date ___. Will get weekly lab work for this. [ ] ___ at ___ will be the Primary Care Physician to write scripts for outpatient IV abx. HEPATOLOGY: [ ] Diuretics (Amiloride and Lasix) held on discharge given active infection, will restart after checking with Dr. ___ (___). [ ] Will plan to start Rifaxamin after IV daptomycin course for chronic suppressive therapy with Caroli Syndrome. Will need to follow up regarding insurance coverage past the end of this year. [ ] Stopped prophylactic Bactrim given he developed bacteremia on this. Will plan to use Rifaxamin as suppressive therapy after course of IV abx. ACUTE ISSUES: ============= #Ampicillin-resistant enterococcus #History of Cholangitis Given the patient's history of recurrent cholangitis and E. faecalis bacteremia, and now again with enterococcus in blood, there was high suspicion for biliary source. Of note, enterococcus was previously ampicillin sensitive, but grew ampicillin resistant this admission. Bacteremia occurred while on suppressive Amox/clav. TEE was performed and showed no evidence of endocarditis. He was changed from IV vancomycin (D1: ___ to IV Daptomycin due to medication-induced neutropenia, and was discharged on IV dapto to be followed by ___ clinic with projected end date ___. #Cirrhosis #___'s disease ___ A. Meld-Na 11. Well-compensated when not actively infected. - VARICES: EGD ___ with grade I varices in distal esophagus. Also PHGP noted in stomach. History of banded varices per patient. Will hold home nadolol for now given risk for decompensation iso bacteremia. - ASCITES: No ascites noted on RUQUS. Patient reports never requiring a paracentesis. Held home diuretics despite evidence of volume overload in setting of infection. Will continue to hold until following up with Dr. ___. - HE: Continued home lactulose. - Continued ursodiol #Pulmonary embolism History of PE with RV strain ___. Unable to tolerate DOAC due to bleeding. Switched to Lovenox which he is tolerating well. No chest pain, shortness of breath, hypoxia, or e/o bleeding. - Continued home LMWH 100 mg SC BID #Dry cough #Dyspnea upon exertion #Pulmonary HTN Patient is asymptomatic and not hypoxic or platypneic to suggest hepatopulmonary syndrome. No ascites for hepatic hydrothorax. CXR in ED unremarkable. Most recent ECHO with PASP 34 mmHg. TTE this admission with higher pulmonary artery pressure, which may explain DOE. Received duonebs PRN, will need to follow up with cardiologist. #Depression: Continued citalopram 20 mg daily #GERD Continued home pantoprazole #Glaucoma Continued home latanoprost #CODE: Full code (confirmed) #CONTACT: ___ (wife) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 100 mg SC Q12H 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 3. Ursodiol 600 mg PO BID 4. Nadolol 20 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Magnesium Oxide 400 mg PO DAILY 7. Citalopram 20 mg PO DAILY 8. aMILoride 5 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Furosemide 40 mg PO DAILY 11. Lactulose 30 mL PO Q8H:PRN encephalopathy Discharge Medications: 1. Daptomycin 600 mg IV Q24H 2. Heparin Flush (10 units/ml) 2 mL IV X1 PRN For Midline Insertion 3. aMILoride 5 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Enoxaparin Sodium 100 mg SC Q12H 6. Furosemide 40 mg PO DAILY 7. Lactulose 30 mL PO Q8H:PRN encephalopathy 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Magnesium Oxide 400 mg PO DAILY 10. Nadolol 20 mg PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. Ursodiol 600 mg PO BID 13.Outpatient Lab Work ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK ICD9: 790.7 Bacteremia Discharge Disposition: Home Discharge Diagnosis: PRIMRARY DIAGNOSIS: ================= Ampicillin-resistant enterococcus bacteremia SECONDARY DIAGNOSIS: =================== Cirrhosis secondary to Caroli's Syndrome History of Pulmonary embolism Thrombocytopenia secondary to cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you were having fevers. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were diagnosed with bacteremia, or bacteria in your blood. - You were started on IV antibiotics. - You got imaging studies of your heart to rule out endocarditis(infection or inflammation of your heart valves) 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. -You will need to follow up with Infectious Disease doctors in ___, but should take your IV daptomycin until ___. After you finish this course, resume taking the oral medication called Rifaxamin for suppression of infection. - We are holding your diuretics (Amiloride and Lasix) on discharge because you have an active infection and it could make your blood pressure too low. Check with Dr. ___ resuming these. - Weigh yourself daily, and if your weight increases more than 3 lbs in 2 days or 5 lbs in 1 week, call Dr. ___ as you may need to restart antibiotics. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "R7881", "I2699", "I8510", "K766", "Q445", "B952", "F329", "K7460", "K7290", "K219", "H409", "I2720", "G4700", "D702", "T368X5A", "D696", "K3189", "R05", "Z23" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: [MASKED] syndrome complicated by gram positive bacteremia Major Surgical or Invasive Procedure: TEE [MASKED]: No discrete vegetation or abscess seen. Mild mitral regurgitation. History of Present Illness: [MASKED] yo M PMHx [MASKED]'s disease c/b cirrhosis with hx varices, HE, recurrent cholangitis and E. faecalis bacteremia, recent PE with RV strain on LMWH presented to ED with fevers that started [MASKED] night and dry cough that started on [MASKED] found to have GPCs in blood. The patient reports a 2 day history of fevers at home as well as a dry cough that started [MASKED]. He otherwise reports some mild nausea and chronic diarrhea [MASKED] lactulose but otherwise no abdominal pain, chest pain, vomiting, headache, black/bloody stools. He takes suppressive Augmentin since his last infection in [MASKED] and reports no missed doses. The patient has multiple hospitalizations for bacteremia and cholangitis, most recently in [MASKED]. He is on chronic suppression with Augmentin. He has also been hospitalized recently in [MASKED] for a submassive PE [MASKED] PICC-associated DVT, originally started on apixaban but had hematemesis, BRBPR, hypotension requiring a MICU admission. Now on Lovenox. He has a history of CRE E. Coli in [MASKED] and reportedly VRE bacteremia per documentation review although not in [MASKED] records. His recent E. faecalis species have been pan-sensitive. Regarding his cirrhosis, he has a history of HE on lactulose and grade I varices on nadolol as of his most recent EGD in [MASKED]. No clear history of ascites although he does take amiloride and furosemide as home medications. In the ED: - Initial vital signs were notable for: Temp 98.4, HR 81, BP 136/74, RR 16 satting 99% on RA Past Medical History: -[MASKED] Syndrome with recurrent cholangitis and bacteremia, most recent from highly resistant E. coli treated with tigecycline (finished late [MASKED] -Cirrhosis -Depression -Osteopenia -Seasonal allergies -Inguinal hernia repair in [MASKED] Social History: [MASKED] Family History: Mother has heart disease. Father died at age [MASKED] from cancer and there is no other liver disease in his family that is known. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 24 HR Data (last updated [MASKED] @ 1835) Temp: 100.2 (Tm 100.2), BP: 116/67, HR: 95, RR: 18, O2 sat: 95%, O2 delivery: RA GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. EOMI. Sclera anicteric. ENT: MMM. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Mild wheezes throughout. No rhonchi or rales. No increased work of breathing. ABDOMEN: Soft, Non-distended, non-tender to deep palpation in all four quadrants. No organomegaly. MSK: No CVA tenderness. No clubbing, cyanosis, or edema. Pulses DP/Radial 3+ bounding bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3. CN2-12 grossly intact. Able to say days of the week backwards. No asterixis. PSYCH: appropriate mood and affect DISCHARGE PHYSICAL EXAM: ============== 24 HR Data (last updated [MASKED] @ 741) Temp: 98.2 (Tm 99.3), BP: 128/79 (118-129/72-79), HR: 93 (91-99), RR: 20 ([MASKED]), O2 sat: 94% (93-95), O2 delivery: Ra, Wt: 218.3 lb/99.02 kg GENERAL: Alert and interactive. In no acute distress. EYES: NCAT. Sclera anicteric. ENT: MMM. JVP elevated CARDIAC: Regular rhythm, normal rate. RESP: decreased breath sounds on R side. No increased work of breathing. ABDOMEN: Soft, Non-distended, non-tender to deep palpation in all four quadrants. +umbilical hernia MSK: No CVA tenderness. Trace peripheral edema. SKIN: Warm. No rash. NEUROLOGIC: AOx3. moving all extremities. Pertinent Results: ADMISSION LABS: =================== [MASKED] 12:52PM BLOOD WBC-2.4* RBC-3.30* Hgb-9.3* Hct-30.4* MCV-92 MCH-28.2 MCHC-30.6* RDW-17.3* RDWSD-58.5* Plt Ct-60* [MASKED] 12:52PM BLOOD Neuts-69.5 Lymphs-13.2* Monos-15.7* Eos-0.8* Baso-0.4 Im [MASKED] AbsNeut-1.68 AbsLymp-0.32* AbsMono-0.38 AbsEos-0.02* AbsBaso-0.01 [MASKED] 02:37PM BLOOD [MASKED] PTT-41.2* [MASKED] [MASKED] 12:52PM BLOOD Glucose-135* UreaN-16 Creat-1.0 Na-138 K-4.7 Cl-106 HCO3-20* AnGap-12 [MASKED] 07:49AM BLOOD ALT-14 AST-20 AlkPhos-149* TotBili-0.5 DirBili-0.2 IndBili-0.3 [MASKED] 12:52PM BLOOD Albumin-3.5 Calcium-8.7 Phos-2.4* Mg-1.9 [MASKED] 07:36AM BLOOD CRP-101.7* [MASKED] 01:20PM BLOOD Lactate-1.5 DISCHARGE LABS: ================== [MASKED] 06:06AM BLOOD WBC-2.3* RBC-2.82* Hgb-7.9* Hct-25.9* MCV-92 MCH-28.0 MCHC-30.5* RDW-17.5* RDWSD-58.8* Plt Ct-49* [MASKED] 06:06AM BLOOD Neuts-70.6 Lymphs-17.1* Monos-10.1 Eos-0.9* Baso-0.4 Im [MASKED] AbsNeut-1.61 AbsLymp-0.39* AbsMono-0.23 AbsEos-0.02* AbsBaso-0.01 [MASKED] 06:06AM BLOOD Glucose-97 UreaN-11 Creat-0.8 Na-145 K-4.3 Cl-111* HCO3-24 AnGap-10 [MASKED] 06:06AM BLOOD ALT-14 AST-20 AlkPhos-142* TotBili-0.6 [MASKED] 06:06AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.7 MICROBIOLOGY DATA: ====================== FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin MIC OF 2 MCG/ML test result performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S PENICILLIN G---------- =>64 R VANCOMYCIN------------ <=0.5 S Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by [MASKED] [MASKED] AT 8:40AM. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. [MASKED] 11:14 pm BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: ENTEROCOCCUS FAECIUM. Identification and susceptibility testing performed on culture # [MASKED] [MASKED]. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. [MASKED] 11:14 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: ENTEROCOCCUS FAECIUM. Identification and susceptibility testing performed on culture # [MASKED] [MASKED]. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. TTE CONCLUSION: There is no spontaneous echo contrast or thrombus in the body of the left atrium/left atrial appendage. The left atrial appendage ejection velocity is normal. No spontaneous echo contrast or thrombus is seen in the body of the right atrium/right atrial appendage. There is no evidence for an atrial septal defect by 2D/color Doppler. Overall left ventricular systolic function is normal. The right ventricle has normal free wall motion. There are no aortic arch atheroma with no atheroma in the descending aorta to 30 cm 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 [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is trivial tricuspid regurgitation. There is no pericardial effusion. IMPRESSION: No discrete vegetation or abscess seen. Mild mitral regurgitation. Brief Hospital Course: BRIEF HOSPITAL COURSE: ==================== [MASKED] yo M PMHx Caroli's disease c/b cirrhosis with hx varices, HE, recurrent cholangitis and E. faecalis bacteremia, recent PE with RV strain on LMWH admitted for fevers that started [MASKED] night and dry cough, found to have ampicillin-resistant enterococcus. He was treated with IV Vanc 1000mg q12 hours. TRANSITIONAL ISSUES: ================== [ ] TTE showing mod-severe pulm hypertension (PAp 58; given concern for this contributing to DOE, was referred to cardiology to follow up outpatient. TTE will need to be repeated in future [ ] Midline placed for IV abx for gram positive bacteremia, will be followed by [MASKED] Infectious Disease clinic, with projected end date [MASKED]. Will get weekly lab work for this. [ ] [MASKED] at [MASKED] will be the Primary Care Physician to write scripts for outpatient IV abx. HEPATOLOGY: [ ] Diuretics (Amiloride and Lasix) held on discharge given active infection, will restart after checking with Dr. [MASKED] ([MASKED]). [ ] Will plan to start Rifaxamin after IV daptomycin course for chronic suppressive therapy with Caroli Syndrome. Will need to follow up regarding insurance coverage past the end of this year. [ ] Stopped prophylactic Bactrim given he developed bacteremia on this. Will plan to use Rifaxamin as suppressive therapy after course of IV abx. ACUTE ISSUES: ============= #Ampicillin-resistant enterococcus #History of Cholangitis Given the patient's history of recurrent cholangitis and E. faecalis bacteremia, and now again with enterococcus in blood, there was high suspicion for biliary source. Of note, enterococcus was previously ampicillin sensitive, but grew ampicillin resistant this admission. Bacteremia occurred while on suppressive Amox/clav. TEE was performed and showed no evidence of endocarditis. He was changed from IV vancomycin (D1: [MASKED] to IV Daptomycin due to medication-induced neutropenia, and was discharged on IV dapto to be followed by [MASKED] clinic with projected end date [MASKED]. #Cirrhosis #[MASKED]'s disease [MASKED] A. Meld-Na 11. Well-compensated when not actively infected. - VARICES: EGD [MASKED] with grade I varices in distal esophagus. Also PHGP noted in stomach. History of banded varices per patient. Will hold home nadolol for now given risk for decompensation iso bacteremia. - ASCITES: No ascites noted on RUQUS. Patient reports never requiring a paracentesis. Held home diuretics despite evidence of volume overload in setting of infection. Will continue to hold until following up with Dr. [MASKED]. - HE: Continued home lactulose. - Continued ursodiol #Pulmonary embolism History of PE with RV strain [MASKED]. Unable to tolerate DOAC due to bleeding. Switched to Lovenox which he is tolerating well. No chest pain, shortness of breath, hypoxia, or e/o bleeding. - Continued home LMWH 100 mg SC BID #Dry cough #Dyspnea upon exertion #Pulmonary HTN Patient is asymptomatic and not hypoxic or platypneic to suggest hepatopulmonary syndrome. No ascites for hepatic hydrothorax. CXR in ED unremarkable. Most recent ECHO with PASP 34 mmHg. TTE this admission with higher pulmonary artery pressure, which may explain DOE. Received duonebs PRN, will need to follow up with cardiologist. #Depression: Continued citalopram 20 mg daily #GERD Continued home pantoprazole #Glaucoma Continued home latanoprost #CODE: Full code (confirmed) #CONTACT: [MASKED] (wife) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 100 mg SC Q12H 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 3. Ursodiol 600 mg PO BID 4. Nadolol 20 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Magnesium Oxide 400 mg PO DAILY 7. Citalopram 20 mg PO DAILY 8. aMILoride 5 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Furosemide 40 mg PO DAILY 11. Lactulose 30 mL PO Q8H:PRN encephalopathy Discharge Medications: 1. Daptomycin 600 mg IV Q24H 2. Heparin Flush (10 units/ml) 2 mL IV X1 PRN For Midline Insertion 3. aMILoride 5 mg PO DAILY 4. Citalopram 20 mg PO DAILY 5. Enoxaparin Sodium 100 mg SC Q12H 6. Furosemide 40 mg PO DAILY 7. Lactulose 30 mL PO Q8H:PRN encephalopathy 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. Magnesium Oxide 400 mg PO DAILY 10. Nadolol 20 mg PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. Ursodiol 600 mg PO BID 13.Outpatient Lab Work ALL LAB RESULTS SHOULD BE SENT TO: ATTN: [MASKED] CLINIC - FAX: [MASKED] DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK ICD9: 790.7 Bacteremia Discharge Disposition: Home Discharge Diagnosis: PRIMRARY DIAGNOSIS: ================= Ampicillin-resistant enterococcus bacteremia SECONDARY DIAGNOSIS: =================== Cirrhosis secondary to Caroli's Syndrome History of Pulmonary embolism Thrombocytopenia secondary to cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you were having fevers. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were diagnosed with bacteremia, or bacteria in your blood. - You were started on IV antibiotics. - You got imaging studies of your heart to rule out endocarditis(infection or inflammation of your heart valves) 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. -You will need to follow up with Infectious Disease doctors in [MASKED], but should take your IV daptomycin until [MASKED]. After you finish this course, resume taking the oral medication called Rifaxamin for suppression of infection. - We are holding your diuretics (Amiloride and Lasix) on discharge because you have an active infection and it could make your blood pressure too low. Check with Dr. [MASKED] resuming these. - Weigh yourself daily, and if your weight increases more than 3 lbs in 2 days or 5 lbs in 1 week, call Dr. [MASKED] as you may need to restart antibiotics. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "F329", "K219", "G4700", "D696" ]	[ "R7881: Bacteremia", "I2699: Other pulmonary embolism without acute cor pulmonale", "I8510: Secondary esophageal varices without bleeding", "K766: Portal hypertension", "Q445: Other congenital malformations of bile ducts", "B952: Enterococcus as the cause of diseases classified elsewhere", "F329: Major depressive disorder, single episode, unspecified", "K7460: Unspecified cirrhosis of liver", "K7290: Hepatic failure, unspecified without coma", "K219: Gastro-esophageal reflux disease without esophagitis", "H409: Unspecified glaucoma", "I2720: Pulmonary hypertension, unspecified", "G4700: Insomnia, unspecified", "D702: Other drug-induced agranulocytosis", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "D696: Thrombocytopenia, unspecified", "K3189: Other diseases of stomach and duodenum", "R05: Cough", "Z23: Encounter for immunization" ]
10,048,061	23,628,963	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Transfer for fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ y/o female with a history of Still's disease who presented to OSH (___) with fevers to 104.8 and arthralgia and transferred for rheumatology evaluation. She first developed Still's symptoms in ___. Her symptoms were a fever to 103+ and rash. In ___, she was diagnosed with Still's disease and began following with Dr. ___ in Rheumatology (___, ___). She was initially started on prednisone 60 mg and a biologic. She was remained on the prednisone for ___ years but had several side effects including weight gain and osteoporosis, so this was stopped. She has also developed several infections as a result of her biologic therapy including a jaw infection and a breast abscess which required significant surgical intervention. Due to her infections on biologics, she was stopped on biologics by her rheumatologist. She has instead been maintained on hydroxychloroquine 400 mg qhs and sulfasalazine 1000 mg daily. At baseline, her Still's symptoms are: ___ pain in various joints (changes every day), morning nausea, morning sore throat, and fevers twice a day between 103.7 and 104s. A few days before this admission, she developed severe pain in her left wrist, right wrist, and left ankle along with a fever to 104.8 which is higher than normal for her. She took a cold shower for 8 minutes but the fever did not improve at all. She called her Rheumatologist who recommended presenting to the hospital. She presented to ___ in ___ on ___. While there, her vital signs were stable. Labs showed WBC 12.2, hgb 11.9, lactate 1.3, procal < 0.05, cr 0.63, UA bland, LFTs normal, albumin 4, trop negative, CRP 5.6, ESR 50, flu negative. She was transferred to ___ for specialist care. In the ED at ___, initial vitals were T 98.8, HR 70, BP 130/80, RR 16, O2 100% RA. Labs notable for WBC 9.5 (35% lymph), hgb 11.4, Cr 0.7, LFTs normal, lipase 15, INR 1.2, UA bland, lactate 0.9, CRP 5.1. A CT abd/pelvis with contrast did not show any intraabdominal pathology. She was given ketorolac x1 and oxycodone. Upon arrival to the floor, patient reports the above history. She feels significant pain in her wrists and left ankle. She says she hasn't had gabapentin in >24 hours. She denies dysuria, frequency, chest pain, cough, headache, visual changes. She does not feel she has an infection, and instead feels like this is an exacerbation of her underlying Still's. She denies any recent travel, changes in medication, changes in diet, or sick contacts. Past Medical History: Still's disease Social History: ___ Family History: Mother died from complications of RA. Father with plaque psoriasis and psoriatic arthritis. Sister with plaque psoriasis. Physical Exam: ADMISSION EXAM VITAL SIGNS: T 98.3, BP 145 / 86, HR 76, RR 20 99 RA GENERAL: Distressed appearing female sitting in bed HEENT: MMM, OP clear, external ear canal normal NECK: Soft, no masses CARDIAC: RRR, normal s1,s2, no m/r/g LUNGS: CTAB ABDOMEN: Soft, nontender, nondistended EXTREMITIES: Right wrist is tender to palpation. Limited mobility of first three fingers due to pain. Left wrist tender to palpation. Both wrists with mild swelling and erythema. Left ankle is significantly tender to palpation and is swollen in the lateral aspect. Right ankle normal. NEUROLOGIC: A&Ox3, strength exam limited by pain, sensation intact to light touch SKIN: No facial rashes noted DISCHARGE EXAM =========== ___ ___ Temp: 98.0 PO BP: 130/79 HR: 64 RR: 18 O2 sat: 99% O2 delivery: Ra GENERAL: resting comfortably in bed seated up right HEENT: anicteric sclera, no scleral injection NECK: Soft, no masses CARDIAC: RRR, normal s1,s2, no m/r/g LUNGS: CTAB ABDOMEN: Soft, nontender, nondistended EXTREMITIES: Right wrist is tender to palpation. Limited mobility of first three fingers due to pain. Left wrist tender to palpation. Right wrist without marked overlying erythema or swelling in comparison to left wrist, no palpable synovitis or joint effusions. Left ankle with tender to palpation at the joint line but no overlying malleolus effusions, erythema or swelling NEUROLOGIC: A&Ox3, strength exam limited by pain, sensation intact to light touch SKIN: No facial rashes noted Pertinent Results: ADMISSION LABS ___ 03:15AM BLOOD WBC-9.5 RBC-4.32 Hgb-11.4 Hct-35.4 MCV-82 MCH-26.4 MCHC-32.2 RDW-14.9 RDWSD-45.1 Plt ___ ___ 03:15AM BLOOD Neuts-56.1 ___ Monos-6.1 Eos-2.1 Baso-0.4 Im ___ AbsNeut-5.34 AbsLymp-3.33 AbsMono-0.58 AbsEos-0.20 AbsBaso-0.04 ___ 03:15AM BLOOD ___ PTT-29.4 ___ ___ 03:15AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-142 K-4.4 Cl-105 HCO3-24 AnGap-13 ___ 03:15AM BLOOD ALT-10 AST-16 AlkPhos-72 TotBili-0.3 ___ 03:15AM BLOOD Lipase-15 ___:15AM BLOOD Albumin-4.0 Calcium-8.6 Phos-3.7 Mg-2.0 Iron-67 ___ 03:15AM BLOOD calTIBC-432 Ferritn-21 TRF-332 ___ 03:15AM BLOOD CRP-5.1* ___ 03:21AM BLOOD Lactate-0.9 INTERVAL LABS ___ 09:00AM BLOOD RheuFac-<10 ___ ___ 03:15AM BLOOD CRP-5.1* DISCHARGE LABS MICROBIOLOGY IMAGING CT A/P With Contrast ___ 1. Soft tissue density just distal to the duodenal jejunal junction suspicious for small bowel mass for which further characterization can be obtained by endoscopy if amenable by location or MRE. 2. No acute intra-abdominal or pelvic abnormalities to correlate with patient's symptoms, specifically no evidence of intra-abdominal abscess. CXR ___ Heart size is normal. Mediastinum is normal. Lungs are clear. There is no pleural effusion. There is no pneumothorax ANKLE MRI: ___ IMPRESSION: -Thickening of syndesmotic ligaments with some adjacent tibial cortical irregularity posteriorly suggestive of prior syndesmotic ligament injury. The ATFL appears slightly irregular also most likely due to prior injury. No acute ligamentous injury is identified. -There is tibiotalar osteoarthritis with full-thickness cartilage loss along the superomedial aspect of the talar dome and the adjacent tibial plafond. There is associated associated subchondral bone marrow edema, osteophytosis and mild synovitis. -Some stranding of the fat with loss of normal signal in sinus tarsi is demonstrated, this may be seen in setting of sinus tarsi syndrome. -Plantar fasciitis with associated plantar calcaneal spur. -Mild atrophy of the abductor digiti minimi muscle which may be seen in the setting of Baxter neuropathy. -Minimal extensor digitorum tenosynovitis. ___, MD electronically signed on SUN ___ 8:15 ___ Microbiology: ========= ___ 5:10 am URINE *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 3:26 am BLOOD CULTURE X2 Blood Culture, Routine (Pending): NGTD D/C Labs: ___ 06:20AM BLOOD WBC-7.1 RBC-4.20 Hgb-11.0 Hct-34.9 MCV-83 MCH-26.2 MCHC-31.5* RDW-14.7 RDWSD-44.6 Plt ___ ___ 06:20AM BLOOD Plt ___ ___ 06:20AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-141 K-4.1 Cl-100 HCO3-27 AnGap-14 ___ 06:20AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0 Brief Hospital Course: Summary: ======= Ms. ___ is a ___ year old female with a history of Still's disease, initially diagnosed in ___ previously on prednisone and biologics, currently maintained on hydroxychloroquine and sulfasalazine who initially presented with fever to 104+ and worsening arthralgias to ___, evaluated by rheumatology and ultimately per their assessment and negative laboratory and imaging findings determined not to have an acute flare of Adult onset Still's disease as a cause of her presentation. # Still's disease # Degenerative joint disease # Fever, joint pain Patient has a history of Still's disease initially diagnosed in ___, previously on prednisone and biologics, currently maintained on hydroxychloroquine and sulfasalazine. She previously did not tolerate biologics due to severe jaw and subsequent breast infection. At baseline has daily fevers measuring approximately 103-104, however presented with fever to 104.8 and severe worsening bilateral wrist and left ankle pain. Patient was evaluated by rheumatology, with recommendations including that she should follow up with her regular rheumatologist and could consider discontinuing her home regiment of sulfasalazine and plaquenil since it has not given her significant relief and worsened her nausea. Given severe left ankle swelling and pain, a left ankle MRI was obtained which showed largely degenerative joint disease without inflammatory changes. There was low suspicion for concomitant infection given low procalcitonin at OSH, no leukocytosis, or other localizing symptoms or signs consistent with infection. Given report of left-sided abdominal pain on admission, CT abdomen and pelvis was obtained which showed no obvious sources of infection, however did show soft tissue density distal to the duodenal-jejunal junction suspicious for small bowel mass. Patient was continued on home sulfasalazine and hydroxychloroquine. Pain was managed with Tylenol, ibuprofen, and oxycodone. Ultimately after a negative testing with a normal ferritin, negative ___, normal rheumatoid factor, their assessment was that this presentation was not consistent with a flair of her known Still's disease. # Possible small bowel mass - CT A/P on admission showed a soft tissue density just distal to the duodenal jejunal junction suspicious for small bowel mass. This will need further outpatient GI work up. TRANSITIONAL ISSUES =================== [ ] New/Changed Medications -None [ ] Discontinued medications -None [ ] patient with degenerative changes of left ankle, consider Ortho evaluation as an outpatient [ ] Recommend GI clinic visit for ongoing work-up of possible small bowel mass # CODE: full (presumed) # CONTACT: ___ Relationship: OTHER Phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydroxychloroquine Sulfate 400 mg PO QHS 2. SulfaSALAzine_ 1000 mg PO DAILY 3. Gabapentin 800 mg PO TID 4. Vitamin D ___ UNIT PO 1X/WEEK (MO) 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 6. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Mild 7. Methocarbamol 750 mg PO BID:PRN muscle spasm 8. Omeprazole 20 mg PO QAM 9. Zolpidem Tartrate 10 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet(s) by mouth three times daily Disp #60 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 3. Nystatin Oral Suspension 5 mL PO QID Duration: 6 Days RX nystatin 100,000 unit/mL 5 mL by mouth four times daily Refills:0 4. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron 4 mg 1 tablet(s) by mouth every eight hours Disp #28 Tablet Refills:0 5. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp #60 Tablet Refills:0 6. Gabapentin 800 mg PO TID 7. Hydroxychloroquine Sulfate 400 mg PO QHS 8. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 9. Methocarbamol 750 mg PO BID:PRN muscle spasm 10. Omeprazole 20 mg PO QAM 11. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Mild RX oxycodone 5 mg 2 tablet(s) by mouth every six hours Disp #16 Tablet Refills:*0 12. SulfaSALAzine_ 1000 mg PO DAILY 13. Vitamin D ___ UNIT PO 1X/WEEK (MO) 14. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Discharge Worksheet-Discharge ___, MD on ___ @ 1024 PRIMARY DIAGNOSIS Degenerative joint disease Chronic Still's disease Possible sinus tarsi syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. Why did you come to the hospital? -You initially presented to an outside hospital with worsening fever and joint pains -You were transferred to ___ for rheumatology evaluation - After the rheumatology evaluation it was determined that this round of pain was likely not due to a flare of your rheumatologic condition. - You also had an MRI of you left ankle which showed some degenerative changes of your ankle. What happened during her hospitalization? - You are evaluated by the rheumatology team and found not to have an acute exacerbation of your Still's disease - A MRI of your left ankle was obtained which showed degenerative changes - A Cat Scan of your abdomen showed a possible mass that will be further evaluated in the outpatient setting Which should you do when you leave the hospital? - Continue to take all your medications as prescribed - Follow-up with your primary care physician ___ 1 week - Please keep all the other scheduled healthcare appointments listed below Sincerely, Your ___ Care Team Followup Instructions: ___	[ "M19072", "M061", "R0600", "K3189", "R509", "L709" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Transfer for fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] y/o female with a history of Still's disease who presented to OSH ([MASKED]) with fevers to 104.8 and arthralgia and transferred for rheumatology evaluation. She first developed Still's symptoms in [MASKED]. Her symptoms were a fever to 103+ and rash. In [MASKED], she was diagnosed with Still's disease and began following with Dr. [MASKED] in Rheumatology ([MASKED], [MASKED]). She was initially started on prednisone 60 mg and a biologic. She was remained on the prednisone for [MASKED] years but had several side effects including weight gain and osteoporosis, so this was stopped. She has also developed several infections as a result of her biologic therapy including a jaw infection and a breast abscess which required significant surgical intervention. Due to her infections on biologics, she was stopped on biologics by her rheumatologist. She has instead been maintained on hydroxychloroquine 400 mg qhs and sulfasalazine 1000 mg daily. At baseline, her Still's symptoms are: [MASKED] pain in various joints (changes every day), morning nausea, morning sore throat, and fevers twice a day between 103.7 and 104s. A few days before this admission, she developed severe pain in her left wrist, right wrist, and left ankle along with a fever to 104.8 which is higher than normal for her. She took a cold shower for 8 minutes but the fever did not improve at all. She called her Rheumatologist who recommended presenting to the hospital. She presented to [MASKED] in [MASKED] on [MASKED]. While there, her vital signs were stable. Labs showed WBC 12.2, hgb 11.9, lactate 1.3, procal < 0.05, cr 0.63, UA bland, LFTs normal, albumin 4, trop negative, CRP 5.6, ESR 50, flu negative. She was transferred to [MASKED] for specialist care. In the ED at [MASKED], initial vitals were T 98.8, HR 70, BP 130/80, RR 16, O2 100% RA. Labs notable for WBC 9.5 (35% lymph), hgb 11.4, Cr 0.7, LFTs normal, lipase 15, INR 1.2, UA bland, lactate 0.9, CRP 5.1. A CT abd/pelvis with contrast did not show any intraabdominal pathology. She was given ketorolac x1 and oxycodone. Upon arrival to the floor, patient reports the above history. She feels significant pain in her wrists and left ankle. She says she hasn't had gabapentin in >24 hours. She denies dysuria, frequency, chest pain, cough, headache, visual changes. She does not feel she has an infection, and instead feels like this is an exacerbation of her underlying Still's. She denies any recent travel, changes in medication, changes in diet, or sick contacts. Past Medical History: Still's disease Social History: [MASKED] Family History: Mother died from complications of RA. Father with plaque psoriasis and psoriatic arthritis. Sister with plaque psoriasis. Physical Exam: ADMISSION EXAM VITAL SIGNS: T 98.3, BP 145 / 86, HR 76, RR 20 99 RA GENERAL: Distressed appearing female sitting in bed HEENT: MMM, OP clear, external ear canal normal NECK: Soft, no masses CARDIAC: RRR, normal s1,s2, no m/r/g LUNGS: CTAB ABDOMEN: Soft, nontender, nondistended EXTREMITIES: Right wrist is tender to palpation. Limited mobility of first three fingers due to pain. Left wrist tender to palpation. Both wrists with mild swelling and erythema. Left ankle is significantly tender to palpation and is swollen in the lateral aspect. Right ankle normal. NEUROLOGIC: A&Ox3, strength exam limited by pain, sensation intact to light touch SKIN: No facial rashes noted DISCHARGE EXAM =========== [MASKED] [MASKED] Temp: 98.0 PO BP: 130/79 HR: 64 RR: 18 O2 sat: 99% O2 delivery: Ra GENERAL: resting comfortably in bed seated up right HEENT: anicteric sclera, no scleral injection NECK: Soft, no masses CARDIAC: RRR, normal s1,s2, no m/r/g LUNGS: CTAB ABDOMEN: Soft, nontender, nondistended EXTREMITIES: Right wrist is tender to palpation. Limited mobility of first three fingers due to pain. Left wrist tender to palpation. Right wrist without marked overlying erythema or swelling in comparison to left wrist, no palpable synovitis or joint effusions. Left ankle with tender to palpation at the joint line but no overlying malleolus effusions, erythema or swelling NEUROLOGIC: A&Ox3, strength exam limited by pain, sensation intact to light touch SKIN: No facial rashes noted Pertinent Results: ADMISSION LABS [MASKED] 03:15AM BLOOD WBC-9.5 RBC-4.32 Hgb-11.4 Hct-35.4 MCV-82 MCH-26.4 MCHC-32.2 RDW-14.9 RDWSD-45.1 Plt [MASKED] [MASKED] 03:15AM BLOOD Neuts-56.1 [MASKED] Monos-6.1 Eos-2.1 Baso-0.4 Im [MASKED] AbsNeut-5.34 AbsLymp-3.33 AbsMono-0.58 AbsEos-0.20 AbsBaso-0.04 [MASKED] 03:15AM BLOOD [MASKED] PTT-29.4 [MASKED] [MASKED] 03:15AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-142 K-4.4 Cl-105 HCO3-24 AnGap-13 [MASKED] 03:15AM BLOOD ALT-10 AST-16 AlkPhos-72 TotBili-0.3 [MASKED] 03:15AM BLOOD Lipase-15 [MASKED]:15AM BLOOD Albumin-4.0 Calcium-8.6 Phos-3.7 Mg-2.0 Iron-67 [MASKED] 03:15AM BLOOD calTIBC-432 Ferritn-21 TRF-332 [MASKED] 03:15AM BLOOD CRP-5.1* [MASKED] 03:21AM BLOOD Lactate-0.9 INTERVAL LABS [MASKED] 09:00AM BLOOD RheuFac-<10 [MASKED] [MASKED] 03:15AM BLOOD CRP-5.1* DISCHARGE LABS MICROBIOLOGY IMAGING CT A/P With Contrast [MASKED] 1. Soft tissue density just distal to the duodenal jejunal junction suspicious for small bowel mass for which further characterization can be obtained by endoscopy if amenable by location or MRE. 2. No acute intra-abdominal or pelvic abnormalities to correlate with patient's symptoms, specifically no evidence of intra-abdominal abscess. CXR [MASKED] Heart size is normal. Mediastinum is normal. Lungs are clear. There is no pleural effusion. There is no pneumothorax ANKLE MRI: [MASKED] IMPRESSION: -Thickening of syndesmotic ligaments with some adjacent tibial cortical irregularity posteriorly suggestive of prior syndesmotic ligament injury. The ATFL appears slightly irregular also most likely due to prior injury. No acute ligamentous injury is identified. -There is tibiotalar osteoarthritis with full-thickness cartilage loss along the superomedial aspect of the talar dome and the adjacent tibial plafond. There is associated associated subchondral bone marrow edema, osteophytosis and mild synovitis. -Some stranding of the fat with loss of normal signal in sinus tarsi is demonstrated, this may be seen in setting of sinus tarsi syndrome. -Plantar fasciitis with associated plantar calcaneal spur. -Mild atrophy of the abductor digiti minimi muscle which may be seen in the setting of Baxter neuropathy. -Minimal extensor digitorum tenosynovitis. [MASKED], MD electronically signed on SUN [MASKED] 8:15 [MASKED] Microbiology: ========= [MASKED] 5:10 am URINE *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 3:26 am BLOOD CULTURE X2 Blood Culture, Routine (Pending): NGTD D/C Labs: [MASKED] 06:20AM BLOOD WBC-7.1 RBC-4.20 Hgb-11.0 Hct-34.9 MCV-83 MCH-26.2 MCHC-31.5* RDW-14.7 RDWSD-44.6 Plt [MASKED] [MASKED] 06:20AM BLOOD Plt [MASKED] [MASKED] 06:20AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-141 K-4.1 Cl-100 HCO3-27 AnGap-14 [MASKED] 06:20AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0 Brief Hospital Course: Summary: ======= Ms. [MASKED] is a [MASKED] year old female with a history of Still's disease, initially diagnosed in [MASKED] previously on prednisone and biologics, currently maintained on hydroxychloroquine and sulfasalazine who initially presented with fever to 104+ and worsening arthralgias to [MASKED], evaluated by rheumatology and ultimately per their assessment and negative laboratory and imaging findings determined not to have an acute flare of Adult onset Still's disease as a cause of her presentation. # Still's disease # Degenerative joint disease # Fever, joint pain Patient has a history of Still's disease initially diagnosed in [MASKED], previously on prednisone and biologics, currently maintained on hydroxychloroquine and sulfasalazine. She previously did not tolerate biologics due to severe jaw and subsequent breast infection. At baseline has daily fevers measuring approximately 103-104, however presented with fever to 104.8 and severe worsening bilateral wrist and left ankle pain. Patient was evaluated by rheumatology, with recommendations including that she should follow up with her regular rheumatologist and could consider discontinuing her home regiment of sulfasalazine and plaquenil since it has not given her significant relief and worsened her nausea. Given severe left ankle swelling and pain, a left ankle MRI was obtained which showed largely degenerative joint disease without inflammatory changes. There was low suspicion for concomitant infection given low procalcitonin at OSH, no leukocytosis, or other localizing symptoms or signs consistent with infection. Given report of left-sided abdominal pain on admission, CT abdomen and pelvis was obtained which showed no obvious sources of infection, however did show soft tissue density distal to the duodenal-jejunal junction suspicious for small bowel mass. Patient was continued on home sulfasalazine and hydroxychloroquine. Pain was managed with Tylenol, ibuprofen, and oxycodone. Ultimately after a negative testing with a normal ferritin, negative [MASKED], normal rheumatoid factor, their assessment was that this presentation was not consistent with a flair of her known Still's disease. # Possible small bowel mass - CT A/P on admission showed a soft tissue density just distal to the duodenal jejunal junction suspicious for small bowel mass. This will need further outpatient GI work up. TRANSITIONAL ISSUES =================== [ ] New/Changed Medications -None [ ] Discontinued medications -None [ ] patient with degenerative changes of left ankle, consider Ortho evaluation as an outpatient [ ] Recommend GI clinic visit for ongoing work-up of possible small bowel mass # CODE: full (presumed) # CONTACT: [MASKED] Relationship: OTHER Phone: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydroxychloroquine Sulfate 400 mg PO QHS 2. SulfaSALAzine 1000 mg PO DAILY 3. Gabapentin 800 mg PO TID 4. Vitamin D [MASKED] UNIT PO 1X/WEEK (MO) 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 6. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Mild 7. Methocarbamol 750 mg PO BID:PRN muscle spasm 8. Omeprazole 20 mg PO QAM 9. Zolpidem Tartrate 10 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet(s) by mouth three times daily Disp #60 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 3. Nystatin Oral Suspension 5 mL PO QID Duration: 6 Days RX nystatin 100,000 unit/mL 5 mL by mouth four times daily Refills:0 4. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron 4 mg 1 tablet(s) by mouth every eight hours Disp #28 Tablet Refills:0 5. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp #60 Tablet Refills:0 6. Gabapentin 800 mg PO TID 7. Hydroxychloroquine Sulfate 400 mg PO QHS 8. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate 9. Methocarbamol 750 mg PO BID:PRN muscle spasm 10. Omeprazole 20 mg PO QAM 11. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Mild RX oxycodone 5 mg 2 tablet(s) by mouth every six hours Disp #16 Tablet Refills:*0 12. SulfaSALAzine 1000 mg PO DAILY 13. Vitamin D [MASKED] UNIT PO 1X/WEEK (MO) 14. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Discharge Worksheet-Discharge [MASKED], MD on [MASKED] @ 1024 PRIMARY DIAGNOSIS Degenerative joint disease Chronic Still's disease Possible sinus tarsi syndrome 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 did you come to the hospital? -You initially presented to an outside hospital with worsening fever and joint pains -You were transferred to [MASKED] for rheumatology evaluation - After the rheumatology evaluation it was determined that this round of pain was likely not due to a flare of your rheumatologic condition. - You also had an MRI of you left ankle which showed some degenerative changes of your ankle. What happened during her hospitalization? - You are evaluated by the rheumatology team and found not to have an acute exacerbation of your Still's disease - A MRI of your left ankle was obtained which showed degenerative changes - A Cat Scan of your abdomen showed a possible mass that will be further evaluated in the outpatient setting Which should you do when you leave the hospital? - Continue to take all your medications as prescribed - Follow-up with your primary care physician [MASKED] 1 week - Please keep all the other scheduled healthcare appointments listed below Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[]	[ "M19072: Primary osteoarthritis, left ankle and foot", "M061: Adult-onset Still's disease", "R0600: Dyspnea, unspecified", "K3189: Other diseases of stomach and duodenum", "R509: Fever, unspecified", "L709: Acne, unspecified" ]
10,048,244	21,843,889	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Attending: ___. Chief Complaint: Acute kidney injury Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with history of HCV cirrhosis complicated by ___ s/p liver transplant ___, course c/b mild acute rejection ___ and recurrent HCV now s/p cure, recurrent cirrhosis, CVA in ___ with residual right sided weakness, and newly diagnosed focal segmental glomerulosclerosis, who is presenting with worsening renal function and chills. The patient was most recently discharged ___, for subcapsular/perinephric hematoma after renal biopsy was done for increasing creatinine and proteinuria. Although his renal function had moderately improved with decreasing tacrolimus level, final biopsy results showed FSGS. He went for routine follow up in primary care clinic yesterday (___) and labs showed creatinine had increased to 3.1, from 2.5 at discharge (baseline low 2s). He was sent to the ED when the labs resulted. Prior to coming to the ED, the patient was feeling well. He has had no fevers, nausea, vomiting, diarrhea, back/flank pain, dysuria, hematuria, or change in urine output, and no ___ swelling. He has had occasional chills. His wife also thought he was more fatigued than usual. In the ED initial vitals: 98.9 79 130/82 16 100RA. Exam was notable for shivering, sleepiness, bibasilar crackles, no ascites and residual RUE and RLE weakness. Labs were notable for Cr 3.2, H/H 8.1/26.1 (baseline), WBC 6.3, LFTs wnl. UA was notable for small blood, few bacteria, RBC 1, WBC 4, >300 protein. Urine protein/cr ratio was 3.8 (was 6.2 ___. Renal ultrasound showed no hydronephrosis, left perinephric hematoma measuring 7.3 x 3.7 x 3.1 cm. CXR had no acute processes. He was given 50 g albumin and 650mg acetaminophen. Upon arrival to the floor, the patient endorses headache, which has been persistent for some time. He denies new numbness or weakness. He denies chest pain, dyspnea, ___ edema, abdominal distension, decreased appetite, pruritus. REVIEW OF SYSTEMS: as per HPI. Past Medical History: # Liver Transplant (___) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented ___ -- c/b mild acute rejection (biopsy ___ -- c/b recurrent HCV s/p treatment and cure # Cirrhosis # Hepatocellular Carcinoma # History of Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD (___) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm (___) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation (___) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: ___ Family History: No family history of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM VITAL SIGNS - 99.6 PO 163 / 74 R Lying 85 20 98 RA GENERAL - well appearing, no acute distress HEENT - MMM NECK - JVP not elevated CARDIAC - RRR, nl S1 S2, no murmurs/rubs/gallops PULMONARY - clear to auscultation bilaterally, no wheeze, rales, rhonchi ABDOMEN - soft, NT, ND, NABS GENITOURINARY - no foley EXTREMITIES - no edema, WWP SKIN - no rash visualized NEUROLOGIC - baseline right arm and leg weakness PSYCHIATRIC - normal mood and affect DISCHARGE PHYSICAL EXAM VITAL SIGNS - 98.3, 150s/80s, 70s, 18, 97% RA GENERAL - well appearing, no acute distress HEENT - MMM CARDIAC - RRR, nl S1 S2, no murmurs/rubs/gallops PULMONARY - clear to auscultation bilaterally, no wheeze, rales, rhonchi ABDOMEN - soft, NT, ND, NABS GENITOURINARY - no foley EXTREMITIES - no edema, WWP SKIN - no rash visualized NEUROLOGIC - baseline right arm and right leg weakness Pertinent Results: ADMISSION LABS ------------------ ___ 01:45PM BLOOD WBC-5.4 RBC-3.28* Hgb-7.9* Hct-24.4* MCV-74* MCH-24.1* MCHC-32.4 RDW-13.1 RDWSD-35.3 Plt ___ ___ 09:30AM BLOOD Neuts-73.1* Lymphs-18.1* Monos-7.3 Eos-0.8* Baso-0.2 Im ___ AbsNeut-4.60# AbsLymp-1.14* AbsMono-0.46 AbsEos-0.05 AbsBaso-0.01 ___ 09:30AM BLOOD ___ PTT-33.3 ___ ___ 01:45PM BLOOD UreaN-36* Creat-3.1* Na-139 K-4.6 Cl-106 HCO3-19* AnGap-19 ___ 01:45PM BLOOD ALT-14 AST-24 AlkPhos-115 TotBili-0.3 ___ 01:45PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.4 Mg-1.9 ___ 01:45PM BLOOD tacroFK-2.3* ___ 10:15AM BLOOD Lactate-1.3 K-4.5 ___ EVEROLIMUS,LC/MS/MS,BLOOD 4.9 ___ 10:20AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 10:20AM URINE Blood-SM Nitrite-NEG Protein->300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 10:20AM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1 ___ 10:20AM URINE Hours-RANDOM UreaN-545 Creat-197 Na-20 K-41 Cl-<20 TotProt-750 Calcium-<0.8 Phos-47.7 Mg-1.7 Prot/Cr-3.8* ___ 10:20AM URINE Osmolal-383 DISCHARGE LABS: --------------- ___ 05:44AM BLOOD WBC-4.7 RBC-3.04* Hgb-7.5* Hct-22.7* MCV-75* MCH-24.7* MCHC-33.0 RDW-13.1 RDWSD-35.4 Plt ___ ___ 05:44AM BLOOD ___ PTT-30.9 ___ ___ 05:44AM BLOOD Glucose-137* UreaN-30* Creat-2.7* Na-138 K-4.6 Cl-106 HCO3-21* AnGap-16 ___ 05:44AM BLOOD ALT-14 AST-20 LD(LDH)-307* AlkPhos-104 TotBili-0.2 ___ 05:44AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0 ___ 05:44AM BLOOD tacroFK-2.6* ___ 05:30AM BLOOD Hapto-318* IMAGING --------- RENAL ULTRASOUND ___: 1. No hydronephrosis. Left perinephric hematoma, extent of which is not clearly defined. Follow-up is recommended. RECOMMENDATION(S): Recommend follow-up. CXR (___): No acute cardiopulmonary process. Stable pleural calcifications. MICROBIOLOGY ---------------- ___ 10:20 am URINE *FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Brief Hospital Course: Mr. ___ is a ___ year old man with history of HCV cirrhosis complicated by ___ s/p liver transplant ___, course c/b mild acute rejection ___ and recurrent HCV now s/p cure, CVA in ___ with residual right sided weakness, and newly diagnosed focal sclerosing glomerulonephritis, presenting with worsening renal function and chills with concern for worsening FSGS, now with slightly improving renal function after stopping everolimus and decreasing the dose of tacrolimus. ___ on CKD, Focal segmental glumerosclerosis: Patient presenting with proteinuria and creatinine 3.2 above baseline low 2s, and discharge Cr of 2.5 (___). Given recent FSGS diagnosis, concerned for worsening disease, as it may be rapidly progressive in some people. Although his biopsy does not comment, suspect FSGS is secondary type and may be secondary to HCV. Patient denied decreased po intake and denies infectious symptoms. Renal ultrasound showing no hydronephrosis and stable left perinephric hematoma. Urine prot/cr worsening (6.5 from 3.8). Renal was consulted who felt that the acute worsening of his renal function could likely be attributed to his immunosuppressants so they recommended minimizing Everolimus and Tacrolimus. He was discharged on a decreased dose of Tacrolimus (2.5 mg bid), OFF of Everolimus, and Prednisone 7.5 mg daily was initiated. #HCV cirrhosis c/b ___ s/p liver Transplant ___, with recurrent cirrhosis: Patient unfortunately developed recurrent cirrhosis despite HCV cure with simeprevir and sofosbuvir. He has had no identified liver lesions c/f HCC. He is currently on a study drug to treat fibrosis. He has no varices on recent EGD, no ascites, and no documentation of recent encephalopathy. He was continued on home study drug (per Dr. ___, and the following immunosuppressants: He was discharged on a decreased dose of Tacrolimus (2.5 mg bid), OFF of Everolimus, and Prednisone 7.5 mg daily was initiated. He will follow up at transplant clinic on ___. #Hypertension: As above, BPs may be more elevated than in his past with the current FSGS and worsening renal function. Currently elevated BP most likely due to missed doses of home medications while in the ED, and BP stabilized but were still elevated to 150's systolic during the hospitalizations. We continue home labetolol 200 mg BID, amlodipine 10 mg PO daily on discharge. Would recommend eventually initiating ___ once kidney function stabilizes. Spironolactone 50 mg daily was held in setting of ___, and remained off on discharge. He should discuss this with his outside providers. # Anemia: Hgb 8 on admission, stable from prior discharge baseline. Last iron studies in ___ c/w AOCD with low retics suggestive of hypoproliferation. Hgb remained stable throughout discharge, Hgb 7.7 on discharge. #Chest pain: The night prior to discharge he developed L sided sharp chest pain which was completely new and happened at rest and resolved spontaneously after less than an hour with no intervention. His ECG and cardiac enzymes were negative and his chest pain did not recur. He was able to walk comfortably without recurrent pain so he was deemed safe for discharge. Discharge: # Esophagitis: Continued home omeprazole # Seizure Disorder: Continued home LevETIRAcetam 1500 mg PO BID. COncern that this dose is too high given recent worsening renal function. He should discuss this with his outpatient neurologist. # Ruptured Cerebral Aneurysm: Continued home Pravastatin 40 mg PO QPM. Transitional Issues: -Check creatinine at next visit. -Spironolactone held on discharge due to ___. Please consider restarting once kidney function stabilizes -Consider starting ___ once renal function stabilizes - Will need consultation with neurologist to discuss Levetiracetam dose. We feel that it is too high for his kidney function -Consider PCP prophylaxis given newly prescribed chronic prednisone. -Make sure he has not had recurrence of L sided chest pain he had the night prior to d/c Full Code Name of health care proxy: ___ Relationship: Wife Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 2. Everolimus 2.25 mg PO BID 3. LevETIRAcetam 1500 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. Tacrolimus 3 mg PO Q12H 8. Vitamin D 1000 UNIT PO DAILY 9. IDN-___/Placebo Study Med ___ mg orally TWICE A DAY 10. amLODIPine 10 mg PO DAILY 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 12. Spironolactone 50 mg PO DAILY 13. Labetalol 200 mg PO BID Discharge Medications: 1. PredniSONE 7.5 mg PO DAILY RX prednisone 5 mg 1 tablet(s) by mouth twice daily Disp #28 Tablet Refills:0 RX prednisone 2.5 mg 1 tablet(s) by mouth twice daily Disp #28 Tablet Refills:0 2. Tacrolimus 2.5 mg PO Q12H RX tacrolimus 1 mg 2 capsule(s) by mouth twice daily Disp #56 Capsule Refills:0 RX tacrolimus 0.5 mg 1 capsule(s) by mouth twice daily Disp #28 Capsule Refills:*0 3. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 6. IDN-___/Placebo Study Med ___ mg orally TWICE A DAY 7. Labetalol 200 mg PO BID 8. LevETIRAcetam 1500 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Pravastatin 40 mg PO QPM 12. Vitamin D 1000 UNIT PO DAILY 13. HELD- Spironolactone 50 mg PO DAILY This medication was held. Do not restart Spironolactone until you speak to your transplant doctors on ___ Discharge Disposition: Home Discharge Diagnosis: Primary: ___ on CKD Secondary: HCV cirrhosis c/b ___ s/p liver Transplant ___, Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Why were you admitted? You were admitted to ___ because your kidney function was slightly worse. We were concerned that this might have been because of your immunosuppressant medications so we stopped your Everolimus and decreased your Tacrolimus to 2.5 mg twice daily. We also started Prednisone 7.5 mg daily. What changes did we make? We changed your immunosuppressant medications to: Decreased Tacrolimus to 2.5 mg twice daily and we also started Prednisone 7.5 mg daily. We stopped your Everolimus. What do you need to do when you leave? -Please follow up with your PCP, your kidney specialist Dr. ___ your liver doctor Dr. ___ below) We wish you all the best. Sincerely, Your care team at ___ Followup Instructions: ___	[ "N179", "Z944", "I671", "I69351", "I129", "D649", "R079", "K209", "G40909", "N183", "Z87891", "R809", "N051", "Z8505" ]	Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Chief Complaint: Acute kidney injury Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with history of HCV cirrhosis complicated by [MASKED] s/p liver transplant [MASKED], course c/b mild acute rejection [MASKED] and recurrent HCV now s/p cure, recurrent cirrhosis, CVA in [MASKED] with residual right sided weakness, and newly diagnosed focal segmental glomerulosclerosis, who is presenting with worsening renal function and chills. The patient was most recently discharged [MASKED], for subcapsular/perinephric hematoma after renal biopsy was done for increasing creatinine and proteinuria. Although his renal function had moderately improved with decreasing tacrolimus level, final biopsy results showed FSGS. He went for routine follow up in primary care clinic yesterday ([MASKED]) and labs showed creatinine had increased to 3.1, from 2.5 at discharge (baseline low 2s). He was sent to the ED when the labs resulted. Prior to coming to the ED, the patient was feeling well. He has had no fevers, nausea, vomiting, diarrhea, back/flank pain, dysuria, hematuria, or change in urine output, and no [MASKED] swelling. He has had occasional chills. His wife also thought he was more fatigued than usual. In the ED initial vitals: 98.9 79 130/82 16 100RA. Exam was notable for shivering, sleepiness, bibasilar crackles, no ascites and residual RUE and RLE weakness. Labs were notable for Cr 3.2, H/H 8.1/26.1 (baseline), WBC 6.3, LFTs wnl. UA was notable for small blood, few bacteria, RBC 1, WBC 4, >300 protein. Urine protein/cr ratio was 3.8 (was 6.2 [MASKED]. Renal ultrasound showed no hydronephrosis, left perinephric hematoma measuring 7.3 x 3.7 x 3.1 cm. CXR had no acute processes. He was given 50 g albumin and 650mg acetaminophen. Upon arrival to the floor, the patient endorses headache, which has been persistent for some time. He denies new numbness or weakness. He denies chest pain, dyspnea, [MASKED] edema, abdominal distension, decreased appetite, pruritus. REVIEW OF SYSTEMS: as per HPI. Past Medical History: # Liver Transplant ([MASKED]) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented [MASKED] -- c/b mild acute rejection (biopsy [MASKED] -- c/b recurrent HCV s/p treatment and cure # Cirrhosis # Hepatocellular Carcinoma # History of Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD ([MASKED]) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm ([MASKED]) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation ([MASKED]) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: [MASKED] Family History: No family history of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM VITAL SIGNS - 99.6 PO 163 / 74 R Lying 85 20 98 RA GENERAL - well appearing, no acute distress HEENT - MMM NECK - JVP not elevated CARDIAC - RRR, nl S1 S2, no murmurs/rubs/gallops PULMONARY - clear to auscultation bilaterally, no wheeze, rales, rhonchi ABDOMEN - soft, NT, ND, NABS GENITOURINARY - no foley EXTREMITIES - no edema, WWP SKIN - no rash visualized NEUROLOGIC - baseline right arm and leg weakness PSYCHIATRIC - normal mood and affect DISCHARGE PHYSICAL EXAM VITAL SIGNS - 98.3, 150s/80s, 70s, 18, 97% RA GENERAL - well appearing, no acute distress HEENT - MMM CARDIAC - RRR, nl S1 S2, no murmurs/rubs/gallops PULMONARY - clear to auscultation bilaterally, no wheeze, rales, rhonchi ABDOMEN - soft, NT, ND, NABS GENITOURINARY - no foley EXTREMITIES - no edema, WWP SKIN - no rash visualized NEUROLOGIC - baseline right arm and right leg weakness Pertinent Results: ADMISSION LABS ------------------ [MASKED] 01:45PM BLOOD WBC-5.4 RBC-3.28* Hgb-7.9* Hct-24.4* MCV-74* MCH-24.1* MCHC-32.4 RDW-13.1 RDWSD-35.3 Plt [MASKED] [MASKED] 09:30AM BLOOD Neuts-73.1* Lymphs-18.1* Monos-7.3 Eos-0.8* Baso-0.2 Im [MASKED] AbsNeut-4.60# AbsLymp-1.14* AbsMono-0.46 AbsEos-0.05 AbsBaso-0.01 [MASKED] 09:30AM BLOOD [MASKED] PTT-33.3 [MASKED] [MASKED] 01:45PM BLOOD UreaN-36* Creat-3.1* Na-139 K-4.6 Cl-106 HCO3-19* AnGap-19 [MASKED] 01:45PM BLOOD ALT-14 AST-24 AlkPhos-115 TotBili-0.3 [MASKED] 01:45PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.4 Mg-1.9 [MASKED] 01:45PM BLOOD tacroFK-2.3* [MASKED] 10:15AM BLOOD Lactate-1.3 K-4.5 [MASKED] EVEROLIMUS,LC/MS/MS,BLOOD 4.9 [MASKED] 10:20AM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 10:20AM URINE Blood-SM Nitrite-NEG Protein->300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 10:20AM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1 [MASKED] 10:20AM URINE Hours-RANDOM UreaN-545 Creat-197 Na-20 K-41 Cl-<20 TotProt-750 Calcium-<0.8 Phos-47.7 Mg-1.7 Prot/Cr-3.8* [MASKED] 10:20AM URINE Osmolal-383 DISCHARGE LABS: --------------- [MASKED] 05:44AM BLOOD WBC-4.7 RBC-3.04* Hgb-7.5* Hct-22.7* MCV-75* MCH-24.7* MCHC-33.0 RDW-13.1 RDWSD-35.4 Plt [MASKED] [MASKED] 05:44AM BLOOD [MASKED] PTT-30.9 [MASKED] [MASKED] 05:44AM BLOOD Glucose-137* UreaN-30* Creat-2.7* Na-138 K-4.6 Cl-106 HCO3-21* AnGap-16 [MASKED] 05:44AM BLOOD ALT-14 AST-20 LD(LDH)-307* AlkPhos-104 TotBili-0.2 [MASKED] 05:44AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0 [MASKED] 05:44AM BLOOD tacroFK-2.6* [MASKED] 05:30AM BLOOD Hapto-318* IMAGING --------- RENAL ULTRASOUND [MASKED]: 1. No hydronephrosis. Left perinephric hematoma, extent of which is not clearly defined. Follow-up is recommended. RECOMMENDATION(S): Recommend follow-up. CXR ([MASKED]): No acute cardiopulmonary process. Stable pleural calcifications. MICROBIOLOGY ---------------- [MASKED] 10:20 am URINE *FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with history of HCV cirrhosis complicated by [MASKED] s/p liver transplant [MASKED], course c/b mild acute rejection [MASKED] and recurrent HCV now s/p cure, CVA in [MASKED] with residual right sided weakness, and newly diagnosed focal sclerosing glomerulonephritis, presenting with worsening renal function and chills with concern for worsening FSGS, now with slightly improving renal function after stopping everolimus and decreasing the dose of tacrolimus. [MASKED] on CKD, Focal segmental glumerosclerosis: Patient presenting with proteinuria and creatinine 3.2 above baseline low 2s, and discharge Cr of 2.5 ([MASKED]). Given recent FSGS diagnosis, concerned for worsening disease, as it may be rapidly progressive in some people. Although his biopsy does not comment, suspect FSGS is secondary type and may be secondary to HCV. Patient denied decreased po intake and denies infectious symptoms. Renal ultrasound showing no hydronephrosis and stable left perinephric hematoma. Urine prot/cr worsening (6.5 from 3.8). Renal was consulted who felt that the acute worsening of his renal function could likely be attributed to his immunosuppressants so they recommended minimizing Everolimus and Tacrolimus. He was discharged on a decreased dose of Tacrolimus (2.5 mg bid), OFF of Everolimus, and Prednisone 7.5 mg daily was initiated. #HCV cirrhosis c/b [MASKED] s/p liver Transplant [MASKED], with recurrent cirrhosis: Patient unfortunately developed recurrent cirrhosis despite HCV cure with simeprevir and sofosbuvir. He has had no identified liver lesions c/f HCC. He is currently on a study drug to treat fibrosis. He has no varices on recent EGD, no ascites, and no documentation of recent encephalopathy. He was continued on home study drug (per Dr. [MASKED], and the following immunosuppressants: He was discharged on a decreased dose of Tacrolimus (2.5 mg bid), OFF of Everolimus, and Prednisone 7.5 mg daily was initiated. He will follow up at transplant clinic on [MASKED]. #Hypertension: As above, BPs may be more elevated than in his past with the current FSGS and worsening renal function. Currently elevated BP most likely due to missed doses of home medications while in the ED, and BP stabilized but were still elevated to 150's systolic during the hospitalizations. We continue home labetolol 200 mg BID, amlodipine 10 mg PO daily on discharge. Would recommend eventually initiating [MASKED] once kidney function stabilizes. Spironolactone 50 mg daily was held in setting of [MASKED], and remained off on discharge. He should discuss this with his outside providers. # Anemia: Hgb 8 on admission, stable from prior discharge baseline. Last iron studies in [MASKED] c/w AOCD with low retics suggestive of hypoproliferation. Hgb remained stable throughout discharge, Hgb 7.7 on discharge. #Chest pain: The night prior to discharge he developed L sided sharp chest pain which was completely new and happened at rest and resolved spontaneously after less than an hour with no intervention. His ECG and cardiac enzymes were negative and his chest pain did not recur. He was able to walk comfortably without recurrent pain so he was deemed safe for discharge. Discharge: # Esophagitis: Continued home omeprazole # Seizure Disorder: Continued home LevETIRAcetam 1500 mg PO BID. COncern that this dose is too high given recent worsening renal function. He should discuss this with his outpatient neurologist. # Ruptured Cerebral Aneurysm: Continued home Pravastatin 40 mg PO QPM. Transitional Issues: -Check creatinine at next visit. -Spironolactone held on discharge due to [MASKED]. Please consider restarting once kidney function stabilizes -Consider starting [MASKED] once renal function stabilizes - Will need consultation with neurologist to discuss Levetiracetam dose. We feel that it is too high for his kidney function -Consider PCP prophylaxis given newly prescribed chronic prednisone. -Make sure he has not had recurrence of L sided chest pain he had the night prior to d/c Full Code Name of health care proxy: [MASKED] Relationship: Wife Phone number: [MASKED] Cell phone: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 2. Everolimus 2.25 mg PO BID 3. LevETIRAcetam 1500 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. Tacrolimus 3 mg PO Q12H 8. Vitamin D 1000 UNIT PO DAILY 9. IDN-[MASKED]/Placebo Study Med [MASKED] mg orally TWICE A DAY 10. amLODIPine 10 mg PO DAILY 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 12. Spironolactone 50 mg PO DAILY 13. Labetalol 200 mg PO BID Discharge Medications: 1. PredniSONE 7.5 mg PO DAILY RX prednisone 5 mg 1 tablet(s) by mouth twice daily Disp #28 Tablet Refills:0 RX prednisone 2.5 mg 1 tablet(s) by mouth twice daily Disp #28 Tablet Refills:0 2. Tacrolimus 2.5 mg PO Q12H RX tacrolimus 1 mg 2 capsule(s) by mouth twice daily Disp #56 Capsule Refills:0 RX tacrolimus 0.5 mg 1 capsule(s) by mouth twice daily Disp #28 Capsule Refills:*0 3. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 6. IDN-[MASKED]/Placebo Study Med [MASKED] mg orally TWICE A DAY 7. Labetalol 200 mg PO BID 8. LevETIRAcetam 1500 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Pravastatin 40 mg PO QPM 12. Vitamin D 1000 UNIT PO DAILY 13. HELD- Spironolactone 50 mg PO DAILY This medication was held. Do not restart Spironolactone until you speak to your transplant doctors on [MASKED] Discharge Disposition: Home Discharge Diagnosis: Primary: [MASKED] on CKD Secondary: HCV cirrhosis c/b [MASKED] s/p liver Transplant [MASKED], Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], Why were you admitted? You were admitted to [MASKED] because your kidney function was slightly worse. We were concerned that this might have been because of your immunosuppressant medications so we stopped your Everolimus and decreased your Tacrolimus to 2.5 mg twice daily. We also started Prednisone 7.5 mg daily. What changes did we make? We changed your immunosuppressant medications to: Decreased Tacrolimus to 2.5 mg twice daily and we also started Prednisone 7.5 mg daily. We stopped your Everolimus. What do you need to do when you leave? -Please follow up with your PCP, your kidney specialist Dr. [MASKED] your liver doctor Dr. [MASKED] below) We wish you all the best. Sincerely, Your care team at [MASKED] Followup Instructions: [MASKED]	[]	[ "N179", "I129", "D649", "Z87891" ]	[ "N179: Acute kidney failure, unspecified", "Z944: Liver transplant status", "I671: Cerebral aneurysm, nonruptured", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "D649: Anemia, unspecified", "R079: Chest pain, unspecified", "K209: Esophagitis, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "N183: Chronic kidney disease, stage 3 (moderate)", "Z87891: Personal history of nicotine dependence", "R809: Proteinuria, unspecified", "N051: Unspecified nephritic syndrome with focal and segmental glomerular lesions", "Z8505: Personal history of malignant neoplasm of liver" ]
10,048,244	21,880,058	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Attending: ___ Chief Complaint: fever, left leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old man with PMHx of hep C cirrhosis s/p liver transplant complicated by recurrent cirrhosis of transplanted liver, HCC, hx of CVA with residual right sided weakness presenting to the ED with left leg pain and fevers. Patient reports he developed left leg pain, over medial aspect of posterior knee 2 days ago. Pain worse when walking. He had no pain with passive R knee movement. He has been having associated fever and chills at home for the past 2 days. Has been taking Tylenol every ___ hours for pain and for fevers. Today fever went up to 102 so patient presented to ED. In the ED, initial vital signs were: T 102.7, ___, 18, 100% RA - Exam was notable for: AOx3. Mild tenderness over medial aspect of L knee, normal panless AROM and PROM of L knee - Labs were notable for: wbc 5.3, H/H ___, plt 109, 82% neutrophils. LFTs wnl. Na 141, K 3.7, Cl 104, Bicarb 26, BUN 18, Cr 2, gluc 108. INR 1.3. UA moderate blood, 600 protein. - ___ negative for DVT of left leg. - CXR Right upper lobe pleural plaque. No acute cardiopulmonary process. - RUQ US with no ascites. Only able to tolerate part of Doppler study, but patent hepatic arteries and right/main vein. - The patient was given: 1g Acetaminophen, 2L NS, Levofloxacin 750mg IV, Cefepime 2g IV, Vanc 1g, Morphine 4mg IV, 650mg - Consults: hepatology consulted, requesting admission to ___ 10 Vitals prior to transfer were: 98.2, HR 79, 133/67, 18, 99RA Upon arrival to the floor, patient febrile to 101.8, HR 107. Patient slightly confused. Having trouble getting words out. Unable to tell me full story. Says that he has had leg pain before, but usually due to edema. He has frequent urination, waking up 4x a night. Denies previous issues with prostate. Denies weak stream, or difficulty initiating urination. Missed both tacro doses today. Per wife, he has difficulty with speech since his surgery, but does all his own medications at home. He ambulates with cane. Of note, spironolactone was increased the beginning of ___ to 50mg from 25mg for persistent hypertension. No one is sick at home. Past Medical History: # Liver Transplant (___) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented ___ -- c/b mild acute rejection (biopsy ___ -- c/b recurrent HCV (biopsy ___ # HCV Cirrhosis -- Genotype 1A -- recurrent infection after transplant # Hepatocellular Carcinoma # Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD (___) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm (___) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation (___) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: ___ Family History: No family history of liver disease. Physical Exam: ================== ADMISSION EXAM ================== VITALS - 101.8, 150/91, 105, 18, 96RA WEIGHT: 95.8kg Bladder scan: 92cc post void GENERAL - middle aged, ___ man, lying in bed, confused, difficulty getting words out HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple CARDIAC - tachycardic, normal S1/S2, no murmurs rubs or gallops PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - well healing scar from liver transplant, normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema. No erythema of left leg, no warmth, nontender. No difference in size between left and right legs. SKIN - without rash NEUROLOGIC - A&Ox1-2 (name, hospital, not ___, right sided facial droop, ___ strength in right arm and leg (baseline). No asterixis. ================== DISCHARGE EXAM ================== VS: 98.3, 144/92, 86, 18, 98RA GENERAL - middle aged, ___ man, lying in bed, appears fatigued, slightly slurred speech HEENT - normocephalic, atraumatic CARDIAC - RRR, normal S1/S2, no murmurs rubs or gallops PULMONARY - CTAB ABDOMEN - well healing scar from liver transplant, normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema. SKIN - without rash NEUROLOGIC - A&Ox3), right sided facial droop, ___ strength in right arm and leg (baseline). ___ strength in left arm and leg. No asterixis in left (cannot raise right arm). Pertinent Results: ADMISSION LABS =============== ___ 02:30PM WBC-5.3 RBC-4.68 HGB-12.0* HCT-37.2* MCV-80* MCH-25.6* MCHC-32.3 RDW-13.1 RDWSD-37.2 ___ 02:30PM NEUTS-82.0* LYMPHS-13.8* MONOS-3.8* EOS-0.0* BASOS-0.2 IM ___ AbsNeut-4.33 AbsLymp-0.73* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.01 ___ 02:30PM PLT COUNT-109* ___ 02:30PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 02:30PM CRP-66.3* ___ 02:30PM ALBUMIN-3.4* URIC ACID-5.4 ___ 02:30PM LIPASE-32 ___ 02:30PM ALT(SGPT)-17 AST(SGOT)-33 CK(CPK)-445* ALK PHOS-94 TOT BILI-0.4 ___ 02:30PM GLUCOSE-108* UREA N-18 CREAT-2.0* SODIUM-141 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15 ___ 02:39PM LACTATE-1.2 ___ 02:40PM ___ PTT-32.3 ___ DISCHARGE LABS ============== ___ 05:36AM BLOOD WBC-5.2 RBC-3.90* Hgb-9.8* Hct-30.6* MCV-79* MCH-25.1* MCHC-32.0 RDW-13.8 RDWSD-39.4 Plt ___ ___ 05:36AM BLOOD Plt ___ ___ 05:36AM BLOOD Glucose-118* UreaN-19 Creat-1.7* Na-142 K-3.5 Cl-108 HCO3-24 AnGap-14 ___ 05:36AM BLOOD ALT-35 AST-38 AlkPhos-68 TotBili-0.3 ___ 05:36AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9 PERTINENT LABS ============== ___ 05:05AM BLOOD tacroFK-5.0 ___ 05:05AM BLOOD tacroFK-3.4* ___ 05:05AM BLOOD tacroFK-4.0* ___ 05:05AM BLOOD tacroFK-4.1* ___ 10:24AM BLOOD tacroFK-4.5* MICRO ===== URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ Blood Culture, Routine (Pending): __________________________________________________________ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. __________________________________________________________ Blood Culture, Routine (Pending): __________________________________________________________ Blood Culture, Routine (Pending): __________________________________________________________ CMV Viral Load (Final ___: CMV DNA not detected. Blood Culture, Routine (Pending): __________________________________________________________ Blood Culture, Routine (Pending): __________________________________________________________ URINE CULTURE (Final ___: <10,000 organisms/ml. __________________________________________________________ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ Blood Culture, Routine (Final ___: NO GROWTH. STUDIES ======= -CXR Oblong opacity projecting over the right upper lung is compatible with calcified pleural plaque. The lungs are otherwise clear. No obvious effusion identified noting that there is exclusion of the right lateral costophrenic angle on the frontal view. The cardiomediastinal silhouette is stable given differences in projection. IMPRESSION: No acute cardiopulmonary process. -Left Lower Extremity Ultrasound No evidence of deep venous thrombosis in the left lower extremity veins. -RUQ Ultrasound Patent portal and hepatic veins. Patent hepatic arteries, the right and main hepatic artery not interrogated by Doppler ultrasound secondary to patient unable to remain still for the remainder of the study. Normal left hepatic artery waveform. No focal hepatic lesion. -CT A/P w/o Contrast 1. Although the exam is somewhat limited given the lack of IV contrast, peripancreatic fat stranding and fullness of the pancreatic head is compatible with pancreatitis. The chronicity of this finding is difficult to accurately assess, but is new since at least ___. 2. No focal fluid collection or intra-abdominal or pelvic abscess is identified. 3. Prior hepatic transplant, with persistent central periportal edema,. 4. Sequelae of portal hypertension includes persistent splenomegaly and perisplenic varices along with small volume intra-abdominal ascites. 5. Punctate, nonobstructing left lower pole renal stone. -CT Chest w/o Contrast No evidence of new infectious process. Chronic abnormalities including pleural effusion, pleural calcifications and bronchial wall thickening in the right lower lobe. Interval decrease in the right upper lobe pneumatoceles currently less than 5 mm in diameter. Brief Hospital Course: ___ year old man with PMHx of hep C cirrhosis s/p liver transplant complicated by recurrent cirrhosis of transplanted liver, HCC, hx of CVA with residual right sided weakness presenting to the ED with left leg pain and fevers, found to have ___. ACTIVE ISSUES ============== # Fever. He presented with fever to 103, with associated rigors and tachycardia, meeting criteria for SIRS. He was started on broad spectrum antibiotics with Vancomycin/Cefepime/Flagyl. He required scheduled APAP and cooling blankets but remainder persistently febrile for the first ___ hours of admission on antibiotics. He defervesced with last fever on ___ in the morning. Infectious work up was unrevealing, including CXR, Chest CT, CT A/P, and left knee xray. CMV VL was negative. Blood and urine cultures were negative. Antibiotics were discontinued after 4 days and he was monitored for 48 hours. He continued to improve without fevers and was discharged to home. The only other possible contributor to his fevers could have been the study drug he has been receiving. # Left knee pain. He presented with left knee pain, however this resolved spontaneously without intervention. Xray was without fracture. Lower extremity ultrasound was without DVT. # ___. Cr on admission was 2, elevated from recent baseline around 1.6. Cr downtrended with holding spironolactone and giving IV albumin. Spironolactone was restarted prior to discharge and Cr was at baseline 1.7. CHRONIC ISSUES ============== # HTN: Initially held amlodipine and spironolactone given SIRS, but restarted prior to discharge. # Hep C cirrhosis s/p extended criteria liver transplant, complicated by recurrent hep C cirrhosis. HCV of transplanted liver cleared with simeprevir and sofosbuvir and he was enrolled in a trial of antifibrotic therapy. He was continued on this study drug while inpatient. His cirrhosis was compensated with no LFT abnormalities, ascites ___ edema. He was continued on home tacrolimus dosing 3mg BID. # Seizure disorder. Continued keppra 1500mg BID # HLD. Continued pravastatin 40mg QHS TRANSITIONAL ISSUES =================== Immunosuppression - Tacrolimus 3mg BID - Resume standing transplant lab order on discharge # CONTACT: Patient, Taunia (Wife, HCP) ___ ___ # CODE STATUS: Full code confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. LeVETiracetam 1500 mg PO BID 3. Pravastatin 40 mg PO QPM 4. Spironolactone 25 mg PO DAILY 5. Tacrolimus 3 mg PO Q12H 6. Acetaminophen 325-650 mg PO Q8H:PRN pain 7. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 8. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. LeVETiracetam 1500 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Pravastatin 40 mg PO QPM 5. Spironolactone 25 mg PO DAILY 6. Tacrolimus 3 mg PO Q12H 7. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 8. IDN-___/placebo Study Med 25 MG PO 2X DAY Discharge Disposition: Home Discharge Diagnosis: Fever, unknown origin Left knee pain Encephalopathy ___ HTN Hep C cirrhosis s/p extended criteria liver transplant Seizure disorder HLD 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 during your hospitalization. Briefly, you were hospitalized with fevers and left knee pain. You were started on antibiotics and your fevers improved. You did not have any factures in your left knee on xray. We watched you in the hospital for 48 hours after stopping antibiotics and you continued to improve. We did not find any bacterial cause for your fevers in the blood or urine. We wish you the best, Your ___ Treatment Team Followup Instructions: ___	[ "R6511", "G9340", "T8649", "N179", "K521", "I69851", "Z944", "K7460", "B1920", "I69820", "R351", "I10", "G40909", "F1021", "E785", "M25562", "T3695XA", "Y92239", "Z006", "Z8505", "Z87891" ]	Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Chief Complaint: fever, left leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old man with PMHx of hep C cirrhosis s/p liver transplant complicated by recurrent cirrhosis of transplanted liver, HCC, hx of CVA with residual right sided weakness presenting to the ED with left leg pain and fevers. Patient reports he developed left leg pain, over medial aspect of posterior knee 2 days ago. Pain worse when walking. He had no pain with passive R knee movement. He has been having associated fever and chills at home for the past 2 days. Has been taking Tylenol every [MASKED] hours for pain and for fevers. Today fever went up to 102 so patient presented to ED. In the ED, initial vital signs were: T 102.7, [MASKED], 18, 100% RA - Exam was notable for: AOx3. Mild tenderness over medial aspect of L knee, normal panless AROM and PROM of L knee - Labs were notable for: wbc 5.3, H/H [MASKED], plt 109, 82% neutrophils. LFTs wnl. Na 141, K 3.7, Cl 104, Bicarb 26, BUN 18, Cr 2, gluc 108. INR 1.3. UA moderate blood, 600 protein. - [MASKED] negative for DVT of left leg. - CXR Right upper lobe pleural plaque. No acute cardiopulmonary process. - RUQ US with no ascites. Only able to tolerate part of Doppler study, but patent hepatic arteries and right/main vein. - The patient was given: 1g Acetaminophen, 2L NS, Levofloxacin 750mg IV, Cefepime 2g IV, Vanc 1g, Morphine 4mg IV, 650mg - Consults: hepatology consulted, requesting admission to [MASKED] 10 Vitals prior to transfer were: 98.2, HR 79, 133/67, 18, 99RA Upon arrival to the floor, patient febrile to 101.8, HR 107. Patient slightly confused. Having trouble getting words out. Unable to tell me full story. Says that he has had leg pain before, but usually due to edema. He has frequent urination, waking up 4x a night. Denies previous issues with prostate. Denies weak stream, or difficulty initiating urination. Missed both tacro doses today. Per wife, he has difficulty with speech since his surgery, but does all his own medications at home. He ambulates with cane. Of note, spironolactone was increased the beginning of [MASKED] to 50mg from 25mg for persistent hypertension. No one is sick at home. Past Medical History: # Liver Transplant ([MASKED]) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented [MASKED] -- c/b mild acute rejection (biopsy [MASKED] -- c/b recurrent HCV (biopsy [MASKED] # HCV Cirrhosis -- Genotype 1A -- recurrent infection after transplant # Hepatocellular Carcinoma # Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD ([MASKED]) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm ([MASKED]) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation ([MASKED]) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: [MASKED] Family History: No family history of liver disease. Physical Exam: ================== ADMISSION EXAM ================== VITALS - 101.8, 150/91, 105, 18, 96RA WEIGHT: 95.8kg Bladder scan: 92cc post void GENERAL - middle aged, [MASKED] man, lying in bed, confused, difficulty getting words out HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple CARDIAC - tachycardic, normal S1/S2, no murmurs rubs or gallops PULMONARY - clear to auscultation bilaterally, without wheezes or rhonchi ABDOMEN - well healing scar from liver transplant, normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema. No erythema of left leg, no warmth, nontender. No difference in size between left and right legs. SKIN - without rash NEUROLOGIC - A&Ox1-2 (name, hospital, not [MASKED], right sided facial droop, [MASKED] strength in right arm and leg (baseline). No asterixis. ================== DISCHARGE EXAM ================== VS: 98.3, 144/92, 86, 18, 98RA GENERAL - middle aged, [MASKED] man, lying in bed, appears fatigued, slightly slurred speech HEENT - normocephalic, atraumatic CARDIAC - RRR, normal S1/S2, no murmurs rubs or gallops PULMONARY - CTAB ABDOMEN - well healing scar from liver transplant, normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema. SKIN - without rash NEUROLOGIC - A&Ox3), right sided facial droop, [MASKED] strength in right arm and leg (baseline). [MASKED] strength in left arm and leg. No asterixis in left (cannot raise right arm). Pertinent Results: ADMISSION LABS =============== [MASKED] 02:30PM WBC-5.3 RBC-4.68 HGB-12.0* HCT-37.2* MCV-80* MCH-25.6* MCHC-32.3 RDW-13.1 RDWSD-37.2 [MASKED] 02:30PM NEUTS-82.0* LYMPHS-13.8* MONOS-3.8* EOS-0.0* BASOS-0.2 IM [MASKED] AbsNeut-4.33 AbsLymp-0.73* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.01 [MASKED] 02:30PM PLT COUNT-109* [MASKED] 02:30PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 02:30PM CRP-66.3* [MASKED] 02:30PM ALBUMIN-3.4* URIC ACID-5.4 [MASKED] 02:30PM LIPASE-32 [MASKED] 02:30PM ALT(SGPT)-17 AST(SGOT)-33 CK(CPK)-445* ALK PHOS-94 TOT BILI-0.4 [MASKED] 02:30PM GLUCOSE-108* UREA N-18 CREAT-2.0* SODIUM-141 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15 [MASKED] 02:39PM LACTATE-1.2 [MASKED] 02:40PM [MASKED] PTT-32.3 [MASKED] DISCHARGE LABS ============== [MASKED] 05:36AM BLOOD WBC-5.2 RBC-3.90* Hgb-9.8* Hct-30.6* MCV-79* MCH-25.1* MCHC-32.0 RDW-13.8 RDWSD-39.4 Plt [MASKED] [MASKED] 05:36AM BLOOD Plt [MASKED] [MASKED] 05:36AM BLOOD Glucose-118* UreaN-19 Creat-1.7* Na-142 K-3.5 Cl-108 HCO3-24 AnGap-14 [MASKED] 05:36AM BLOOD ALT-35 AST-38 AlkPhos-68 TotBili-0.3 [MASKED] 05:36AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9 PERTINENT LABS ============== [MASKED] 05:05AM BLOOD tacroFK-5.0 [MASKED] 05:05AM BLOOD tacroFK-3.4* [MASKED] 05:05AM BLOOD tacroFK-4.0* [MASKED] 05:05AM BLOOD tacroFK-4.1* [MASKED] 10:24AM BLOOD tacroFK-4.5* MICRO ===== URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] Blood Culture, Routine (Pending): [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. [MASKED] Blood Culture, Routine (Pending): [MASKED] Blood Culture, Routine (Pending): [MASKED] CMV Viral Load (Final [MASKED]: CMV DNA not detected. Blood Culture, Routine (Pending): [MASKED] Blood Culture, Routine (Pending): [MASKED] URINE CULTURE (Final [MASKED]: <10,000 organisms/ml. [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. STUDIES ======= -CXR Oblong opacity projecting over the right upper lung is compatible with calcified pleural plaque. The lungs are otherwise clear. No obvious effusion identified noting that there is exclusion of the right lateral costophrenic angle on the frontal view. The cardiomediastinal silhouette is stable given differences in projection. IMPRESSION: No acute cardiopulmonary process. -Left Lower Extremity Ultrasound No evidence of deep venous thrombosis in the left lower extremity veins. -RUQ Ultrasound Patent portal and hepatic veins. Patent hepatic arteries, the right and main hepatic artery not interrogated by Doppler ultrasound secondary to patient unable to remain still for the remainder of the study. Normal left hepatic artery waveform. No focal hepatic lesion. -CT A/P w/o Contrast 1. Although the exam is somewhat limited given the lack of IV contrast, peripancreatic fat stranding and fullness of the pancreatic head is compatible with pancreatitis. The chronicity of this finding is difficult to accurately assess, but is new since at least [MASKED]. 2. No focal fluid collection or intra-abdominal or pelvic abscess is identified. 3. Prior hepatic transplant, with persistent central periportal edema,. 4. Sequelae of portal hypertension includes persistent splenomegaly and perisplenic varices along with small volume intra-abdominal ascites. 5. Punctate, nonobstructing left lower pole renal stone. -CT Chest w/o Contrast No evidence of new infectious process. Chronic abnormalities including pleural effusion, pleural calcifications and bronchial wall thickening in the right lower lobe. Interval decrease in the right upper lobe pneumatoceles currently less than 5 mm in diameter. Brief Hospital Course: [MASKED] year old man with PMHx of hep C cirrhosis s/p liver transplant complicated by recurrent cirrhosis of transplanted liver, HCC, hx of CVA with residual right sided weakness presenting to the ED with left leg pain and fevers, found to have [MASKED]. ACTIVE ISSUES ============== # Fever. He presented with fever to 103, with associated rigors and tachycardia, meeting criteria for SIRS. He was started on broad spectrum antibiotics with Vancomycin/Cefepime/Flagyl. He required scheduled APAP and cooling blankets but remainder persistently febrile for the first [MASKED] hours of admission on antibiotics. He defervesced with last fever on [MASKED] in the morning. Infectious work up was unrevealing, including CXR, Chest CT, CT A/P, and left knee xray. CMV VL was negative. Blood and urine cultures were negative. Antibiotics were discontinued after 4 days and he was monitored for 48 hours. He continued to improve without fevers and was discharged to home. The only other possible contributor to his fevers could have been the study drug he has been receiving. # Left knee pain. He presented with left knee pain, however this resolved spontaneously without intervention. Xray was without fracture. Lower extremity ultrasound was without DVT. # [MASKED]. Cr on admission was 2, elevated from recent baseline around 1.6. Cr downtrended with holding spironolactone and giving IV albumin. Spironolactone was restarted prior to discharge and Cr was at baseline 1.7. CHRONIC ISSUES ============== # HTN: Initially held amlodipine and spironolactone given SIRS, but restarted prior to discharge. # Hep C cirrhosis s/p extended criteria liver transplant, complicated by recurrent hep C cirrhosis. HCV of transplanted liver cleared with simeprevir and sofosbuvir and he was enrolled in a trial of antifibrotic therapy. He was continued on this study drug while inpatient. His cirrhosis was compensated with no LFT abnormalities, ascites [MASKED] edema. He was continued on home tacrolimus dosing 3mg BID. # Seizure disorder. Continued keppra 1500mg BID # HLD. Continued pravastatin 40mg QHS TRANSITIONAL ISSUES =================== Immunosuppression - Tacrolimus 3mg BID - Resume standing transplant lab order on discharge # CONTACT: Patient, Taunia (Wife, HCP) [MASKED] [MASKED] # CODE STATUS: Full code confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. LeVETiracetam 1500 mg PO BID 3. Pravastatin 40 mg PO QPM 4. Spironolactone 25 mg PO DAILY 5. Tacrolimus 3 mg PO Q12H 6. Acetaminophen 325-650 mg PO Q8H:PRN pain 7. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 8. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. LeVETiracetam 1500 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Pravastatin 40 mg PO QPM 5. Spironolactone 25 mg PO DAILY 6. Tacrolimus 3 mg PO Q12H 7. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 8. IDN-[MASKED]/placebo Study Med 25 MG PO 2X DAY Discharge Disposition: Home Discharge Diagnosis: Fever, unknown origin Left knee pain Encephalopathy [MASKED] HTN Hep C cirrhosis s/p extended criteria liver transplant Seizure disorder HLD 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 during your hospitalization. Briefly, you were hospitalized with fevers and left knee pain. You were started on antibiotics and your fevers improved. You did not have any factures in your left knee on xray. We watched you in the hospital for 48 hours after stopping antibiotics and you continued to improve. We did not find any bacterial cause for your fevers in the blood or urine. We wish you the best, Your [MASKED] Treatment Team Followup Instructions: [MASKED]	[]	[ "N179", "I10", "E785", "Z87891" ]	[ "R6511: Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction", "G9340: Encephalopathy, unspecified", "T8649: Other complications of liver transplant", "N179: Acute kidney failure, unspecified", "K521: Toxic gastroenteritis and colitis", "I69851: Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side", "Z944: Liver transplant status", "K7460: Unspecified cirrhosis of liver", "B1920: Unspecified viral hepatitis C without hepatic coma", "I69820: Aphasia following other cerebrovascular disease", "R351: Nocturia", "I10: Essential (primary) hypertension", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "F1021: Alcohol dependence, in remission", "E785: Hyperlipidemia, unspecified", "M25562: Pain in left knee", "T3695XA: Adverse effect of unspecified systemic antibiotic, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z8505: Personal history of malignant neoplasm of liver", "Z87891: Personal history of nicotine dependence" ]
10,048,244	24,756,551	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Attending: ___ Chief Complaint: renal subcapsular hematoma Major Surgical or Invasive Procedure: Left Renal Biopsy ___ History of Present Illness: This is a ___ year old male with PMHx of hepatitis C (s/p treatment and cure) cirrhosis complicated by ___ s/p liver transplant, now with recurrent cirrhosis of transplanted liver, history of CVA with residual right sided weakness, and subacute renal disease who is presenting after undergoing elective renal biopsy. He was scheduled for elective renal biopsy on ___ for progressive renal dysfunction. The biopsy was complicated by a small subcapsular hematoma after pass 1 and a moderate subcapsular/perinephric hematoma after pass 2 which remained stable by ultrasound after extended compression. He remained hemodynamically stable but was admitted for observation overnight. On arrival to the floor, pt reports that he feels well. He does not have any pain at the biopsy site and does not feel lightheaded, dizzy, or short of breath. Past Medical History: # Liver Transplant (___) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented ___ -- c/b mild acute rejection (biopsy ___ -- c/b recurrent HCV s/p treatment and cure # Cirrhosis # Hepatocellular Carcinoma # History of Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD (___) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm (___) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation (___) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: ___ Family History: No family history of liver disease. Physical Exam: =========== ADMISSION =========== Vitals: 98.0 151/73 63 18 95% RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly. GU: no foley. Left flank with bandage which is c/d/I. No pain or bruising over left flank. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: right sided facial droop. Right arm paresis. =========== DISCHARGE =========== Vitals: 98.5 129/79 66 18 98% RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly. GU: no foley. Left flank with bandage which is c/d/I. No pain or bruising over left flank. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: right sided facial droop. Right arm paresis. Pertinent Results: ================= ADMISSION LABS ================= ___ 09:40PM BLOOD WBC-4.4 RBC-3.29* Hgb-8.0* Hct-24.9* MCV-76* MCH-24.3* MCHC-32.1 RDW-13.3 RDWSD-36.2 Plt ___ =========== IMAGING =========== - Kidney Biopsy ___: IMPRESSION: Ultrasound guidance for percutaneous left kidney biopsy, with small subcapsular hematoma after pass 1 and moderate subcapsular/perinephric hematoma after pass 2 which remained stable by ultrasound after extended compression. Plan was made to admit the patient for observation. ================ DISCHARGE LABS ================ ___ 06:56AM BLOOD WBC-4.4 RBC-3.38* Hgb-8.3* Hct-26.0* MCV-77* MCH-24.6* MCHC-31.9* RDW-13.5 RDWSD-37.4 Plt ___ ___ 06:56AM BLOOD Glucose-103* UreaN-23* Creat-2.5* Na-146* K-3.9 Cl-109* HCO3-24 AnGap-17 ___ 06:56AM BLOOD ALT-10 AST-17 AlkPhos-91 TotBili-0.3 ___ 06:56AM BLOOD Albumin-3.5 Calcium-8.7 Phos-2.7 Mg-1.7 ___ 06:56AM BLOOD tacroFK-<2.0* Brief Hospital Course: This is a ___ male with PMHx of hepatitis C (s/p treatment and cure) cirrhosis and HCC s/p liver transplant, now with recurrent cirrhosis of transplanted liver, history of CVA with residual right sided weakness, and subacute renal disease who is presenting after undergoing elective renal biopsy which was complicated by subcapsular biopsy. ============= ACUTE ISSUES ============= # Subcapsular/perinephric hematoma: Patient underwent elective renal biopsy on ___ which was complicated by a small subcapsular hematoma as well as a moderate subcapsular/perinephric hematoma based on ultrasound during the procedure. Overnight, he remained hemodynamically stable and hemoglobin remained stable (8.0 on admission -> 8.3 the next morning). He did have have any pain or bruising at the biopsy site. # Subacute Kidney Disease: Patient with subacute progressive proteinuric renal disease. Renal believes it could be Prograf toxicity, although the degree of proteinuria seems to be high for this, and his renal function has not improved with tapering down of the Prograf levels. Patient needs to follow up with renal as an outpatient. =============== CHRONIC ISSUES =============== # Liver Transplant (HCV cirrhosis and HCC): Transplant ___, c/b anastamotic bile leak and stricture (stented ___, mild acute rejection (biopsy ___, recurrent HCV (s/p treatment and cure), and recurrent cirrhosis. Patient is currently on tacrolimus 2 mg BID and everolimus 2.25 mg BID for immunosuppression. He is also enrolled in a study for fibrosis and received a study drug twice daily. # Esophagitis: Continued omeprazole # Hypertension: Held BP medications overnight in setting of potential bleed. Blood pressure remained stable, on the high side, and restarted his home medications prior to discharge (Labetalol 200 mg PO BID, amLODIPine 10 mg PO DAILY, spironolactone 50 mg daily). # Seizure Disorder: Continued LevETIRAcetam 1500 mg PO BID. # Ruptured Cerebral Aneurysm: Patient with ruptured cerebral aneurysm in ___ with residual right sided weakness. Patient reports an allergy to aspirin. Continued Pravastatin 40 mg PO QPM. ==================== TRANSITIONAL ISSUES ==================== [] Renal biopsy results pending on discharge. [] Tacro level < 2, however, he missed his morning dose the day of the biopsy. Repeat as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 2. LevETIRAcetam 1500 mg PO BID 3. Labetalol 200 mg PO BID 4. amLODIPine 10 mg PO DAILY 5. Pravastatin 40 mg PO QPM 6. Everolimus 2.25 mg PO BID 7. Tacrolimus 2 mg PO Q12H 8. Spironolactone 50 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 12. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 4. Everolimus 2.25 mg PO BID 5. IDN-6556/Placebo Study Med ___ mg orally TWICE A DAY 6. Labetalol 200 mg PO BID 7. LevETIRAcetam 1500 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Pravastatin 40 mg PO QPM 11. Spironolactone 50 mg PO DAILY 12. Tacrolimus 2 mg PO Q12H 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Renal subcapsular hematoma Secondary Diagnosis: Hepatitis C Cirrhosis s/p liver transplant Recurrent Cirrhosis Chronic Kidney Disease History of Ruptured Cerebral Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You underwent a biopsy of your kidney and were admitted to the hospital for close observation overnight to make sure that you did not bleed into your kidney. Overnight, everything went well and you were able to go home. Please continue to take all of your medications as prescribed previously and follow up at your outpatient appointments (see below). It was a pleasure meeting and taking care of you while you were in the hospital. -Your ___ Team Followup Instructions: ___	[ "I129", "N189", "N9961", "Y848", "Y92238", "K7460", "T8649", "Y830", "Y929", "Z8505", "I69351", "I69320", "K209", "G40909", "Z006", "Z87891" ]	Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Chief Complaint: renal subcapsular hematoma Major Surgical or Invasive Procedure: Left Renal Biopsy [MASKED] History of Present Illness: This is a [MASKED] year old male with PMHx of hepatitis C (s/p treatment and cure) cirrhosis complicated by [MASKED] s/p liver transplant, now with recurrent cirrhosis of transplanted liver, history of CVA with residual right sided weakness, and subacute renal disease who is presenting after undergoing elective renal biopsy. He was scheduled for elective renal biopsy on [MASKED] for progressive renal dysfunction. The biopsy was complicated by a small subcapsular hematoma after pass 1 and a moderate subcapsular/perinephric hematoma after pass 2 which remained stable by ultrasound after extended compression. He remained hemodynamically stable but was admitted for observation overnight. On arrival to the floor, pt reports that he feels well. He does not have any pain at the biopsy site and does not feel lightheaded, dizzy, or short of breath. Past Medical History: # Liver Transplant ([MASKED]) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented [MASKED] -- c/b mild acute rejection (biopsy [MASKED] -- c/b recurrent HCV s/p treatment and cure # Cirrhosis # Hepatocellular Carcinoma # History of Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD ([MASKED]) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm ([MASKED]) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation ([MASKED]) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: [MASKED] Family History: No family history of liver disease. Physical Exam: =========== ADMISSION =========== Vitals: 98.0 151/73 63 18 95% RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly. GU: no foley. Left flank with bandage which is c/d/I. No pain or bruising over left flank. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: right sided facial droop. Right arm paresis. =========== DISCHARGE =========== Vitals: 98.5 129/79 66 18 98% RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly. GU: no foley. Left flank with bandage which is c/d/I. No pain or bruising over left flank. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: right sided facial droop. Right arm paresis. Pertinent Results: ================= ADMISSION LABS ================= [MASKED] 09:40PM BLOOD WBC-4.4 RBC-3.29* Hgb-8.0* Hct-24.9* MCV-76* MCH-24.3* MCHC-32.1 RDW-13.3 RDWSD-36.2 Plt [MASKED] =========== IMAGING =========== - Kidney Biopsy [MASKED]: IMPRESSION: Ultrasound guidance for percutaneous left kidney biopsy, with small subcapsular hematoma after pass 1 and moderate subcapsular/perinephric hematoma after pass 2 which remained stable by ultrasound after extended compression. Plan was made to admit the patient for observation. ================ DISCHARGE LABS ================ [MASKED] 06:56AM BLOOD WBC-4.4 RBC-3.38* Hgb-8.3* Hct-26.0* MCV-77* MCH-24.6* MCHC-31.9* RDW-13.5 RDWSD-37.4 Plt [MASKED] [MASKED] 06:56AM BLOOD Glucose-103* UreaN-23* Creat-2.5* Na-146* K-3.9 Cl-109* HCO3-24 AnGap-17 [MASKED] 06:56AM BLOOD ALT-10 AST-17 AlkPhos-91 TotBili-0.3 [MASKED] 06:56AM BLOOD Albumin-3.5 Calcium-8.7 Phos-2.7 Mg-1.7 [MASKED] 06:56AM BLOOD tacroFK-<2.0* Brief Hospital Course: This is a [MASKED] male with PMHx of hepatitis C (s/p treatment and cure) cirrhosis and HCC s/p liver transplant, now with recurrent cirrhosis of transplanted liver, history of CVA with residual right sided weakness, and subacute renal disease who is presenting after undergoing elective renal biopsy which was complicated by subcapsular biopsy. ============= ACUTE ISSUES ============= # Subcapsular/perinephric hematoma: Patient underwent elective renal biopsy on [MASKED] which was complicated by a small subcapsular hematoma as well as a moderate subcapsular/perinephric hematoma based on ultrasound during the procedure. Overnight, he remained hemodynamically stable and hemoglobin remained stable (8.0 on admission -> 8.3 the next morning). He did have have any pain or bruising at the biopsy site. # Subacute Kidney Disease: Patient with subacute progressive proteinuric renal disease. Renal believes it could be Prograf toxicity, although the degree of proteinuria seems to be high for this, and his renal function has not improved with tapering down of the Prograf levels. Patient needs to follow up with renal as an outpatient. =============== CHRONIC ISSUES =============== # Liver Transplant (HCV cirrhosis and HCC): Transplant [MASKED], c/b anastamotic bile leak and stricture (stented [MASKED], mild acute rejection (biopsy [MASKED], recurrent HCV (s/p treatment and cure), and recurrent cirrhosis. Patient is currently on tacrolimus 2 mg BID and everolimus 2.25 mg BID for immunosuppression. He is also enrolled in a study for fibrosis and received a study drug twice daily. # Esophagitis: Continued omeprazole # Hypertension: Held BP medications overnight in setting of potential bleed. Blood pressure remained stable, on the high side, and restarted his home medications prior to discharge (Labetalol 200 mg PO BID, amLODIPine 10 mg PO DAILY, spironolactone 50 mg daily). # Seizure Disorder: Continued LevETIRAcetam 1500 mg PO BID. # Ruptured Cerebral Aneurysm: Patient with ruptured cerebral aneurysm in [MASKED] with residual right sided weakness. Patient reports an allergy to aspirin. Continued Pravastatin 40 mg PO QPM. ==================== TRANSITIONAL ISSUES ==================== [] Renal biopsy results pending on discharge. [] Tacro level < 2, however, he missed his morning dose the day of the biopsy. Repeat as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 2. LevETIRAcetam 1500 mg PO BID 3. Labetalol 200 mg PO BID 4. amLODIPine 10 mg PO DAILY 5. Pravastatin 40 mg PO QPM 6. Everolimus 2.25 mg PO BID 7. Tacrolimus 2 mg PO Q12H 8. Spironolactone 50 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 12. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 4. Everolimus 2.25 mg PO BID 5. IDN-6556/Placebo Study Med [MASKED] mg orally TWICE A DAY 6. Labetalol 200 mg PO BID 7. LevETIRAcetam 1500 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Pravastatin 40 mg PO QPM 11. Spironolactone 50 mg PO DAILY 12. Tacrolimus 2 mg PO Q12H 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Renal subcapsular hematoma Secondary Diagnosis: Hepatitis C Cirrhosis s/p liver transplant Recurrent Cirrhosis Chronic Kidney Disease History of Ruptured Cerebral Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You underwent a biopsy of your kidney and were admitted to the hospital for close observation overnight to make sure that you did not bleed into your kidney. Overnight, everything went well and you were able to go home. Please continue to take all of your medications as prescribed previously and follow up at your outpatient appointments (see below). It was a pleasure meeting and taking care of you while you were in the hospital. -Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "I129", "N189", "Y929", "Z87891" ]	[ "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "N9961: Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92238: Other place in hospital as the place of occurrence of the external cause", "K7460: Unspecified cirrhosis of liver", "T8649: Other complications of liver transplant", "Y830: Surgical operation with transplant of whole organ as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z8505: Personal history of malignant neoplasm of liver", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "I69320: Aphasia following cerebral infarction", "K209: Esophagitis, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z87891: Personal history of nicotine dependence" ]
10,048,244	26,292,888	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Attending: ___ Chief Complaint: Swelling Major Surgical or Invasive Procedure: None History of Present Illness: ___ with HCV cirrhosis complicated by ___ s/p liver transplant, now with recurrent HCV cirrhosis of transplanted liver (s/p Harvoni and cure), history of CVA ___ years ago with residual right sided paralysis, and CKD with FSGS on biopsy who presents from hepatology appointment with 3 weeks of ___ edema and facial swelling and uncontrolled hypertension. He says he uses a pill box for his medications, but he is not sure exactly what his regimen is. With regards to his swelling, he says that he has noticed foamier urine over this time as well, and that the edema has slowly progressed over the past few weeks where it has been difficult for him to close his shoes. It is worse in his right, weak side. He denies shortness of breath, fever/chills, other systemic symptoms. Past Medical History: # Liver Transplant (___) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented ___ -- c/b mild acute rejection (biopsy ___ -- c/b recurrent HCV s/p treatment and cure # Cirrhosis # Hepatocellular Carcinoma # History of Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD (___) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm (___) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation (___) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: ___ Family History: No family history of liver disease. Physical Exam: ADMISSION EXAM: VS: 98.2, 175 / 91, 81, 1898ra GENERAL: Well-appearing, lying in bed in NAD HEENT: MMM, no scleral icterus, EOMI. Slight edema in ___ cheeks. NECK: JVP ~3cm above clavicle. ~1+ pitting edema behind neck. CARDIAC: RRR, no r/m, ?S4 gallop PULMONARY: Decreased BS at ___ bases, L>R. Otherwise CTAB ABDOMEN: Soft, non-tender, non-distended. No fluid wave. GENITOURINARY: No foley. EXTREMITIES: 2+ pitting ___ edema to knee on right, 1+ on left. SKIN: No rash NEUROLOGIC: AO x 3. Residual R arm and R leg paralysis. Significant dysarthria. PSYCHIATRIC: Affect appropriate. DISCHARGE EXAM: VS: 98.5, 159 / 89, 79, 18, 97% Ra GENERAL: Well-appearing, lying in bed in NAD HEENT: MMM, no scleral icterus, EOMI. Slight edema in ___ cheeks. NECK: JVP ~3cm above clavicle. ~1+ pitting edema behind neck. CARDIAC: RRR, no r/m, ?S4 gallop PULMONARY: Decreased BS at ___ bases, L>R. Otherwise CTAB ABDOMEN: Soft, non-tender, non-distended. No fluid wave. GENITOURINARY: No foley. EXTREMITIES: 1+ pitting ___ edema to knee on right, trace on left. SKIN: No rash NEUROLOGIC: AO x 3. Residual R arm and R leg paralysis. Significant dysarthria. PSYCHIATRIC: Affect appropriate. Pertinent Results: ADMISSION RESULTS: ___ 08:20AM BLOOD WBC-8.7 RBC-4.57* Hgb-12.1* Hct-37.3* MCV-82 MCH-26.5 MCHC-32.4 RDW-14.9 RDWSD-44.5 Plt ___ ___ 08:20AM BLOOD UreaN-51* Creat-3.0* Na-145 K-3.8 Cl-106 HCO3-25 AnGap-18 ___ 08:20AM BLOOD ALT-33 AST-30 AlkPhos-69 TotBili-0.2 ___ 08:20AM BLOOD proBNP-748* ___ 08:20AM BLOOD tacroFK-2.6* ___ 08:20AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.3 Mg-1.9 ___ 08:40PM URINE Hours-RANDOM UreaN-276 Creat-32 TotProt-264 Prot/Cr-8.3* DISCHARGE RESULTS: ___ 04:53AM BLOOD WBC-7.1 RBC-4.23* Hgb-11.7* Hct-35.3* MCV-84 MCH-27.7 MCHC-33.1 RDW-15.3 RDWSD-46.4* Plt ___ ___ 04:53AM BLOOD Glucose-100 UreaN-50* Creat-3.0* Na-145 K-4.1 Cl-106 HCO3-30 AnGap-13 ___ 04:53AM BLOOD ALT-26 AST-25 LD(LDH)-307* AlkPhos-62 TotBili-0.2 ___ 04:53AM BLOOD TotProt-5.4* Albumin-3.0* Globuln-2.4 Calcium-8.5 Phos-4.1 Mg-1.___ with HCV cirrhosis complicated by ___ s/p liver transplant, now with recurrent HCV cirrhosis of transplanted liver (s/p Harvoni and cure), history of CVA ___ years ago with residual right sided weakness, and CKD with FSGS on biopsy who presents from PCP ___ 3 weeks of ___ edema and facial swelling I/s/o worsening foamy urine, found to have slight ___ on CKD. Edema largely resolved with one dose of torsemide 40mg, and he was discharged with instructions to take 3 days of 20mg torsemide, 4 days of 40 mg torsemide. His hypertension also resolved after giving his home medication. In discussion with his outpatient nephrologist Dr. ___ was determined to likely be his new baseline creatinine, and no specific interventions were aimed at his kidney disease. He was discharged with plan for follow-up with PCP, ___, and nephrology, with focus on medication adherence. He was given extensive instruction on his medication regimen while inpatient. #Edema/Facial swelling: Given low total protein, high prot/Cr ratio, likely due to pt's known nephrotic syndrome. Prot/Cr ratio slightly decreased from ___. Pt has baseline FSGS with nephrotic syndrome of currently uncertain etiology. His nephrologist had been considering treating him as primary FSGS and increasing his steroids, however this was not done. For unclear reasons, pt has been taking 7.5mg prednisone BID at home--it is possible that this has contributed to his fluid retention. Not currently hypoxic or SOB, and with relatively stable renal function, no need for urgent intervention. Edema largely resolved with one dose of 40mg torsemide. Pt was discharged with 4 days of 20mg torsemide, 3 days 40mg torsemide on discharge. ___ on CKD: Cr to 3 from ___ ~2.5. FeUrea ~50% indicating intrinsic process (e.g. worsening of pt's FSGS). Per discussion with outpt nephrologist Dr. ___ may represent new normal. Pt was kept on a low K diet while inpatient. #HTN: Pt with difficult to control HTN, and likely long history of HTN given stroke in his ___. 170s/90s-100s on admission, but came down to 140s-150s/80s with his home labetalol. Likely has not been adherent to mediation regimen at home. Medication adherence was reviewed extensively while admitted. #s/p Liver transplant c/b HCV cirrhosis s/p Harvoni: Pt without s/s of decompensated cirrhosis. No ascites on exam. Last EGD was in ___ and showed no varices. He was continued on his home tacrolimus and prednisone. In discussion with his outpatient hepatologist Dr. ___ was instructed to only take his prednisone once daily rather than the twice daily he had been. #GERD: continued ___ omeprazole #ASCVD risk: continued home pravastatin #Seizure disorder: continued home Keppra 500mg BID # CODE: Full, confirmed # CONTACT: ___ Relationship: WIFE Phone: ___ Other Phone: ___ TRANSITIONAL ISSUES: - Discharge weight 95kg (209lb) - Draw chemistries on ___ in ___ clinic to monitor Cr/electrolytes on higher dose torsemide - Started Torsemide 40mg alternating with 20mg daily - Patient was taking 7.5mg prednisone BID but this should be only daily - Monitor weight and adjust torsemide if needed - ___ will be sent to patient's house to assist in medication management after discharge but patient may benefit from ongoing support Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Labetalol 200 mg PO BID 3. LevETIRAcetam 500 mg PO BID 4. Lisinopril 5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. PredniSONE 7.5 mg PO DAILY 8. Tacrolimus 2.5 mg PO Q12H 9. Torsemide 20 mg PO DAILY 10. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 12. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Torsemide 40 mg PO 4X/WEEK (___) 2. Torsemide 20 mg PO 3X/WEEK (___) 3. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 6. Labetalol 200 mg PO BID 7. LevETIRAcetam 500 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Pravastatin 40 mg PO QPM 11. PredniSONE 7.5 mg PO DAILY 12. Tacrolimus 2.5 mg PO Q12H 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Nephrotic syndrome SECONDARY DIAGNOSES: Hepatitis C cirrhosis Chronic kidney disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You came to the hospital with swelling and high blood pressure. While you were here, you had an ultrasound of your leg which showed that you did not have a blood clot. We checked your blood and found that you did not have any infection, and that there has been no significant change in your kidney function. We increased your torsemide medication to help take off extra fluid. Please take torsemide 1 pill (20mg) on ___, ___, and ___ alternating with 2 pills (40mg) on ___, and ___. Your PCP office should be calling you with an appointment in the next week. Please bring your medications to this visit to go over your medication schedule. It is important that you weigh yourself every day and call your doctor if your weight goes up or down by more than 3 pounds. We spoke with your doctors and your ___ should be taken only once per day. Your medications should be taken as follows: Once per day medications: ========================= PREDNISONE: Please take 7.5mg (3 pills) ONCE per day TORSEMIDE: Please take 20mg (1 pill) ___ and ___ and take 40mg (2 pills) ___, and ___ AMLODIPINE: Please take 10mg (1 pill) ONCE per day OMEPRAZOLE: Please take 20mg (1 pill) ONCE per day LISINOPRIL: Please take 5mg (1 pill) ONCE per day VITAMIN D: Please take 1000U (1 pill) ONCE per day CALCIUM CARBONATE-VITAMIN D3: Please take 2 pills ONCE per day Twice per day medications: ========================== TACROLIMUS: Please take 2.5mg (2 big pills, 1 small pill) TWICE per day LABETALOL: Please take 200mg (1 pill) TWICE per day LEVETIRACETAM: Please take 500mg (2 pills) TWICE per day Night-time medication: ====================== PRAVASTATIN: Please take 40mg (1 pill) ONCE at night Thank you for allowing us to participate in your care. Sincerely, Your ___ Team Followup Instructions: ___	[ "N049", "N179", "K7460", "B182", "I129", "N189", "Z8505", "Z944", "I69351", "K219", "G40909", "Z87891" ]	Allergies: Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine / Oxycodone / pantoprazole Chief Complaint: Swelling Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with HCV cirrhosis complicated by [MASKED] s/p liver transplant, now with recurrent HCV cirrhosis of transplanted liver (s/p Harvoni and cure), history of CVA [MASKED] years ago with residual right sided paralysis, and CKD with FSGS on biopsy who presents from hepatology appointment with 3 weeks of [MASKED] edema and facial swelling and uncontrolled hypertension. He says he uses a pill box for his medications, but he is not sure exactly what his regimen is. With regards to his swelling, he says that he has noticed foamier urine over this time as well, and that the edema has slowly progressed over the past few weeks where it has been difficult for him to close his shoes. It is worse in his right, weak side. He denies shortness of breath, fever/chills, other systemic symptoms. Past Medical History: # Liver Transplant ([MASKED]) -- HCV cirrhosis and HCC -- c/b anastamotic bile leak and stricture (stented [MASKED] -- c/b mild acute rejection (biopsy [MASKED] -- c/b recurrent HCV s/p treatment and cure # Cirrhosis # Hepatocellular Carcinoma # History of Cavitary Pneumonia -- Mycobacterium fortuitum # Severe Esophagitis -- EGD ([MASKED]) # Hypertension # Alcohol Abuse History # Seizure Disorder -- none in many years # Ruptured Cerebral Aneurysm ([MASKED]) -- residual right hemiparesis and aphasia # Craniotomy with Clot Evacuation ([MASKED]) # Left Knee Surgery # Ulnar Neuropathy History # CVA with right sided weakness Social History: [MASKED] Family History: No family history of liver disease. Physical Exam: ADMISSION EXAM: VS: 98.2, 175 / 91, 81, 1898ra GENERAL: Well-appearing, lying in bed in NAD HEENT: MMM, no scleral icterus, EOMI. Slight edema in [MASKED] cheeks. NECK: JVP ~3cm above clavicle. ~1+ pitting edema behind neck. CARDIAC: RRR, no r/m, ?S4 gallop PULMONARY: Decreased BS at [MASKED] bases, L>R. Otherwise CTAB ABDOMEN: Soft, non-tender, non-distended. No fluid wave. GENITOURINARY: No foley. EXTREMITIES: 2+ pitting [MASKED] edema to knee on right, 1+ on left. SKIN: No rash NEUROLOGIC: AO x 3. Residual R arm and R leg paralysis. Significant dysarthria. PSYCHIATRIC: Affect appropriate. DISCHARGE EXAM: VS: 98.5, 159 / 89, 79, 18, 97% Ra GENERAL: Well-appearing, lying in bed in NAD HEENT: MMM, no scleral icterus, EOMI. Slight edema in [MASKED] cheeks. NECK: JVP ~3cm above clavicle. ~1+ pitting edema behind neck. CARDIAC: RRR, no r/m, ?S4 gallop PULMONARY: Decreased BS at [MASKED] bases, L>R. Otherwise CTAB ABDOMEN: Soft, non-tender, non-distended. No fluid wave. GENITOURINARY: No foley. EXTREMITIES: 1+ pitting [MASKED] edema to knee on right, trace on left. SKIN: No rash NEUROLOGIC: AO x 3. Residual R arm and R leg paralysis. Significant dysarthria. PSYCHIATRIC: Affect appropriate. Pertinent Results: ADMISSION RESULTS: [MASKED] 08:20AM BLOOD WBC-8.7 RBC-4.57* Hgb-12.1* Hct-37.3* MCV-82 MCH-26.5 MCHC-32.4 RDW-14.9 RDWSD-44.5 Plt [MASKED] [MASKED] 08:20AM BLOOD UreaN-51* Creat-3.0* Na-145 K-3.8 Cl-106 HCO3-25 AnGap-18 [MASKED] 08:20AM BLOOD ALT-33 AST-30 AlkPhos-69 TotBili-0.2 [MASKED] 08:20AM BLOOD proBNP-748* [MASKED] 08:20AM BLOOD tacroFK-2.6* [MASKED] 08:20AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.3 Mg-1.9 [MASKED] 08:40PM URINE Hours-RANDOM UreaN-276 Creat-32 TotProt-264 Prot/Cr-8.3* DISCHARGE RESULTS: [MASKED] 04:53AM BLOOD WBC-7.1 RBC-4.23* Hgb-11.7* Hct-35.3* MCV-84 MCH-27.7 MCHC-33.1 RDW-15.3 RDWSD-46.4* Plt [MASKED] [MASKED] 04:53AM BLOOD Glucose-100 UreaN-50* Creat-3.0* Na-145 K-4.1 Cl-106 HCO3-30 AnGap-13 [MASKED] 04:53AM BLOOD ALT-26 AST-25 LD(LDH)-307* AlkPhos-62 TotBili-0.2 [MASKED] 04:53AM BLOOD TotProt-5.4* Albumin-3.0* Globuln-2.4 Calcium-8.5 Phos-4.1 Mg-1.[MASKED] with HCV cirrhosis complicated by [MASKED] s/p liver transplant, now with recurrent HCV cirrhosis of transplanted liver (s/p Harvoni and cure), history of CVA [MASKED] years ago with residual right sided weakness, and CKD with FSGS on biopsy who presents from PCP [MASKED] 3 weeks of [MASKED] edema and facial swelling I/s/o worsening foamy urine, found to have slight [MASKED] on CKD. Edema largely resolved with one dose of torsemide 40mg, and he was discharged with instructions to take 3 days of 20mg torsemide, 4 days of 40 mg torsemide. His hypertension also resolved after giving his home medication. In discussion with his outpatient nephrologist Dr. [MASKED] was determined to likely be his new baseline creatinine, and no specific interventions were aimed at his kidney disease. He was discharged with plan for follow-up with PCP, [MASKED], and nephrology, with focus on medication adherence. He was given extensive instruction on his medication regimen while inpatient. #Edema/Facial swelling: Given low total protein, high prot/Cr ratio, likely due to pt's known nephrotic syndrome. Prot/Cr ratio slightly decreased from [MASKED]. Pt has baseline FSGS with nephrotic syndrome of currently uncertain etiology. His nephrologist had been considering treating him as primary FSGS and increasing his steroids, however this was not done. For unclear reasons, pt has been taking 7.5mg prednisone BID at home--it is possible that this has contributed to his fluid retention. Not currently hypoxic or SOB, and with relatively stable renal function, no need for urgent intervention. Edema largely resolved with one dose of 40mg torsemide. Pt was discharged with 4 days of 20mg torsemide, 3 days 40mg torsemide on discharge. [MASKED] on CKD: Cr to 3 from [MASKED] ~2.5. FeUrea ~50% indicating intrinsic process (e.g. worsening of pt's FSGS). Per discussion with outpt nephrologist Dr. [MASKED] may represent new normal. Pt was kept on a low K diet while inpatient. #HTN: Pt with difficult to control HTN, and likely long history of HTN given stroke in his [MASKED]. 170s/90s-100s on admission, but came down to 140s-150s/80s with his home labetalol. Likely has not been adherent to mediation regimen at home. Medication adherence was reviewed extensively while admitted. #s/p Liver transplant c/b HCV cirrhosis s/p Harvoni: Pt without s/s of decompensated cirrhosis. No ascites on exam. Last EGD was in [MASKED] and showed no varices. He was continued on his home tacrolimus and prednisone. In discussion with his outpatient hepatologist Dr. [MASKED] was instructed to only take his prednisone once daily rather than the twice daily he had been. #GERD: continued [MASKED] omeprazole #ASCVD risk: continued home pravastatin #Seizure disorder: continued home Keppra 500mg BID # CODE: Full, confirmed # CONTACT: [MASKED] Relationship: WIFE Phone: [MASKED] Other Phone: [MASKED] TRANSITIONAL ISSUES: - Discharge weight 95kg (209lb) - Draw chemistries on [MASKED] in [MASKED] clinic to monitor Cr/electrolytes on higher dose torsemide - Started Torsemide 40mg alternating with 20mg daily - Patient was taking 7.5mg prednisone BID but this should be only daily - Monitor weight and adjust torsemide if needed - [MASKED] will be sent to patient's house to assist in medication management after discharge but patient may benefit from ongoing support Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Labetalol 200 mg PO BID 3. LevETIRAcetam 500 mg PO BID 4. Lisinopril 5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. PredniSONE 7.5 mg PO DAILY 8. Tacrolimus 2.5 mg PO Q12H 9. Torsemide 20 mg PO DAILY 10. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 12. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Torsemide 40 mg PO 4X/WEEK ([MASKED]) 2. Torsemide 20 mg PO 3X/WEEK ([MASKED]) 3. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral BID 6. Labetalol 200 mg PO BID 7. LevETIRAcetam 500 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Pravastatin 40 mg PO QPM 11. PredniSONE 7.5 mg PO DAILY 12. Tacrolimus 2.5 mg PO Q12H 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Nephrotic syndrome SECONDARY DIAGNOSES: Hepatitis C cirrhosis Chronic kidney disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], You came to the hospital with swelling and high blood pressure. While you were here, you had an ultrasound of your leg which showed that you did not have a blood clot. We checked your blood and found that you did not have any infection, and that there has been no significant change in your kidney function. We increased your torsemide medication to help take off extra fluid. Please take torsemide 1 pill (20mg) on [MASKED], [MASKED], and [MASKED] alternating with 2 pills (40mg) on [MASKED], and [MASKED]. Your PCP office should be calling you with an appointment in the next week. Please bring your medications to this visit to go over your medication schedule. It is important that you weigh yourself every day and call your doctor if your weight goes up or down by more than 3 pounds. We spoke with your doctors and your [MASKED] should be taken only once per day. Your medications should be taken as follows: Once per day medications: ========================= PREDNISONE: Please take 7.5mg (3 pills) ONCE per day TORSEMIDE: Please take 20mg (1 pill) [MASKED] and [MASKED] and take 40mg (2 pills) [MASKED], and [MASKED] AMLODIPINE: Please take 10mg (1 pill) ONCE per day OMEPRAZOLE: Please take 20mg (1 pill) ONCE per day LISINOPRIL: Please take 5mg (1 pill) ONCE per day VITAMIN D: Please take 1000U (1 pill) ONCE per day CALCIUM CARBONATE-VITAMIN D3: Please take 2 pills ONCE per day Twice per day medications: ========================== TACROLIMUS: Please take 2.5mg (2 big pills, 1 small pill) TWICE per day LABETALOL: Please take 200mg (1 pill) TWICE per day LEVETIRACETAM: Please take 500mg (2 pills) TWICE per day Night-time medication: ====================== PRAVASTATIN: Please take 40mg (1 pill) ONCE at night Thank you for allowing us to participate in your care. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "N179", "I129", "N189", "K219", "Z87891" ]	[ "N049: Nephrotic syndrome with unspecified morphologic changes", "N179: Acute kidney failure, unspecified", "K7460: Unspecified cirrhosis of liver", "B182: Chronic viral hepatitis C", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z8505: Personal history of malignant neoplasm of liver", "Z944: Liver transplant status", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "K219: Gastro-esophageal reflux disease without esophagitis", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z87891: Personal history of nicotine dependence" ]
10,048,262	20,845,468	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aloe / apple / egg Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: =================== ___ 06:45PM BLOOD WBC-9.3 RBC-5.11 Hgb-15.2 Hct-44.8 MCV-88 MCH-29.7 MCHC-33.9 RDW-13.6 RDWSD-43.7 Plt Ct-UNABLE TO ___ 06:45PM BLOOD Neuts-88.0* Lymphs-4.0* Monos-7.0 Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.22* AbsLymp-0.37* AbsMono-0.65 AbsEos-0.00* AbsBaso-0.02 ___ 06:45PM BLOOD ___ PTT-32.8 ___ ___ 06:45PM BLOOD Glucose-130* UreaN-12 Creat-0.5 Na-140 K-3.2* Cl-98 HCO3-22 AnGap-20* ___ 06:45PM BLOOD ALT-30 AST-24 AlkPhos-60 TotBili-0.5 ___ 06:45PM BLOOD cTropnT-<0.01 ___ 06:45PM BLOOD Albumin-4.2 Calcium-9.1 Phos-1.9* Mg-1.6 ___ 06:51PM BLOOD ___ pO2-121* pCO2-30* pH-7.50* calTCO2-24 Base XS-1 Comment-GREEN TOP ___ 06:51PM BLOOD Lactate-3.8* ___ 10:10PM BLOOD Lactate-3.1* ___ 02:52AM BLOOD Lactate-4.3* ___ 06:37AM BLOOD Lactate-2.6* PERTINENT LABS: ================== ___ 09:07AM BLOOD WBC-3.6* RBC-3.46* Hgb-10.2* Hct-31.0* MCV-90 MCH-29.5 MCHC-32.9 RDW-14.3 RDWSD-46.5* Plt Ct-67* ___ 05:10AM BLOOD WBC-8.0 RBC-3.43* Hgb-10.2* Hct-32.2* MCV-94 MCH-29.7 MCHC-31.7* RDW-14.2 RDWSD-48.0* Plt ___ ___ 09:07AM BLOOD ___ PTT-32.3 ___ ___ 05:10AM BLOOD ___ PTT-28.0 ___ ___ 02:28AM BLOOD ALT-34 AST-34 AlkPhos-52 TotBili-0.7 ___ 04:41AM BLOOD ALT-193* AST-161* AlkPhos-66 TotBili-0.4 ___ 05:21AM BLOOD ALT-105* AST-38 AlkPhos-62 TotBili-0.3 ___ 06:45PM BLOOD cTropnT-<0.01 ___ 09:07AM BLOOD calTIBC-168* ___ Ferritn-1202* TRF-129* ___ 09:07AM BLOOD ___ 09:07AM BLOOD Ret Aut-1.1 Abs Ret-0.04 ___ 04:12AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG ___ 04:12AM BLOOD HCV Ab-NEG ___ 05:38PM BLOOD Lactate-4.2* ___ 09:46AM BLOOD Lactate-1.3 MICRO: =========== ___ 6:45 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: ___ ___. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ___ \| AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 R TRIMETHOPRIM/SULFA---- <=1 S ___ 11:55 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 5:05 pm BLOOD CULTURE Source: Venipuncture. *FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING: ====================================== CTA CHEST Study Date of ___ 7:54 ___ 1. Nonspecific 1.4 cm nodular left upper lobe opacity which may represent pneumonia. Recommend follow-up CT chest in 3 months to assess for resolution. Pulmonary nodule not excluded. 2. Malpositioned Foley catheter with balloon in the base of the penis. 3. Moderate amount stool in the distal sigmoid colon/rectosigmoid. Equivocal associated mild wall thickening, possible early stercoral colitis. 4. Chronic appearing left hip dislocation with adjacent soft tissue thickening, adjacent joint effusion not excluded. KUB ___: There are diffusely air-filled dilated loops of large bowel involving the right and transverse colon with moderate descending and sigmoid colonic stool burden. No dilated loops of small bowel visualized. There is no evidence of free intraperitoneal air. Right lower abdominal wall battery pack and single spinal stimulator lead noted overlying the right lower abdomen and pelvis. Surgical clips in the right upper quadrant again noted. At least moderate bilateral hip degenerative changes, incompletely assessed. IMPRESSION: 1. No evidence of pneumoperitoneum. 2. Nonobstructive bowel gas pattern with moderate stool burden. RUQ US ___: LIVER: The left lobe of the liver is not adequately visualized due to overlying bowel gas. Otherwise, the hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 5 mm GALLBLADDER: The gallbladder is not definitively visualized. However, there is a rounded structure in the area of the gallbladder fossa measuring 1.2 x 1.6 x 1.0 cm, which may represent a contracted gallbladder. IMPRESSION: 1. No evidence of intrahepatic or extrahepatic biliary dilatation. 2. Likely contracted gallbladder. 3. Splenomegaly. DISCHARGE LABS: ================== No labs collected ___ 05:21AM BLOOD WBC-8.5 RBC-3.52 Hgb-10.5* Hct-32.7* MCV-93 MCH-29.8 MCHC-32.1 RDW-14.6 RDWSD-48.3* Plt ___ ___ 05:21AM BLOOD Plt ___ ___ 05:21AM BLOOD Glucose-109* UreaN-11 Creat-0.4* Na-142 K-4.4 Cl-101 HCO3-26 AnGap-15 ___ 05:21AM BLOOD ALT-105* AST-38 AlkPhos-62 TotBili-0.3 ___ 05:21AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0 DISCHARGE EXAM: ================== VITALS: ___ 0809 Temp: 97.9 PO BP: 108/70 L Lying HR: 86 RR: 18 O2 sat: 94% O2 delivery: RA HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, or gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm with 2+ pulses, trace pitting edema in the feet bilaterally, boots on Skin: No rashes or lesions Neuro: responds appropriately to questions and follows commands, unable to move ___ bilaterally. LABS: Reviewed in ___ Brief Hospital Course: SUMMARY: ===================== Mr. ___ is a ___ man with a history of advanced secondary progressive multiple sclerosis with cognitive decline, who presented from his group home with sepsis and lactic acidosis requiring brief MICU admission (<24h) and found to have Providencia stuartii bacteremia. On presentation to the ED, his UA was consistent with possible UTI, but his urine cultures remained without growth during his hospital course. He had a CT torso that showed a possible L lingular pneumonia and he was briefly on CTX/azithro in the setting of new oxygen requirement (___) but he was quickly weaned off of oxygen and did not have other symptoms of pneumonia/URI and it was stopped. Additionally, CT torso showed possible stercoral colitis and he was briefly on flagyl. His hospital course was complicated by constipation requiring manual disimpaction in the ED after which he remained constipated and his bowel regimen was escalated until he had several large bowel movements after 5 days without any. On presentation to the ED, he had hematuria from a traumatic foley in his urethera that was placed at the group home. The foley was removed and he was voiding well with a condom catheter although retaining ~500cc before urinating, which per the patient and his family is what he usually uses. For treatment of his Providencia stuartii bacteremia, he underwent ___ guided R PICC placement and ID was consulted and he was started on cefepime to complete a 2 week course from his last negative blood culture (___) with a plan to switch to ertapenem at discharge for ease of dosing. He was noted to have transaminitis on ___ and RUQ US showed no evidence of structural causes and his transaminitis was thought to be secondary to cephalosporins and he was switched to meropenem on ___ with improvement of his transaminitis. He remained hemodynamically stable and afebrile on IV antibiotics with negative surveillance cultures and with resolution of his thrombocytopenia, which was thought to be secondary to sepsis, and he was discharged back to his group home on ertapenem to complete his course of IV antibiotics (last day ___. TRANSITIONAL ISSUES: ====================== [] He will need to continue IV antibiotics with ertapenem 1g q24 hours until ___ (last day ___. Okay to remove PICC line after course of IV antibiotics completed. [] He is due for a refill of his baclofen pump on ___. Confirmed with group home that they will be able to refill it there when he gets back. [] Have physician at ___ home check CBC and LFTs in ~1 week (___) to make sure that his thrombocytopenia and transaminitis have resolved. [] Please follow-up with his neurologist about management of his possible early urinary retention/neurogenic bladder. Please avoid foley as he is voiding well with a condom catheter but he usually doesn't void until he is retaining 500-600ccs. [] Please order a repeat CT chest in 3 months to evaluate for resolution of L lingular opacity. [] His CT imaging demonstrated left hip fluid collection/joint effusion. Ortho reviewed the imaging and it appears chronic since ___ based on prior Xray. [] He is not immune to Hep B (surface ab neg) but has an egg allergy (?sneezing). If allergy not severe, he should receive the Hep B vaccine. ACUTE ISSUES ======================= #Fever #Sepsis #?UTI #?L lingula pneumonia #Provide___ bacteremia Patient was febrile to 105 at outpatient facility and was 104 on presentation to the ___ ED. His UA was grossly positive with prior dysuria c/f UTI in the setting of recent foley (possibly placed on ___ for possible chronic urinary retention although usually urinates well with a condom cath. Of note, his urine culture from the ER without growth. CT chest concerning for possible L lingula pneumonia but patient clinically without symptoms of pneumonia and stopped CTX/azithro (___) as penumonia unlikely. BCx from ___ growing Providencia ___, which is usually from a urinary source, but of note all his urine cultures remained negative. ID was consulted and recommended a 2 week course of abx from first negative culture (___) with Cefepime 2 mg IV q12h while inpatient and plan to discharge on ertapenem 1 g IV daily for ease of once daily dosing. However, due to elevated transaminases thought to be due to cephalosporins, he was changed from cefepime to meropenem ___ with improvement in his transaminitis. He remained afebrile and hemodynamically stable with negative blood cultures on IV antibiotics and was discharged back to his group home on ertapenem 1 g q24h through ___. #Elevated LFTs #Transaminitis #Drug induced liver injury Elevated ALT/AST with normal alk phos and bili c/w hepatocellular pattern. Notably LFTs were normal upon presentation. Hepatitis panel with Hep B non-immune but otherwise negative. RUQUS with poorly visualized left liver lobe but otherwise normal hepatic parenchyma. Given no structural deficits, transaminitis thought to be due to cephalosporins and he was switched to meropenem on ___ with gradual improvement in his LFTs. #?Urinary retention #Hematuria #Traumatic foley placement He has a questionable history of urinary retention and it is unclear why he had a foley on presentation to the ED as he is usually able to void okay with a condom catheter per the patient and his family but notes from the OSH state it was placed for urinary retention. On CT A/P in the ED, his foley was misplaced in his urethra and likely was the cause of his hematuria. The foley was replaced in the ED and removed in the ICU and a condom cath was placed. We paged urology several times about if he could be straight cathed if necessary or if he would require another foley if he was retaining urine but we did not get a response. His hematuria resolved and he was voiding well with the condom cath and did not require straight cath. Of note, he was retaining 500-600 cc on bladder scan before voiding. #?Stercoral colitis #Constipation CT A/P was concerning for stercoral colitis and he was manually disimpacted in ED. In one of the notes from the group home, there was mention of ulcerative colitis but per patient and family there is no diagnosis of UC and he is not on treatment for it. He has chronic constipation at baseline and his bowel regimen was escalated, including miralax, senna, lactulose, bisacodyl, and multiple enemas, until he finally had several large bowel movements on the 5 day without any. He developed nausea and abdominal cramping from his constipation and KUB at that time showed moderate stool burden without evidence of ileus, obstruction, or perforation. #Multiple Sclerosis #Baclofen pump Patient has a history of advanced progressive MS with cognitive decline and has a baclofen pump. He stated that his pump needs to be refilled soon and anesthesia was consulted for baclofen pump interrogation (on 299mcg/day) and he is due for a refill on ___. Before discharge, we confirmed with his group home that they will be able to refill his pump when he returns. #Dislocated Hip w/ Effusion CT A/P demonstrated chronic appearing left hip dislocation with complex fluid collection c/f hematoma vs. infection within the hip joint without evidence of bone erosion. Ortho reviewed the images and thought it was most likely chronic dislocation (since ___ in a patient that is mostly bedbound. We had low clinical suspicion for a septic joint as he did not have any pain and remained stable on antibiotics for treatment of his ___ bacteremia. #Thrombocytopenia (resolved) Patient presented with thrombocytopenia (plt 67 at lowest) and initially it was unclear if it was chronic but was not present as of ___ and his labs were negative for hemolylsis or DIC. With treatment of his sepsis/bacteremia, his platelet count gradually recovered and was normal on day of discharge (199) and was thought to be secondary to sepsis. #Lactic Acidosis (resolved) He presented with lactic acidosis in the ED likely iso sepsis as above. He was initially fluid responsive to 2L IVF, but his lactic acidosis uptrended upon arrival to the ICU likely in the setting of insufficient fluid resuscitation. His lactic acidosis then resolved on ___ (1.3) after adequate fluid resuscitation with an additional 2L of LR. CHRONIC ISSUES ======================= #Vitamin D deficiency #Osteoporosis He was continued on his home vitamin D and calcium. #CODE STATUS: Full confirmed (MOLST in chart) #CONTACT: HCP: ___ (Mother) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 1500 mg PO BID 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO BID 4. Senna 17.2 mg PO DAILY 5. Naproxen 440 mg PO Q12H:PRN Pain - Mild 6. Acetaminophen 650 mg PR Q6H:PRN Pain - Mild/Fever 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 8. Clotrimazole Cream 1 Appl TP BID:PRN rash 9. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID 10. Loratadine 10 mg PO DAILY:PRN allergy 11. Vitamin D 3000 UNIT PO DAILY 12. Lioresal (baclofen) 2,000 mcg/mL injection DAILY 13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line Discharge Medications: 1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose 2. Acetaminophen 650 mg PR Q6H:PRN Pain - Mild/Fever 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Calcium Carbonate 1500 mg PO BID 5. Clotrimazole Cream 1 Appl TP BID:PRN rash 6. Docusate Sodium 100 mg PO BID 7. Lioresal (baclofen) 2,000 mcg/mL injection DAILY 8. Loratadine 10 mg PO DAILY:PRN allergy 9. Multivitamins 1 TAB PO BID 10. Naproxen 440 mg PO Q12H:PRN Pain - Mild 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 12. Senna 17.2 mg PO DAILY 13. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID 14. Vitamin D 3000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ======================= # Providencia ___ bacteremia # Sepsis SECONDARY DIAGNOSIS: ====================== # Fever # L lingular opacity without evidence of pneumonia # Transaminitis # Drug induced liver injury # Hematuria secondary to traumatic foley placement # Possible stercoral colitis # Constipation # Multiple sclerosis with baclofen pump # Chronically dislocated left hip with effusion # Thrombocytopenia (resolved) # Lactic acidosis (resolved) # Vitamin D deficiency 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 privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were admitted to the hospital because you had a fever (105 degrees) WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were found to have an infection in your blood (___ ___) and were started on IV antibiotics - The foley catheter in you bladder wasn't in the correct place and it was removed and you were voiding okay without it - You were not having bowel movements and you finally had a bowel movement after lots of medications WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your ___ appointments. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___	[ "A4189", "G92", "J9601", "N390", "E872", "D61818", "R918", "T361X5A", "Y92239", "R945", "K5289", "K5900", "G35", "M24452", "D6959", "E559", "Z978", "M810", "R339", "Z87891", "E860", "R32" ]	Allergies: Aloe / apple / egg Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: =================== [MASKED] 06:45PM BLOOD WBC-9.3 RBC-5.11 Hgb-15.2 Hct-44.8 MCV-88 MCH-29.7 MCHC-33.9 RDW-13.6 RDWSD-43.7 Plt Ct-UNABLE TO [MASKED] 06:45PM BLOOD Neuts-88.0* Lymphs-4.0* Monos-7.0 Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-8.22* AbsLymp-0.37* AbsMono-0.65 AbsEos-0.00* AbsBaso-0.02 [MASKED] 06:45PM BLOOD [MASKED] PTT-32.8 [MASKED] [MASKED] 06:45PM BLOOD Glucose-130* UreaN-12 Creat-0.5 Na-140 K-3.2* Cl-98 HCO3-22 AnGap-20* [MASKED] 06:45PM BLOOD ALT-30 AST-24 AlkPhos-60 TotBili-0.5 [MASKED] 06:45PM BLOOD cTropnT-<0.01 [MASKED] 06:45PM BLOOD Albumin-4.2 Calcium-9.1 Phos-1.9* Mg-1.6 [MASKED] 06:51PM BLOOD [MASKED] pO2-121* pCO2-30* pH-7.50* calTCO2-24 Base XS-1 Comment-GREEN TOP [MASKED] 06:51PM BLOOD Lactate-3.8* [MASKED] 10:10PM BLOOD Lactate-3.1* [MASKED] 02:52AM BLOOD Lactate-4.3* [MASKED] 06:37AM BLOOD Lactate-2.6* PERTINENT LABS: ================== [MASKED] 09:07AM BLOOD WBC-3.6* RBC-3.46* Hgb-10.2* Hct-31.0* MCV-90 MCH-29.5 MCHC-32.9 RDW-14.3 RDWSD-46.5* Plt Ct-67* [MASKED] 05:10AM BLOOD WBC-8.0 RBC-3.43* Hgb-10.2* Hct-32.2* MCV-94 MCH-29.7 MCHC-31.7* RDW-14.2 RDWSD-48.0* Plt [MASKED] [MASKED] 09:07AM BLOOD [MASKED] PTT-32.3 [MASKED] [MASKED] 05:10AM BLOOD [MASKED] PTT-28.0 [MASKED] [MASKED] 02:28AM BLOOD ALT-34 AST-34 AlkPhos-52 TotBili-0.7 [MASKED] 04:41AM BLOOD ALT-193* AST-161* AlkPhos-66 TotBili-0.4 [MASKED] 05:21AM BLOOD ALT-105* AST-38 AlkPhos-62 TotBili-0.3 [MASKED] 06:45PM BLOOD cTropnT-<0.01 [MASKED] 09:07AM BLOOD calTIBC-168* [MASKED] Ferritn-1202* TRF-129* [MASKED] 09:07AM BLOOD [MASKED] 09:07AM BLOOD Ret Aut-1.1 Abs Ret-0.04 [MASKED] 04:12AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG [MASKED] 04:12AM BLOOD HCV Ab-NEG [MASKED] 05:38PM BLOOD Lactate-4.2* [MASKED] 09:46AM BLOOD Lactate-1.3 MICRO: =========== [MASKED] 6:45 pm BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: [MASKED] [MASKED]. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] [MASKED] \| AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 R TRIMETHOPRIM/SULFA---- <=1 S [MASKED] 11:55 pm URINE FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 5:05 pm BLOOD CULTURE Source: Venipuncture. *FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. IMAGING: ====================================== CTA CHEST Study Date of [MASKED] 7:54 [MASKED] 1. Nonspecific 1.4 cm nodular left upper lobe opacity which may represent pneumonia. Recommend follow-up CT chest in 3 months to assess for resolution. Pulmonary nodule not excluded. 2. Malpositioned Foley catheter with balloon in the base of the penis. 3. Moderate amount stool in the distal sigmoid colon/rectosigmoid. Equivocal associated mild wall thickening, possible early stercoral colitis. 4. Chronic appearing left hip dislocation with adjacent soft tissue thickening, adjacent joint effusion not excluded. KUB [MASKED]: There are diffusely air-filled dilated loops of large bowel involving the right and transverse colon with moderate descending and sigmoid colonic stool burden. No dilated loops of small bowel visualized. There is no evidence of free intraperitoneal air. Right lower abdominal wall battery pack and single spinal stimulator lead noted overlying the right lower abdomen and pelvis. Surgical clips in the right upper quadrant again noted. At least moderate bilateral hip degenerative changes, incompletely assessed. IMPRESSION: 1. No evidence of pneumoperitoneum. 2. Nonobstructive bowel gas pattern with moderate stool burden. RUQ US [MASKED]: LIVER: The left lobe of the liver is not adequately visualized due to overlying bowel gas. Otherwise, the hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 5 mm GALLBLADDER: The gallbladder is not definitively visualized. However, there is a rounded structure in the area of the gallbladder fossa measuring 1.2 x 1.6 x 1.0 cm, which may represent a contracted gallbladder. IMPRESSION: 1. No evidence of intrahepatic or extrahepatic biliary dilatation. 2. Likely contracted gallbladder. 3. Splenomegaly. DISCHARGE LABS: ================== No labs collected [MASKED] 05:21AM BLOOD WBC-8.5 RBC-3.52 Hgb-10.5* Hct-32.7* MCV-93 MCH-29.8 MCHC-32.1 RDW-14.6 RDWSD-48.3* Plt [MASKED] [MASKED] 05:21AM BLOOD Plt [MASKED] [MASKED] 05:21AM BLOOD Glucose-109* UreaN-11 Creat-0.4* Na-142 K-4.4 Cl-101 HCO3-26 AnGap-15 [MASKED] 05:21AM BLOOD ALT-105* AST-38 AlkPhos-62 TotBili-0.3 [MASKED] 05:21AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0 DISCHARGE EXAM: ================== VITALS: [MASKED] 0809 Temp: 97.9 PO BP: 108/70 L Lying HR: 86 RR: 18 O2 sat: 94% O2 delivery: RA HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, or gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm with 2+ pulses, trace pitting edema in the feet bilaterally, boots on Skin: No rashes or lesions Neuro: responds appropriately to questions and follows commands, unable to move [MASKED] bilaterally. LABS: Reviewed in [MASKED] Brief Hospital Course: SUMMARY: ===================== Mr. [MASKED] is a [MASKED] man with a history of advanced secondary progressive multiple sclerosis with cognitive decline, who presented from his group home with sepsis and lactic acidosis requiring brief MICU admission (<24h) and found to have Providencia stuartii bacteremia. On presentation to the ED, his UA was consistent with possible UTI, but his urine cultures remained without growth during his hospital course. He had a CT torso that showed a possible L lingular pneumonia and he was briefly on CTX/azithro in the setting of new oxygen requirement ([MASKED]) but he was quickly weaned off of oxygen and did not have other symptoms of pneumonia/URI and it was stopped. Additionally, CT torso showed possible stercoral colitis and he was briefly on flagyl. His hospital course was complicated by constipation requiring manual disimpaction in the ED after which he remained constipated and his bowel regimen was escalated until he had several large bowel movements after 5 days without any. On presentation to the ED, he had hematuria from a traumatic foley in his urethera that was placed at the group home. The foley was removed and he was voiding well with a condom catheter although retaining ~500cc before urinating, which per the patient and his family is what he usually uses. For treatment of his Providencia stuartii bacteremia, he underwent [MASKED] guided R PICC placement and ID was consulted and he was started on cefepime to complete a 2 week course from his last negative blood culture ([MASKED]) with a plan to switch to ertapenem at discharge for ease of dosing. He was noted to have transaminitis on [MASKED] and RUQ US showed no evidence of structural causes and his transaminitis was thought to be secondary to cephalosporins and he was switched to meropenem on [MASKED] with improvement of his transaminitis. He remained hemodynamically stable and afebrile on IV antibiotics with negative surveillance cultures and with resolution of his thrombocytopenia, which was thought to be secondary to sepsis, and he was discharged back to his group home on ertapenem to complete his course of IV antibiotics (last day [MASKED]. TRANSITIONAL ISSUES: ====================== [] He will need to continue IV antibiotics with ertapenem 1g q24 hours until [MASKED] (last day [MASKED]. Okay to remove PICC line after course of IV antibiotics completed. [] He is due for a refill of his baclofen pump on [MASKED]. Confirmed with group home that they will be able to refill it there when he gets back. [] Have physician at [MASKED] home check CBC and LFTs in ~1 week ([MASKED]) to make sure that his thrombocytopenia and transaminitis have resolved. [] Please follow-up with his neurologist about management of his possible early urinary retention/neurogenic bladder. Please avoid foley as he is voiding well with a condom catheter but he usually doesn't void until he is retaining 500-600ccs. [] Please order a repeat CT chest in 3 months to evaluate for resolution of L lingular opacity. [] His CT imaging demonstrated left hip fluid collection/joint effusion. Ortho reviewed the imaging and it appears chronic since [MASKED] based on prior Xray. [] He is not immune to Hep B (surface ab neg) but has an egg allergy (?sneezing). If allergy not severe, he should receive the Hep B vaccine. ACUTE ISSUES ======================= #Fever #Sepsis #?UTI #?L lingula pneumonia #Provide bacteremia Patient was febrile to 105 at outpatient facility and was 104 on presentation to the [MASKED] ED. His UA was grossly positive with prior dysuria c/f UTI in the setting of recent foley (possibly placed on [MASKED] for possible chronic urinary retention although usually urinates well with a condom cath. Of note, his urine culture from the ER without growth. CT chest concerning for possible L lingula pneumonia but patient clinically without symptoms of pneumonia and stopped CTX/azithro ([MASKED]) as penumonia unlikely. BCx from [MASKED] growing Providencia [MASKED], which is usually from a urinary source, but of note all his urine cultures remained negative. ID was consulted and recommended a 2 week course of abx from first negative culture ([MASKED]) with Cefepime 2 mg IV q12h while inpatient and plan to discharge on ertapenem 1 g IV daily for ease of once daily dosing. However, due to elevated transaminases thought to be due to cephalosporins, he was changed from cefepime to meropenem [MASKED] with improvement in his transaminitis. He remained afebrile and hemodynamically stable with negative blood cultures on IV antibiotics and was discharged back to his group home on ertapenem 1 g q24h through [MASKED]. #Elevated LFTs #Transaminitis #Drug induced liver injury Elevated ALT/AST with normal alk phos and bili c/w hepatocellular pattern. Notably LFTs were normal upon presentation. Hepatitis panel with Hep B non-immune but otherwise negative. RUQUS with poorly visualized left liver lobe but otherwise normal hepatic parenchyma. Given no structural deficits, transaminitis thought to be due to cephalosporins and he was switched to meropenem on [MASKED] with gradual improvement in his LFTs. #?Urinary retention #Hematuria #Traumatic foley placement He has a questionable history of urinary retention and it is unclear why he had a foley on presentation to the ED as he is usually able to void okay with a condom catheter per the patient and his family but notes from the OSH state it was placed for urinary retention. On CT A/P in the ED, his foley was misplaced in his urethra and likely was the cause of his hematuria. The foley was replaced in the ED and removed in the ICU and a condom cath was placed. We paged urology several times about if he could be straight cathed if necessary or if he would require another foley if he was retaining urine but we did not get a response. His hematuria resolved and he was voiding well with the condom cath and did not require straight cath. Of note, he was retaining 500-600 cc on bladder scan before voiding. #?Stercoral colitis #Constipation CT A/P was concerning for stercoral colitis and he was manually disimpacted in ED. In one of the notes from the group home, there was mention of ulcerative colitis but per patient and family there is no diagnosis of UC and he is not on treatment for it. He has chronic constipation at baseline and his bowel regimen was escalated, including miralax, senna, lactulose, bisacodyl, and multiple enemas, until he finally had several large bowel movements on the 5 day without any. He developed nausea and abdominal cramping from his constipation and KUB at that time showed moderate stool burden without evidence of ileus, obstruction, or perforation. #Multiple Sclerosis #Baclofen pump Patient has a history of advanced progressive MS with cognitive decline and has a baclofen pump. He stated that his pump needs to be refilled soon and anesthesia was consulted for baclofen pump interrogation (on 299mcg/day) and he is due for a refill on [MASKED]. Before discharge, we confirmed with his group home that they will be able to refill his pump when he returns. #Dislocated Hip w/ Effusion CT A/P demonstrated chronic appearing left hip dislocation with complex fluid collection c/f hematoma vs. infection within the hip joint without evidence of bone erosion. Ortho reviewed the images and thought it was most likely chronic dislocation (since [MASKED] in a patient that is mostly bedbound. We had low clinical suspicion for a septic joint as he did not have any pain and remained stable on antibiotics for treatment of his [MASKED] bacteremia. #Thrombocytopenia (resolved) Patient presented with thrombocytopenia (plt 67 at lowest) and initially it was unclear if it was chronic but was not present as of [MASKED] and his labs were negative for hemolylsis or DIC. With treatment of his sepsis/bacteremia, his platelet count gradually recovered and was normal on day of discharge (199) and was thought to be secondary to sepsis. #Lactic Acidosis (resolved) He presented with lactic acidosis in the ED likely iso sepsis as above. He was initially fluid responsive to 2L IVF, but his lactic acidosis uptrended upon arrival to the ICU likely in the setting of insufficient fluid resuscitation. His lactic acidosis then resolved on [MASKED] (1.3) after adequate fluid resuscitation with an additional 2L of LR. CHRONIC ISSUES ======================= #Vitamin D deficiency #Osteoporosis He was continued on his home vitamin D and calcium. #CODE STATUS: Full confirmed (MOLST in chart) #CONTACT: HCP: [MASKED] (Mother) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 1500 mg PO BID 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO BID 4. Senna 17.2 mg PO DAILY 5. Naproxen 440 mg PO Q12H:PRN Pain - Mild 6. Acetaminophen 650 mg PR Q6H:PRN Pain - Mild/Fever 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 8. Clotrimazole Cream 1 Appl TP BID:PRN rash 9. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID 10. Loratadine 10 mg PO DAILY:PRN allergy 11. Vitamin D 3000 UNIT PO DAILY 12. Lioresal (baclofen) 2,000 mcg/mL injection DAILY 13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line Discharge Medications: 1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose 2. Acetaminophen 650 mg PR Q6H:PRN Pain - Mild/Fever 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Calcium Carbonate 1500 mg PO BID 5. Clotrimazole Cream 1 Appl TP BID:PRN rash 6. Docusate Sodium 100 mg PO BID 7. Lioresal (baclofen) 2,000 mcg/mL injection DAILY 8. Loratadine 10 mg PO DAILY:PRN allergy 9. Multivitamins 1 TAB PO BID 10. Naproxen 440 mg PO Q12H:PRN Pain - Mild 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 12. Senna 17.2 mg PO DAILY 13. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID 14. Vitamin D 3000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: ======================= # Providencia [MASKED] bacteremia # Sepsis SECONDARY DIAGNOSIS: ====================== # Fever # L lingular opacity without evidence of pneumonia # Transaminitis # Drug induced liver injury # Hematuria secondary to traumatic foley placement # Possible stercoral colitis # Constipation # Multiple sclerosis with baclofen pump # Chronically dislocated left hip with effusion # Thrombocytopenia (resolved) # Lactic acidosis (resolved) # Vitamin D deficiency 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 privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were admitted to the hospital because you had a fever (105 degrees) WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were found to have an infection in your blood ([MASKED] [MASKED]) and were started on IV antibiotics - The foley catheter in you bladder wasn't in the correct place and it was removed and you were voiding okay without it - You were not having bowel movements and you finally had a bowel movement after lots of medications WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "J9601", "N390", "E872", "K5900", "Z87891" ]	[ "A4189: Other specified sepsis", "G92: Toxic encephalopathy", "J9601: Acute respiratory failure with hypoxia", "N390: Urinary tract infection, site not specified", "E872: Acidosis", "D61818: Other pancytopenia", "R918: Other nonspecific abnormal finding of lung field", "T361X5A: Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R945: Abnormal results of liver function studies", "K5289: Other specified noninfective gastroenteritis and colitis", "K5900: Constipation, unspecified", "G35: Multiple sclerosis", "M24452: Recurrent dislocation, left hip", "D6959: Other secondary thrombocytopenia", "E559: Vitamin D deficiency, unspecified", "Z978: Presence of other specified devices", "M810: Age-related osteoporosis without current pathological fracture", "R339: Retention of urine, unspecified", "Z87891: Personal history of nicotine dependence", "E860: Dehydration", "R32: Unspecified urinary incontinence" ]
10,048,451	25,200,609	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: periprosthetic fracture of the left hip Major Surgical or Invasive Procedure: ___: revision left total hip arthroplasty History of Present Illness: ___ year old female s/p L THA ___ (anterior approach) with increased pain, difficulty with ambulation noted to have periprosthetic fracture of the left hip on hip X-ray ___, admitted for surgical repair on ___. Past Medical History: COPD, Bipolar, s/p club foot repair Social History: ___ Family History: Non-contributory Physical Exam: Exam on discharge: Vitals: AVSS General: Well-appearing, breathing comfortably on 2LNC. MSK: Left lower extremity: - Abduction pillow in place - Hip incision (from L THA ___ with area of eschar at middle aspect - Thigh soft, compressible - Lateral dressing clean, dry, and intact - Fires ___ - Sensation intact to light touch in SPN/DPN/Tibial/saphenous/Sural distributions - Foot WWP Pertinent Results: ___ 04:10AM BLOOD WBC-7.9 RBC-2.55* Hgb-7.6* Hct-23.8* MCV-93 MCH-29.8 MCHC-31.9* RDW-13.6 RDWSD-46.3 Plt ___ ___ 04:20AM BLOOD WBC-6.9 RBC-2.17* Hgb-6.7* Hct-20.5* MCV-95 MCH-30.9 MCHC-32.7 RDW-12.9 RDWSD-44.8 Plt ___ ___ 04:20AM BLOOD Glucose-122* UreaN-14 Creat-0.5 Na-138 K-3.9 Cl-100 HCO3-27 AnGap-11 ___ 07:00PM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.8 Mg-2.0 Iron-19* Brief Hospital Course: The patient was admitted to the orthopedic surgery service from clinic after she was found to have a periprosthetic fracture of her left hip. She was admitted for pre-operative clearance. She was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: The patient received 1 unit of blood for a low hematocrit. The patient responded appropriately. She is asymptomatic and hemodynamically stable on discharge. We recommend obtaining a follow up hematocrit this week. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#8 after surgery. The foley was removed and the patient was voiding independently thereafter. 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 partial (50%) weight-bearing on the operative extremity with no hip bridging, no repetitive resistant hip flexion. Walker or two crutches at all times for 6 weeks. Ms. ___ is discharged to rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO BID 2. RisperiDONE 1 mg PO QAM 3. RisperiDONE 2 mg PO QPM 4. DULoxetine 120 mg PO QAM 5. BuPROPion 200 mg PO BID 6. Ibuprofen 800 mg PO BID:PRN Pain - Mild 7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 8. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 9. Womens Daily Formula ( m u l t i v i t - i r o n - F A - c a l cium-mins;<br>multivitamin-Ca-iron-minerals;<br>mv-mn-iron-FA-Ca carb-vit K) ___ mg oral DAILY Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks Start: Today - ___, First Dose: Next Routine Administration Time 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 5. Pantoprazole 40 mg PO Q24H 6. Senna 8.6 mg PO BID 7. Gabapentin 600 mg PO BID 8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 9. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN Dyspepsia 10. BuPROPion 200 mg PO BID 11. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 12. DULoxetine 120 mg PO QAM 13. RisperiDONE 1 mg PO QAM 14. RisperiDONE 2 mg PO QPM 15. Womens Daily Formula ( m u l t i v i t - i r o n - F A - c a l cium-mins;<br>multivitamin-Ca-iron-minerals;<br>mv-mn-iron-FA-Ca carb-vit K) ___ mg oral DAILY 16. HELD- Ibuprofen 800 mg PO BID:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until you follow up with Dr. ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: periprosthetic fracture of the left hip Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking Aspirin prior to your surgery, you should hold this medication during your one-month course of anticoagulation medication. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: partial (50%) weight-bear with walker or 2 crutches at all times. Posterior precautions, abduction pillow while sleeping. No hip bridging. No repetitive resistant hip flexion. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: -Partial (50%) weight-bear, posterior precautions, abuction pillow while sleeping -Assistive device for ambulation (i.e., 2 crutches, walker) -No hip bridging and no repetitive resistant hip flexion -Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips (on POD14-17 at ___ Followup Instructions: ___	[ "M84452A", "M9702XA", "T84031A", "J449", "D62", "Y831", "Y92038", "F319", "Z96643", "M5136", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: periprosthetic fracture of the left hip Major Surgical or Invasive Procedure: [MASKED]: revision left total hip arthroplasty History of Present Illness: [MASKED] year old female s/p L THA [MASKED] (anterior approach) with increased pain, difficulty with ambulation noted to have periprosthetic fracture of the left hip on hip X-ray [MASKED], admitted for surgical repair on [MASKED]. Past Medical History: COPD, Bipolar, s/p club foot repair Social History: [MASKED] Family History: Non-contributory Physical Exam: Exam on discharge: Vitals: AVSS General: Well-appearing, breathing comfortably on 2LNC. MSK: Left lower extremity: - Abduction pillow in place - Hip incision (from L THA [MASKED] with area of eschar at middle aspect - Thigh soft, compressible - Lateral dressing clean, dry, and intact - Fires [MASKED] - Sensation intact to light touch in SPN/DPN/Tibial/saphenous/Sural distributions - Foot WWP Pertinent Results: [MASKED] 04:10AM BLOOD WBC-7.9 RBC-2.55* Hgb-7.6* Hct-23.8* MCV-93 MCH-29.8 MCHC-31.9* RDW-13.6 RDWSD-46.3 Plt [MASKED] [MASKED] 04:20AM BLOOD WBC-6.9 RBC-2.17* Hgb-6.7* Hct-20.5* MCV-95 MCH-30.9 MCHC-32.7 RDW-12.9 RDWSD-44.8 Plt [MASKED] [MASKED] 04:20AM BLOOD Glucose-122* UreaN-14 Creat-0.5 Na-138 K-3.9 Cl-100 HCO3-27 AnGap-11 [MASKED] 07:00PM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.8 Mg-2.0 Iron-19* Brief Hospital Course: The patient was admitted to the orthopedic surgery service from clinic after she was found to have a periprosthetic fracture of her left hip. She was admitted for pre-operative clearance. She was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: The patient received 1 unit of blood for a low hematocrit. The patient responded appropriately. She is asymptomatic and hemodynamically stable on discharge. We recommend obtaining a follow up hematocrit this week. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#8 after surgery. The foley was removed and the patient was voiding independently thereafter. 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 partial (50%) weight-bearing on the operative extremity with no hip bridging, no repetitive resistant hip flexion. Walker or two crutches at all times for 6 weeks. Ms. [MASKED] is discharged to rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO BID 2. RisperiDONE 1 mg PO QAM 3. RisperiDONE 2 mg PO QPM 4. DULoxetine 120 mg PO QAM 5. BuPROPion 200 mg PO BID 6. Ibuprofen 800 mg PO BID:PRN Pain - Mild 7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 8. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 9. Womens Daily Formula ( m u l t i v i t - i r o n - F A - c a l cium-mins;<br>multivitamin-Ca-iron-minerals;<br>mv-mn-iron-FA-Ca carb-vit K) [MASKED] mg oral DAILY Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks Start: Today - [MASKED], First Dose: Next Routine Administration Time 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:*0 5. Pantoprazole 40 mg PO Q24H 6. Senna 8.6 mg PO BID 7. Gabapentin 600 mg PO BID 8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 9. Aluminum-Magnesium Hydrox.-Simethicone [MASKED] ml PO Q6H:PRN Dyspepsia 10. BuPROPion 200 mg PO BID 11. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 12. DULoxetine 120 mg PO QAM 13. RisperiDONE 1 mg PO QAM 14. RisperiDONE 2 mg PO QPM 15. Womens Daily Formula ( m u l t i v i t - i r o n - F A - c a l cium-mins;<br>multivitamin-Ca-iron-minerals;<br>mv-mn-iron-FA-Ca carb-vit K) [MASKED] mg oral DAILY 16. HELD- Ibuprofen 800 mg PO BID:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until you follow up with Dr. [MASKED]. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: periprosthetic fracture of the left hip Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking Aspirin prior to your surgery, you should hold this medication during your one-month course of anticoagulation medication. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: partial (50%) weight-bear with walker or 2 crutches at all times. Posterior precautions, abduction pillow while sleeping. No hip bridging. No repetitive resistant hip flexion. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: -Partial (50%) weight-bear, posterior precautions, abuction pillow while sleeping -Assistive device for ambulation (i.e., 2 crutches, walker) -No hip bridging and no repetitive resistant hip flexion -Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips (on POD14-17 at [MASKED] Followup Instructions: [MASKED]	[]	[ "J449", "D62", "Z87891" ]	[ "M84452A: Pathological fracture, left femur, initial encounter for fracture", "M9702XA: Periprosthetic fracture around internal prosthetic left hip joint, initial encounter", "T84031A: Mechanical loosening of internal left hip prosthetic joint, initial encounter", "J449: Chronic obstructive pulmonary disease, unspecified", "D62: Acute posthemorrhagic anemia", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92038: Other place in apartment as the place of occurrence of the external cause", "F319: Bipolar disorder, unspecified", "Z96643: Presence of artificial hip joint, bilateral", "M5136: Other intervertebral disc degeneration, lumbar region", "Z87891: Personal history of nicotine dependence" ]
10,048,451	27,501,766	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: left hip osteoarthritis Major Surgical or Invasive Procedure: ___: s/p left total hip replacement via anterior approach with Dr. ___ History of Present Illness: ___ y/o female with history of left hip osteoarthritis who has failed conservative measures and has elected to undergo definite surgical management Past Medical History: COPD, Bipolar, s/p club foot repair Social History: ___ Family History: non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing clean, dry and intact * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ - LLE ultrasound: No evidence of deep venous thrombosis in the left lower extremity veins. ___ - Chest X-ray: In comparison with the study of ___, the cardiomediastinal silhouette is stable and there is no evidence of vascular congestion. There are small bilateral pleural effusions with compressive basilar atelectasis bilaterally. No evidence of acute focal pneumonia. ___ 08:10AM BLOOD WBC-10.7* RBC-2.97* Hgb-9.5* Hct-28.7* MCV-97 MCH-32.0 MCHC-33.1 RDW-12.8 RDWSD-45.7 Plt ___ ___ 08:20AM BLOOD WBC-8.4 RBC-2.76* Hgb-8.7* Hct-26.9* MCV-98 MCH-31.5 MCHC-32.3 RDW-13.0 RDWSD-46.5* Plt ___ ___ 11:24AM BLOOD WBC-9.7 RBC-3.37* Hgb-10.7* Hct-32.9* MCV-98 MCH-31.8 MCHC-32.5 RDW-12.8 RDWSD-45.6 Plt ___ ___ 08:10AM BLOOD Plt ___ ___ 08:20AM BLOOD Plt ___ ___ 11:24AM BLOOD Plt ___ ___ 08:10AM BLOOD Glucose-119* UreaN-8 Creat-0.5 Na-140 K-4.1 Cl-99 HCO3-28 AnGap-13 ___ 08:20AM BLOOD Glucose-134* UreaN-10 Creat-0.5 Na-141 K-4.0 Cl-103 HCO3-26 AnGap-12 Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: On POD#2, the patient was sent for a chest x-ray to rule out pneumonia due to a low oxygen saturation and increasing white count. Chest x-ray showed basilar atelectasis bilaterally and her incentive spirometer was encouraged. She was also sent for a left lower extremity ultrasound to rule out a blood clot due to left thigh swelling. The ultrasound was negative for a blood clot. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with anterior precautions, no hip bridging, no repetitive resistant hip flexion. Walker or two crutches at all times for 6 weeks. Ms. ___ is discharged to home with services in stable condition. Medications on Admission: 1. BuPROPion (Sustained Release) 200 mg PO BID 2. DULoxetine 120 mg PO DAILY 3. Gabapentin 600 mg PO BID 4. Ibuprofen 800 mg PO BID:PRN Pain - Moderate 5. RisperiDONE 1 mg PO QAM 6. RisperiDONE 2 mg PO QPM 7. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 9. Womens Daily Formula ( m u l t i v i t - i r o n - F A - c a l cium-mins;<br>multivitamin-Ca-iron-minerals;<br>mv-mn-iron-FA-Ca carb-vit K) ___ mg oral DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID Stop taking if having loose stools. 2. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate 4. Senna 8.6 mg PO BID Stop taking if having loose stools. 5. Acetaminophen 1000 mg PO Q8H 6. BuPROPion (Sustained Release) 200 mg PO BID 7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 8. DULoxetine 120 mg PO DAILY 9. Gabapentin 600 mg PO BID 10. RisperiDONE 1 mg PO QAM 11. RisperiDONE 2 mg PO QPM 12. Womens Daily Formula ( m u l t i v i t - i r o n - F A - c a l cium-mins;<br>multivitamin-Ca-iron-minerals;<br>mv-mn-iron-FA-Ca carb-vit K) ___ mg oral DAILY 13. HELD- Ibuprofen 800 mg PO BID:PRN Pain - Moderate This medication was held. Do not restart Ibuprofen until you complete your course of Lovenox. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left hip osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. ___ (once at home): Home ___, dressing changes as instructed, wound checks. 11. ACTIVITY: Weight bearing as tolerated with walker or 2 crutches at all times for six weeks. Anterior precautions, no hip bridging, no repetitive resistant hip flexion. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: WBAT LLE No hip bridging and no repetitive resistant hip flexion Mobilize frequently Assistive device x 6 weeks (I.e., two crutches or walker) Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions: ___	[ "M1612", "Z96641", "J449", "J9811", "R0902", "D72829", "R2242", "Z87891", "F319" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left hip osteoarthritis Major Surgical or Invasive Procedure: [MASKED]: s/p left total hip replacement via anterior approach with Dr. [MASKED] History of Present Illness: [MASKED] y/o female with history of left hip osteoarthritis who has failed conservative measures and has elected to undergo definite surgical management Past Medical History: COPD, Bipolar, s/p club foot repair Social History: [MASKED] Family History: non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing clean, dry and intact * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] - LLE ultrasound: No evidence of deep venous thrombosis in the left lower extremity veins. [MASKED] - Chest X-ray: In comparison with the study of [MASKED], the cardiomediastinal silhouette is stable and there is no evidence of vascular congestion. There are small bilateral pleural effusions with compressive basilar atelectasis bilaterally. No evidence of acute focal pneumonia. [MASKED] 08:10AM BLOOD WBC-10.7* RBC-2.97* Hgb-9.5* Hct-28.7* MCV-97 MCH-32.0 MCHC-33.1 RDW-12.8 RDWSD-45.7 Plt [MASKED] [MASKED] 08:20AM BLOOD WBC-8.4 RBC-2.76* Hgb-8.7* Hct-26.9* MCV-98 MCH-31.5 MCHC-32.3 RDW-13.0 RDWSD-46.5* Plt [MASKED] [MASKED] 11:24AM BLOOD WBC-9.7 RBC-3.37* Hgb-10.7* Hct-32.9* MCV-98 MCH-31.8 MCHC-32.5 RDW-12.8 RDWSD-45.6 Plt [MASKED] [MASKED] 08:10AM BLOOD Plt [MASKED] [MASKED] 08:20AM BLOOD Plt [MASKED] [MASKED] 11:24AM BLOOD Plt [MASKED] [MASKED] 08:10AM BLOOD Glucose-119* UreaN-8 Creat-0.5 Na-140 K-4.1 Cl-99 HCO3-28 AnGap-13 [MASKED] 08:20AM BLOOD Glucose-134* UreaN-10 Creat-0.5 Na-141 K-4.0 Cl-103 HCO3-26 AnGap-12 Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: On POD#2, the patient was sent for a chest x-ray to rule out pneumonia due to a low oxygen saturation and increasing white count. Chest x-ray showed basilar atelectasis bilaterally and her incentive spirometer was encouraged. She was also sent for a left lower extremity ultrasound to rule out a blood clot due to left thigh swelling. The ultrasound was negative for a blood clot. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with anterior precautions, no hip bridging, no repetitive resistant hip flexion. Walker or two crutches at all times for 6 weeks. Ms. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. BuPROPion (Sustained Release) 200 mg PO BID 2. DULoxetine 120 mg PO DAILY 3. Gabapentin 600 mg PO BID 4. Ibuprofen 800 mg PO BID:PRN Pain - Moderate 5. RisperiDONE 1 mg PO QAM 6. RisperiDONE 2 mg PO QPM 7. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 9. Womens Daily Formula ( m u l t i v i t - i r o n - F A - c a l cium-mins;<br>multivitamin-Ca-iron-minerals;<br>mv-mn-iron-FA-Ca carb-vit K) [MASKED] mg oral DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID Stop taking if having loose stools. 2. Enoxaparin Sodium 40 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate 4. Senna 8.6 mg PO BID Stop taking if having loose stools. 5. Acetaminophen 1000 mg PO Q8H 6. BuPROPion (Sustained Release) 200 mg PO BID 7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 8. DULoxetine 120 mg PO DAILY 9. Gabapentin 600 mg PO BID 10. RisperiDONE 1 mg PO QAM 11. RisperiDONE 2 mg PO QPM 12. Womens Daily Formula ( m u l t i v i t - i r o n - F A - c a l cium-mins;<br>multivitamin-Ca-iron-minerals;<br>mv-mn-iron-FA-Ca carb-vit K) [MASKED] mg oral DAILY 13. HELD- Ibuprofen 800 mg PO BID:PRN Pain - Moderate This medication was held. Do not restart Ibuprofen until you complete your course of Lovenox. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: left hip osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, wound checks. 11. ACTIVITY: Weight bearing as tolerated with walker or 2 crutches at all times for six weeks. Anterior precautions, no hip bridging, no repetitive resistant hip flexion. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: WBAT LLE No hip bridging and no repetitive resistant hip flexion Mobilize frequently Assistive device x 6 weeks (I.e., two crutches or walker) Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions: [MASKED]	[]	[ "J449", "Z87891" ]	[ "M1612: Unilateral primary osteoarthritis, left hip", "Z96641: Presence of right artificial hip joint", "J449: Chronic obstructive pulmonary disease, unspecified", "J9811: Atelectasis", "R0902: Hypoxemia", "D72829: Elevated white blood cell count, unspecified", "R2242: Localized swelling, mass and lump, left lower limb", "Z87891: Personal history of nicotine dependence", "F319: Bipolar disorder, unspecified" ]
10,048,779	22,324,221	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / hydromorphone / morphine / allopurinol / Dilaudid Attending: ___. Chief Complaint: ___ with a complex PMHx presenting with stage IIIB recurrent retroperitoneal sarcoma Major Surgical or Invasive Procedure: s/p ex-lap, debulking of recurrent liposarcoma of abdomen & gastric repair ___ History of Present Illness: Pt has a complex past medical history including recurrent liposarcoma. Summarized below: In ___, pt had a retroperitoneal liposarcoma resection (w/ en block sigmoid resection) at the ___. Pt received radiotherapy for 5 weeks prior to operation. Pathology report at that time - grade 1 well-differentiated liposarcoma, no areas of dedifferentiation, no information provided on margins. In ___, a colonoscopy was performed which found a new submucosal mass in the mid sigmoid colon, with normal overlying mucosa was found. Imaging found a 7 cm lobulated mass. ___, pt had MRI of the abdomen which showed a 3cm soft tissue mass with multiple T2 hypointense nodules in the are of the anterolateral left psoas and adjacent mesentery. Core needle biopsy showed a low-grade liposarcoma, which was MDM 2 and CDK 4 positive. ___ - Dr. ___ a left colectomy and resection of the underlying superficial psoas. The left colon showed a multifocal, well differentiated liposarcoma, sclerosing subtype, low grade, involving the colonic wall and extending to the radial resection margin. The largest tumor mass measured 8.2 cm and six lymph nodes were normal. An anterior abdominal wall nodule also showed recurrent low grade liposarcoma with necrosis extending to the specimen margin. ___ - CT abd/pelvis shows a fatty and soft tissue lesion in the gastro hepatic region, concerning for recurrent liposarcoma with other unchanged soft tissue lesions near the iliac bone, left common iliac artery, nodule in pancreatic tail. Patient was not operated on at that time because she was in severe CHF and pending a mitral valve replacement (___). ___ - Pt was noticed to have lesion that increased in size on CT imaging. ___ - MRI had concerning findings for recurrence of liposarcoma with increased size of a soft tissue and fatty mass in the area of the lesser sac, with additional masses in the left lower abdominal mesentery and near the tail of the pancreas. She was planned for an abdominal debulking procedure with Dr. ___. Past Medical History: liposarcoma L abdomen s/p radiation, resection; T2N0 right breast cancer s/p partial mastectomy, ___ ___, radiation. Multifocal invasive lobular carcinoma; A fib with thrombotic events, LVH, mild pulmonary HTN, h/o pulmonary embolisms, superficial phlebitis, DM2, glaucoma, HLD, HTN, renal failure, GERD, DJD low back PSH: ___ sarcoma excision, spinal fusion, R breast partial mastectomy and SLNB ___, L knee arthroscopy, ___ rotator cuff repairs, L2-S1 spinal fusion ___ Social History: ___ Family History: Mother - breast CA, age ___ Father - melanoma ___ aunts (3x) - breast cancer, ages ___ Maternal uncle - liver cancer No family members with sarcoma. Physical Exam: Gen: alert, awake, calm, cooperative, pleasant CV: RRR, normal s1/s2, no rubs, murmurs, gallops. Resp: CTAB with no wheezing, crackles, rales, rhonchi Abd: Dressing over ex-laparotomy scar, soft, no masses, no distention Pertinent Results: ___ 09:00AM BLOOD WBC-6.8 RBC-4.20 Hgb-11.2 Hct-35.9 MCV-86 MCH-26.7 MCHC-31.2* RDW-14.7 RDWSD-46.5* Plt ___ ___ 09:00AM BLOOD ___ PTT-24.6* ___ ___ 09:00AM BLOOD Glucose-152* UreaN-14 Creat-0.8 Na-141 K-4.7 Cl-110* HCO3-21* AnGap-10 ___ 09:00AM BLOOD Calcium-9.9 Phos-2.0* Mg-2.0 ___ 07:45AM BLOOD WBC-4.1 RBC-3.95 Hgb-10.5* Hct-33.6* MCV-85 MCH-26.6 MCHC-31.3* RDW-14.9 RDWSD-45.7 Plt ___ ___ 07:45AM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-144 K-4.0 Cl-107 HCO3-24 AnGap-13 ___ 07:45AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.5* Brief Hospital Course: Ms. ___ presented to ___ holding at ___ on ___ for an ex-lap to debulk a recurrent liposarcoma and gastric repair. She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was well controlled on Tylenol, toradol, dilaudid PCA (later tramadol) CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. Had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was initially kept NPO after the procedure and was managed with an NGT and IVFs. NGT was pulled ___ and the pt tolerated PO (clear liquid diet) without N/V/abdominal pain. The patient was later advanced to and tolerated a regular diet at time of discharge with return of bowel function. Patient's intake and output were closely monitored. GU: The patient had a Foley catheter that was removed prior to discharge. Urine output was monitored as indicated. At time of discharge, the patient was voiding without difficulty. ID: The patient was closely monitored for signs and symptoms of infection and fever. Heme: The patient had blood and electrolyte levels checked routinely during their hospital course to monitor for signs of bleeding and metabolic disturbance. The patient received subcutaneous heparin, INR monitoring with lovenox bridging for warfarin, and ___ dyne boots as well as encouragement to get up and ambulate as early as possible. On ___, the patient was discharged to home. At discharge, she was tolerating a regular diet, passing flatus, voiding, and ambulating independently. She will follow-up in the clinic in 1 week with Dr. ___ and to keep her dressing on until then. This information was communicated to the patient directly prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 2 mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Exemestane 25 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Metoprolol Succinate XL 50 mg PO DAILY 7. brimonidine 0.2 % ophthalmic (eye) BID 8. Potassium Chloride 20 mEq PO DAILY 9. Simvastatin 20 mg PO QPM 10. TraZODone 50 mg PO QHS Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Omeprazole 40 mg PO DAILY Duration: 30 Days RX omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:0 3. TraMADol 25 mg PO Q4H:PRN Pain - Moderate RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #5 Tablet Refills:0 4. Warfarin 4 mg PO ONCE Duration: 1 Dose 5. brimonidine 0.2 % ophthalmic (eye) BID 6. Citalopram 20 mg PO DAILY 7. Exemestane 25 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Potassium Chloride 20 mEq PO DAILY 12. Simvastatin 20 mg PO QPM 13. TraZODone 50 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Recurrent stage IIIB recurrent retroperitoneal liposarcoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___, You were admitted to ___ on ___ for an exploratory laparotomy with excision of 15 cm retrogastric mass (IIIB recurrent retroperitoneal sarcoma) and suture repair of gastric laceration. You tolerated the procedure well without complications and were able to advance and tolerate a regular diet, with return of your bowel and urinary function. After discharge from the hospital please refrain from participating in any heavy lifting greater than 15 pounds. Attempt to keep your dressing clean and dry and monitor for warning signs such as warmth, redness, discharge, swelling, fevers. Please call the office or the nearest emergency room if you experience pain with eating or drinking, using the restroom, bleeding, persistent nausea and vomiting, and/or abdominal swelling. Please do not ibuprofen following you surgery for the next month due to your gastric surgical repair **It is important that you receive a check of your INR level tomorrow as an outpaitent and to keep your dressing intact until you see Dr. ___ in 1 week. Followup Instructions: ___	[ "C480", "I5032", "Z923", "I482", "Z7901", "I2720", "Z86711", "E785", "H409", "Z006", "C50911", "I110", "E119", "E8339", "Z86718" ]	Allergies: Penicillins / hydromorphone / morphine / allopurinol / Dilaudid Chief Complaint: [MASKED] with a complex PMHx presenting with stage IIIB recurrent retroperitoneal sarcoma Major Surgical or Invasive Procedure: s/p ex-lap, debulking of recurrent liposarcoma of abdomen & gastric repair [MASKED] History of Present Illness: Pt has a complex past medical history including recurrent liposarcoma. Summarized below: In [MASKED], pt had a retroperitoneal liposarcoma resection (w/ en block sigmoid resection) at the [MASKED]. Pt received radiotherapy for 5 weeks prior to operation. Pathology report at that time - grade 1 well-differentiated liposarcoma, no areas of dedifferentiation, no information provided on margins. In [MASKED], a colonoscopy was performed which found a new submucosal mass in the mid sigmoid colon, with normal overlying mucosa was found. Imaging found a 7 cm lobulated mass. [MASKED], pt had MRI of the abdomen which showed a 3cm soft tissue mass with multiple T2 hypointense nodules in the are of the anterolateral left psoas and adjacent mesentery. Core needle biopsy showed a low-grade liposarcoma, which was MDM 2 and CDK 4 positive. [MASKED] - Dr. [MASKED] a left colectomy and resection of the underlying superficial psoas. The left colon showed a multifocal, well differentiated liposarcoma, sclerosing subtype, low grade, involving the colonic wall and extending to the radial resection margin. The largest tumor mass measured 8.2 cm and six lymph nodes were normal. An anterior abdominal wall nodule also showed recurrent low grade liposarcoma with necrosis extending to the specimen margin. [MASKED] - CT abd/pelvis shows a fatty and soft tissue lesion in the gastro hepatic region, concerning for recurrent liposarcoma with other unchanged soft tissue lesions near the iliac bone, left common iliac artery, nodule in pancreatic tail. Patient was not operated on at that time because she was in severe CHF and pending a mitral valve replacement ([MASKED]). [MASKED] - Pt was noticed to have lesion that increased in size on CT imaging. [MASKED] - MRI had concerning findings for recurrence of liposarcoma with increased size of a soft tissue and fatty mass in the area of the lesser sac, with additional masses in the left lower abdominal mesentery and near the tail of the pancreas. She was planned for an abdominal debulking procedure with Dr. [MASKED]. Past Medical History: liposarcoma L abdomen s/p radiation, resection; T2N0 right breast cancer s/p partial mastectomy, [MASKED] [MASKED], radiation. Multifocal invasive lobular carcinoma; A fib with thrombotic events, LVH, mild pulmonary HTN, h/o pulmonary embolisms, superficial phlebitis, DM2, glaucoma, HLD, HTN, renal failure, GERD, DJD low back PSH: [MASKED] sarcoma excision, spinal fusion, R breast partial mastectomy and SLNB [MASKED], L knee arthroscopy, [MASKED] rotator cuff repairs, L2-S1 spinal fusion [MASKED] Social History: [MASKED] Family History: Mother - breast CA, age [MASKED] Father - melanoma [MASKED] aunts (3x) - breast cancer, ages [MASKED] Maternal uncle - liver cancer No family members with sarcoma. Physical Exam: Gen: alert, awake, calm, cooperative, pleasant CV: RRR, normal s1/s2, no rubs, murmurs, gallops. Resp: CTAB with no wheezing, crackles, rales, rhonchi Abd: Dressing over ex-laparotomy scar, soft, no masses, no distention Pertinent Results: [MASKED] 09:00AM BLOOD WBC-6.8 RBC-4.20 Hgb-11.2 Hct-35.9 MCV-86 MCH-26.7 MCHC-31.2* RDW-14.7 RDWSD-46.5* Plt [MASKED] [MASKED] 09:00AM BLOOD [MASKED] PTT-24.6* [MASKED] [MASKED] 09:00AM BLOOD Glucose-152* UreaN-14 Creat-0.8 Na-141 K-4.7 Cl-110* HCO3-21* AnGap-10 [MASKED] 09:00AM BLOOD Calcium-9.9 Phos-2.0* Mg-2.0 [MASKED] 07:45AM BLOOD WBC-4.1 RBC-3.95 Hgb-10.5* Hct-33.6* MCV-85 MCH-26.6 MCHC-31.3* RDW-14.9 RDWSD-45.7 Plt [MASKED] [MASKED] 07:45AM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-144 K-4.0 Cl-107 HCO3-24 AnGap-13 [MASKED] 07:45AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.5* Brief Hospital Course: Ms. [MASKED] presented to [MASKED] holding at [MASKED] on [MASKED] for an ex-lap to debulk a recurrent liposarcoma and gastric repair. She tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was well controlled on Tylenol, toradol, dilaudid PCA (later tramadol) CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. Had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was initially kept NPO after the procedure and was managed with an NGT and IVFs. NGT was pulled [MASKED] and the pt tolerated PO (clear liquid diet) without N/V/abdominal pain. The patient was later advanced to and tolerated a regular diet at time of discharge with return of bowel function. Patient's intake and output were closely monitored. GU: The patient had a Foley catheter that was removed prior to discharge. Urine output was monitored as indicated. At time of discharge, the patient was voiding without difficulty. ID: The patient was closely monitored for signs and symptoms of infection and fever. Heme: The patient had blood and electrolyte levels checked routinely during their hospital course to monitor for signs of bleeding and metabolic disturbance. The patient received subcutaneous heparin, INR monitoring with lovenox bridging for warfarin, and [MASKED] dyne boots as well as encouragement to get up and ambulate as early as possible. On [MASKED], the patient was discharged to home. At discharge, she was tolerating a regular diet, passing flatus, voiding, and ambulating independently. She will follow-up in the clinic in 1 week with Dr. [MASKED] and to keep her dressing on until then. This information was communicated to the patient directly prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 2 mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Exemestane 25 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Metoprolol Succinate XL 50 mg PO DAILY 7. brimonidine 0.2 % ophthalmic (eye) BID 8. Potassium Chloride 20 mEq PO DAILY 9. Simvastatin 20 mg PO QPM 10. TraZODone 50 mg PO QHS Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Omeprazole 40 mg PO DAILY Duration: 30 Days RX omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #30 Capsule Refills:0 3. TraMADol 25 mg PO Q4H:PRN Pain - Moderate RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #5 Tablet Refills:0 4. Warfarin 4 mg PO ONCE Duration: 1 Dose 5. brimonidine 0.2 % ophthalmic (eye) BID 6. Citalopram 20 mg PO DAILY 7. Exemestane 25 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Potassium Chloride 20 mEq PO DAILY 12. Simvastatin 20 mg PO QPM 13. TraZODone 50 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Recurrent stage IIIB recurrent retroperitoneal liposarcoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [MASKED], You were admitted to [MASKED] on [MASKED] for an exploratory laparotomy with excision of 15 cm retrogastric mass (IIIB recurrent retroperitoneal sarcoma) and suture repair of gastric laceration. You tolerated the procedure well without complications and were able to advance and tolerate a regular diet, with return of your bowel and urinary function. After discharge from the hospital please refrain from participating in any heavy lifting greater than 15 pounds. Attempt to keep your dressing clean and dry and monitor for warning signs such as warmth, redness, discharge, swelling, fevers. Please call the office or the nearest emergency room if you experience pain with eating or drinking, using the restroom, bleeding, persistent nausea and vomiting, and/or abdominal swelling. Please do not ibuprofen following you surgery for the next month due to your gastric surgical repair **It is important that you receive a check of your INR level tomorrow as an outpaitent and to keep your dressing intact until you see Dr. [MASKED] in 1 week. Followup Instructions: [MASKED]	[]	[ "I5032", "Z7901", "E785", "I110", "E119", "Z86718" ]	[ "C480: Malignant neoplasm of retroperitoneum", "I5032: Chronic diastolic (congestive) heart failure", "Z923: Personal history of irradiation", "I482: Chronic atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "I2720: Pulmonary hypertension, unspecified", "Z86711: Personal history of pulmonary embolism", "E785: Hyperlipidemia, unspecified", "H409: Unspecified glaucoma", "Z006: Encounter for examination for normal comparison and control in clinical research program", "C50911: Malignant neoplasm of unspecified site of right female breast", "I110: Hypertensive heart disease with heart failure", "E119: Type 2 diabetes mellitus without complications", "E8339: Other disorders of phosphorus metabolism", "Z86718: Personal history of other venous thrombosis and embolism" ]
10,048,779	28,546,472	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Liposarcoma Major Surgical or Invasive Procedure: Left colectomy, radical excision of RP liposarcoma History of Present Illness: ___ presented on ___ for evaluation of a new retroperitoneal mass occurring in close proximity to the distal sigmoid colon and involving the psoas and colonic mesentery. She had related a history of undergoing surgery for a large retroperitoneal lesion in the year ___. Records indicate that CT in ___ showed a large mass within the left hemiabdomen, extending from the pancreatic tail and left kidney to the deep pelvis, involving the left iliac artery. MRI ___ tumor nearly surrounding the aorta and left iliac vessels with compression and near obliteration of the vascular signal within the left iliac vein. Apparently, she received 5 weeks of radiation therapy. She then underwent en-bloc resection large tumor adherent to the left iliac veins with a markedly displaced left ureter and marked involvement of the sigmoid colon mesentery. A transverse colon to sigmoid anastomosis was described. Apparently because of the compression of the iliac vein an IVC filter was placed at the time of surgery. Pathology showed grade 1 well-differentiated liposarcoma with no areas of dedifferentiation involving the pericolonic fat and " mesovarium" but it did not invade the muscularis of the bowel wall or the fallopian tube or ovary. The tumor is stated to abut the inked surfaces in multiple areas. No microscopic margins were provided. Recently, CT scan of ___, showed a soft tissue mass within the mesocolon invading into the mesentery measuring about 3 cm. There are also multiple T2 hypointense enhancing soft tissue nodules in the same region, which most likely invade the anterolateral aspect of the left psoas muscle. There is some soft tissue stranding around the celiac axis and in association with the left renal vessels and anterior perirenal fascia, which is of uncertain significance. Nothing is seen in the region of the left iliac vessels. The MRI was limited in scope because of the presence of extensive spinal hardware. Core biopsy of her left retroperitoneal mass in ___ showed recurrent liposarcoma. She presents today for resection. Past Medical History: liposarcoma L abdomen s/p radiation, resection; T2N0 right breast cancer s/p partial mastectomy, ___ ___, radiation. Multifocal invasive lobular carcinoma; A fib with thrombotic events, LVH, mild pulmonary HTN, h/o pulmonary embolisms, superficial phlebitis, DM2, glaucoma, HLD, HTN, renal failure, GERD, DJD low back PSH: ___ sarcoma excision, spinal fusion, R breast partial mastectomy and SLNB ___, L knee arthroscopy, ___ rotator cuff repairs, L2-S1 spinal fusion ___ Physical Exam: DISCHARGE EXAM: T98.3, HR99 BP130/84, RR18 98%RA GEN: NAD, AOx3 CV: regular rate, irregular rhythm, +s1/S2 PULM: CTAB GI: soft, NT, minimally distended WOUND: midline incision, staples clean, dry, intact, minimal staple line erythema, no drainage, no induration EXT: WWP, no CCE Brief Hospital Course: ___ was admitted on ___ for surgical treatment of her left retroperitoneal mass. She was on aFib before surgery. She underwent left colectomy and radical excision of RP liposarcoma. Her EBL was 700 cc and she received crystalloid and Albumin in her early postoperatory to maintain normal blood pressure and adequate urine output. The patient was kept NPO, had a Foley and a right IJ line. She had a PCA for analgesia. She had daily Chem10 and her electrolytes were repleted. On ___, her Hct dropped to 22.8 and her HR maintained in the 140s. She received one unit of RBC. During the following days, her HR was very labile, around 110-120s at rest and up to 160s with minimal activity. On ___, she was passing flatus and had one bowel movement. Her home atenolol and Lasix were started. Cardiology was consulted and recommended stopping atenolol, starting metoprolol and increasing the dose while assessing her response. She also had persistent loose bowel movements from ___ to ___. C diff and stool studies were negative. She received 2 mg of Loperamide x2 (___) with significant improvement in her diarrhea. She was bridged from Lovenox to Warfarin on ___. After receiving 2 doses of warfarin, her INR was 3.8. Warfarin was held and INR was monitored daily, being 2.4 at discharge. At the time of discharge, the patient was doing well, tolerating a regular diet, having normal bowel movements, therapeutic on Warfarin and her heart rate was controlled. She received discharge teaching and follow-up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Citalopram 20 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Simvastatin 10 mg PO QPM 8. TraZODone 50 mg PO QHS:PRN insomnia 9. Warfarin 5 mg PO DAILY16 10. Enoxaparin Sodium 80 mg SC BID Discharge Medications: 1. Metoprolol Succinate XL 150 mg PO BID RX metoprolol succinate 50 mg 3 tablet(s) by mouth twice per day Disp #180 Tablet Refills:0 2. Warfarin 2 mg PO DAILY16 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 4. Citalopram 20 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Simvastatin 10 mg PO QPM 9. TraZODone 50 mg PO QHS:PRN insomnia 10. HELD- Atenolol 25 mg PO DAILY This medication was held. Do not restart Atenolol until you discuss with your cardiologist. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Liposarcoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to ___ and underwent surgery to remove your left colon and an abdominal tumor. You have been recovering well, and the health of your skin graft is improving. The following is a summary of discharge instructions. MEDICATIONS 1. Please resume all home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. 2. Please take all pain medications as prescribed, as needed. You may not drive or operate heavy machinery while taking narcotic pain medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. WOUND CARE 1. Monitor the wounds for signs of infection, including redness that is spreading or increased drainge from wounds. Please call Dr. ___ if you experience any of these symptoms. 2. Your staples will be removed at your next appointment. ACTIVITY 1. No strenuous activity until cleared by Dr. ___. 2. No showering until cleared by Dr. ___ sponge baths only. Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision. 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. Return to the ER if: If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: ___	[ "C480", "D62", "I482", "E860", "I110", "I5032", "E119", "E785", "K219", "I9581", "R159", "Z981", "Z853", "Z9011", "Z86711", "Z86718", "Z923", "Z7901" ]	Allergies: Penicillins Chief Complaint: Liposarcoma Major Surgical or Invasive Procedure: Left colectomy, radical excision of RP liposarcoma History of Present Illness: [MASKED] presented on [MASKED] for evaluation of a new retroperitoneal mass occurring in close proximity to the distal sigmoid colon and involving the psoas and colonic mesentery. She had related a history of undergoing surgery for a large retroperitoneal lesion in the year [MASKED]. Records indicate that CT in [MASKED] showed a large mass within the left hemiabdomen, extending from the pancreatic tail and left kidney to the deep pelvis, involving the left iliac artery. MRI [MASKED] tumor nearly surrounding the aorta and left iliac vessels with compression and near obliteration of the vascular signal within the left iliac vein. Apparently, she received 5 weeks of radiation therapy. She then underwent en-bloc resection large tumor adherent to the left iliac veins with a markedly displaced left ureter and marked involvement of the sigmoid colon mesentery. A transverse colon to sigmoid anastomosis was described. Apparently because of the compression of the iliac vein an IVC filter was placed at the time of surgery. Pathology showed grade 1 well-differentiated liposarcoma with no areas of dedifferentiation involving the pericolonic fat and " mesovarium" but it did not invade the muscularis of the bowel wall or the fallopian tube or ovary. The tumor is stated to abut the inked surfaces in multiple areas. No microscopic margins were provided. Recently, CT scan of [MASKED], showed a soft tissue mass within the mesocolon invading into the mesentery measuring about 3 cm. There are also multiple T2 hypointense enhancing soft tissue nodules in the same region, which most likely invade the anterolateral aspect of the left psoas muscle. There is some soft tissue stranding around the celiac axis and in association with the left renal vessels and anterior perirenal fascia, which is of uncertain significance. Nothing is seen in the region of the left iliac vessels. The MRI was limited in scope because of the presence of extensive spinal hardware. Core biopsy of her left retroperitoneal mass in [MASKED] showed recurrent liposarcoma. She presents today for resection. Past Medical History: liposarcoma L abdomen s/p radiation, resection; T2N0 right breast cancer s/p partial mastectomy, [MASKED] [MASKED], radiation. Multifocal invasive lobular carcinoma; A fib with thrombotic events, LVH, mild pulmonary HTN, h/o pulmonary embolisms, superficial phlebitis, DM2, glaucoma, HLD, HTN, renal failure, GERD, DJD low back PSH: [MASKED] sarcoma excision, spinal fusion, R breast partial mastectomy and SLNB [MASKED], L knee arthroscopy, [MASKED] rotator cuff repairs, L2-S1 spinal fusion [MASKED] Physical Exam: DISCHARGE EXAM: T98.3, HR99 BP130/84, RR18 98%RA GEN: NAD, AOx3 CV: regular rate, irregular rhythm, +s1/S2 PULM: CTAB GI: soft, NT, minimally distended WOUND: midline incision, staples clean, dry, intact, minimal staple line erythema, no drainage, no induration EXT: WWP, no CCE Brief Hospital Course: [MASKED] was admitted on [MASKED] for surgical treatment of her left retroperitoneal mass. She was on aFib before surgery. She underwent left colectomy and radical excision of RP liposarcoma. Her EBL was 700 cc and she received crystalloid and Albumin in her early postoperatory to maintain normal blood pressure and adequate urine output. The patient was kept NPO, had a Foley and a right IJ line. She had a PCA for analgesia. She had daily Chem10 and her electrolytes were repleted. On [MASKED], her Hct dropped to 22.8 and her HR maintained in the 140s. She received one unit of RBC. During the following days, her HR was very labile, around 110-120s at rest and up to 160s with minimal activity. On [MASKED], she was passing flatus and had one bowel movement. Her home atenolol and Lasix were started. Cardiology was consulted and recommended stopping atenolol, starting metoprolol and increasing the dose while assessing her response. She also had persistent loose bowel movements from [MASKED] to [MASKED]. C diff and stool studies were negative. She received 2 mg of Loperamide x2 ([MASKED]) with significant improvement in her diarrhea. She was bridged from Lovenox to Warfarin on [MASKED]. After receiving 2 doses of warfarin, her INR was 3.8. Warfarin was held and INR was monitored daily, being 2.4 at discharge. At the time of discharge, the patient was doing well, tolerating a regular diet, having normal bowel movements, therapeutic on Warfarin and her heart rate was controlled. She received discharge teaching and follow-up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 3. Citalopram 20 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Simvastatin 10 mg PO QPM 8. TraZODone 50 mg PO QHS:PRN insomnia 9. Warfarin 5 mg PO DAILY16 10. Enoxaparin Sodium 80 mg SC BID Discharge Medications: 1. Metoprolol Succinate XL 150 mg PO BID RX metoprolol succinate 50 mg 3 tablet(s) by mouth twice per day Disp #180 Tablet Refills:0 2. Warfarin 2 mg PO DAILY16 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H 4. Citalopram 20 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Simvastatin 10 mg PO QPM 9. TraZODone 50 mg PO QHS:PRN insomnia 10. HELD- Atenolol 25 mg PO DAILY This medication was held. Do not restart Atenolol until you discuss with your cardiologist. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Liposarcoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were admitted to [MASKED] and underwent surgery to remove your left colon and an abdominal tumor. You have been recovering well, and the health of your skin graft is improving. The following is a summary of discharge instructions. MEDICATIONS 1. Please resume all home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. 2. Please take all pain medications as prescribed, as needed. You may not drive or operate heavy machinery while taking narcotic pain medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. WOUND CARE 1. Monitor the wounds for signs of infection, including redness that is spreading or increased drainge from wounds. Please call Dr. [MASKED] if you experience any of these symptoms. 2. Your staples will be removed at your next appointment. ACTIVITY 1. No strenuous activity until cleared by Dr. [MASKED]. 2. No showering until cleared by Dr. [MASKED] sponge baths only. Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision. 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. Return to the ER if: If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: [MASKED]	[]	[ "D62", "I110", "I5032", "E119", "E785", "K219", "Z86718", "Z7901" ]	[ "C480: Malignant neoplasm of retroperitoneum", "D62: Acute posthemorrhagic anemia", "I482: Chronic atrial fibrillation", "E860: Dehydration", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I9581: Postprocedural hypotension", "R159: Full incontinence of feces", "Z981: Arthrodesis status", "Z853: Personal history of malignant neoplasm of breast", "Z9011: Acquired absence of right breast and nipple", "Z86711: Personal history of pulmonary embolism", "Z86718: Personal history of other venous thrombosis and embolism", "Z923: Personal history of irradiation", "Z7901: Long term (current) use of anticoagulants" ]
10,048,825	24,421,300	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: None attach Pertinent Results: DC EXAM: VS: ___ ___ Temp: 98.5 BP: 165/80 L Lying HR: 83 RR: 18 O2 sat: 90% O2 delivery: Ra GENERAL: Pleasant fatigued-appearing man, in no distress, lying in bed HEENT: Anicteric, PERLL, OP clear. MMM CARDIAC: RRR, no murmurs. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally with no focal crackles or wheeze ABD: Soft, non-tender, non-distended, positive bowel sounds. EXT: Warm, well perfused, no lower extremity edema,. NEURO: A&Ox3, good attention and linear thought, gross strength and sensation intact. Able to state ___ backwards. SKIN: No significant rashes. ___ 12:42PM BLOOD WBC-5.3 RBC-2.54* Hgb-7.7* Hct-24.2* MCV-95 MCH-30.3 MCHC-31.8* RDW-18.4* RDWSD-62.2* Plt ___ ___ 07:45PM BLOOD ___ PTT-33.2 ___ ___ 12:42PM BLOOD Glucose-138* UreaN-16 Creat-1.0 Na-141 K-3.9 Cl-104 HCO3-24 AnGap-13 ___ 12:42PM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0 ___ 07:45PM BLOOD Ferritn-6047* CXR: IMPRESSION: Opacification in the right lower lobe adjacent to the right heart border and retrocardiac opacification best appreciated on lateral film, concerning for a right lower lobe pneumonia. Brief Hospital Course: Mr. ___ is a ___ male with MDS and prostate cancer ___ localized prostate cancer on Lupron with questionable rib metastasis, HTN, Parkinsons who presented with fever and pneumonia. # Acute Bacterial Pneumonia: Dx based on fever, CXR findings. Viral vs bacterial but treated for bacterial. No recent antbx, no recent hospitalizations. Flu neg. Legionella negative. He responded to CTX/azithro and was transitioned to complete course of Cefpodoxime/Azitho through ___ and ___, respectively. # Anemia in Malignancy: # Thrombocytopenia: Likely due to underlying MDS and now worsening with bone marrow involvement of prostate cancer. He responded appropriately to his blood transfusion and has outpatient follow up thereafter. # Prostate Cancer: Now with bone marrow involvement with recent bone marrow biopsy. - Follow-up with Dr. ___ # Back Pain - ___ want to consider repeat bone scan as outpatient # MDS: Not on MDS-directed therapy. - Continue to monitor # Urinary Symptoms - Continue home Tamsulosin # Hypertension: He was hypertensive to SBP 180s, asymptomatic. He was initiated back on his HCTZ which he had stopped. He was subsequently found to have orthostasis with SBP decrease to 150s standing. Asymptomatic. HE may have dysautonomia as a result of his Parkinsons. He was instructed to monitor his BP at home and follow up with his PCP and neurologist to see if he requires further medication adjustment. # ___ Disease - Continue Sinemet BID # Hypothyroidism - He states he no longer takes levothyroxine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO QHS 2. Carbidopa-Levodopa (___) 2 TAB PO BID 3. Loratadine 10 mg PO DAILY 4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 2 Doses take on ___ and ___ RX azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #2 Tablet Refills:0 2. Cefpodoxime Proxetil 200 mg PO Q12H start on ___ and take through ___ RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 3. Hydrochlorothiazide 25 mg PO DAILY RX hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. TraMADol 50 mg PO BID severe back pain RX tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #15 Tablet Refills:0 5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever RX acetaminophen 325 mg ___ tablet(s) by mouth four times a day Disp #120 Tablet Refills:*0 6. Carbidopa-Levodopa (___) 2 TAB PO BID 7. Loratadine 10 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Bacterial pneumonia Chronic anemia/MDS ___ CA ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with fever and fatigue. You were found to have pneumonia and started on antibiotics. You will need to complete a course of treatment as prescribed. You were also given a blood transfusion due to your chronic anemia. Please follow up with your hematologist for ongoing care. You were also seen by your Prostate oncologist. You will follow up with her to monitor response to treatment. Finally, you were restarted on hydrochlorothiazide for high blood pressure in the hospital. Please check your blood pressure at home when you are feeling better and bring your readings to your next doctor appointment. We have provided information to establish a new PCP at ___ at ___. Please call to schedule an appointment with a new doctor Followup Instructions: ___	[ "J159", "C7951", "D469", "C61", "I10", "Z85850", "E890", "G20", "D630", "D696", "M549" ]	Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: None attach Pertinent Results: DC EXAM: VS: [MASKED] [MASKED] Temp: 98.5 BP: 165/80 L Lying HR: 83 RR: 18 O2 sat: 90% O2 delivery: Ra GENERAL: Pleasant fatigued-appearing man, in no distress, lying in bed HEENT: Anicteric, PERLL, OP clear. MMM CARDIAC: RRR, no murmurs. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally with no focal crackles or wheeze ABD: Soft, non-tender, non-distended, positive bowel sounds. EXT: Warm, well perfused, no lower extremity edema,. NEURO: A&Ox3, good attention and linear thought, gross strength and sensation intact. Able to state [MASKED] backwards. SKIN: No significant rashes. [MASKED] 12:42PM BLOOD WBC-5.3 RBC-2.54* Hgb-7.7* Hct-24.2* MCV-95 MCH-30.3 MCHC-31.8* RDW-18.4* RDWSD-62.2* Plt [MASKED] [MASKED] 07:45PM BLOOD [MASKED] PTT-33.2 [MASKED] [MASKED] 12:42PM BLOOD Glucose-138* UreaN-16 Creat-1.0 Na-141 K-3.9 Cl-104 HCO3-24 AnGap-13 [MASKED] 12:42PM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0 [MASKED] 07:45PM BLOOD Ferritn-6047* CXR: IMPRESSION: Opacification in the right lower lobe adjacent to the right heart border and retrocardiac opacification best appreciated on lateral film, concerning for a right lower lobe pneumonia. Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with MDS and prostate cancer [MASKED] localized prostate cancer on Lupron with questionable rib metastasis, HTN, Parkinsons who presented with fever and pneumonia. # Acute Bacterial Pneumonia: Dx based on fever, CXR findings. Viral vs bacterial but treated for bacterial. No recent antbx, no recent hospitalizations. Flu neg. Legionella negative. He responded to CTX/azithro and was transitioned to complete course of Cefpodoxime/Azitho through [MASKED] and [MASKED], respectively. # Anemia in Malignancy: # Thrombocytopenia: Likely due to underlying MDS and now worsening with bone marrow involvement of prostate cancer. He responded appropriately to his blood transfusion and has outpatient follow up thereafter. # Prostate Cancer: Now with bone marrow involvement with recent bone marrow biopsy. - Follow-up with Dr. [MASKED] # Back Pain - [MASKED] want to consider repeat bone scan as outpatient # MDS: Not on MDS-directed therapy. - Continue to monitor # Urinary Symptoms - Continue home Tamsulosin # Hypertension: He was hypertensive to SBP 180s, asymptomatic. He was initiated back on his HCTZ which he had stopped. He was subsequently found to have orthostasis with SBP decrease to 150s standing. Asymptomatic. HE may have dysautonomia as a result of his Parkinsons. He was instructed to monitor his BP at home and follow up with his PCP and neurologist to see if he requires further medication adjustment. # [MASKED] Disease - Continue Sinemet BID # Hypothyroidism - He states he no longer takes levothyroxine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO QHS 2. Carbidopa-Levodopa ([MASKED]) 2 TAB PO BID 3. Loratadine 10 mg PO DAILY 4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 2 Doses take on [MASKED] and [MASKED] RX azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #2 Tablet Refills:0 2. Cefpodoxime Proxetil 200 mg PO Q12H start on [MASKED] and take through [MASKED] RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 3. Hydrochlorothiazide 25 mg PO DAILY RX hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. TraMADol 50 mg PO BID severe back pain RX tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #15 Tablet Refills:0 5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever RX acetaminophen 325 mg [MASKED] tablet(s) by mouth four times a day Disp #120 Tablet Refills:*0 6. Carbidopa-Levodopa ([MASKED]) 2 TAB PO BID 7. Loratadine 10 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Bacterial pneumonia Chronic anemia/MDS [MASKED] CA [MASKED] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with fever and fatigue. You were found to have pneumonia and started on antibiotics. You will need to complete a course of treatment as prescribed. You were also given a blood transfusion due to your chronic anemia. Please follow up with your hematologist for ongoing care. You were also seen by your Prostate oncologist. You will follow up with her to monitor response to treatment. Finally, you were restarted on hydrochlorothiazide for high blood pressure in the hospital. Please check your blood pressure at home when you are feeling better and bring your readings to your next doctor appointment. We have provided information to establish a new PCP at [MASKED] at [MASKED]. Please call to schedule an appointment with a new doctor Followup Instructions: [MASKED]	[]	[ "I10", "D696" ]	[ "J159: Unspecified bacterial pneumonia", "C7951: Secondary malignant neoplasm of bone", "D469: Myelodysplastic syndrome, unspecified", "C61: Malignant neoplasm of prostate", "I10: Essential (primary) hypertension", "Z85850: Personal history of malignant neoplasm of thyroid", "E890: Postprocedural hypothyroidism", "G20: Parkinson's disease", "D630: Anemia in neoplastic disease", "D696: Thrombocytopenia, unspecified", "M549: Dorsalgia, unspecified" ]
10,048,986	23,742,207	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril Attending: ___. Chief Complaint: Bloody stool Major Surgical or Invasive Procedure: ___: EGD History of Present Illness: Mr. ___ is an ___ yo man with a history of GERD, OA (on celecoxib) anemia who presents to the ED after having had dark BMs for the past couple of days. He has noted some feelings of heartburn at home and says that he has missed ___ doses of his omeprazole over the past couple weeks. He denies dizziness, light headedness, chest pain, palpitations, N,V, diarrhea, constipation. He also suffered a mechanical fall 2 weeks ago. No fracture present on XRAY, MRI preformed on ___ (read pending). In the ED his initial VS were 98.0 81 113/65 20 97% RA. His exam was notable for guaiac positive stool. He was given pantoprazole 40mg IV and 1L NS. He was typed and crossed but not transfused. A bladder scan was also done for concern for urinary retention and he had 66cc in his bladder. On arrival to the floor, patient reports that overall he is feeling well. He is having pain in his L elbow (because of recent fall) and some mild abdominal discomfort. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: -GERD -knee osteoarthritis -AAA -BPH -spinal stenosis -? hx of pancytopenia per PCP, MDS ___ hernia -insomnia -lower extremity edema wearing compression stockings Social History: ___ Family History: coronary artery disease Physical Exam: ADMISSION PHYSICAL EXAM: ============================== VS: 97.5PO 109 / 66 61 18 98 GENERAL: NAD, appears stated age, well-nourished HEENT: atraumatic, normocephalic, EOMI, PERRL, MMM HEART: RRR, no murmurs, rubs, gallops LUNGS: CTAB, no wheezes, ronchi, rales ABDOMEN: NABS, mildly tender to palpation in LLQ, no rebound or guarding EXTREMITIES: wwp, 2+ pitting edema of bilateral lower extremities with L slightly greater than R. Contusion on L elbow with intact ROM but tenderness to palpation NEURO: A&Ox3, moving all 4 extremities with purpose, CN II-XII intact, able to say months of the year backwards SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ============================== VS: T97.7 136/63 65 18 96% RA GENERAL: In no acute distress, sitting comfortably in his chair HEENT: AT/NC, anicteric sclera, pink conjunctiva NECK: Nontender supple neck, no LAD, no JVD HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Nondistended, active bowel sounds, nontender to palpation, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Bilateral lower extremity edema extending to knee, tender to touch bilaterally, ___ stockings in place PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII grossly intact SKIN: Large ecchymoses present in left inner elbow and tracking down to left wrist, some ecchymoses also present on right arm. Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ===================== ___ 06:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 04:15PM ___ PTT-29.3 ___ ___ 03:24PM GLUCOSE-99 UREA N-41* CREAT-1.4* SODIUM-140 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15 ___ 03:24PM WBC-6.6 RBC-2.46* HGB-8.1* HCT-24.5* MCV-100* MCH-32.9* MCHC-33.1 RDW-15.0 RDWSD-55.1* ___ 03:24PM NEUTS-61.5 ___ MONOS-12.0 EOS-4.6 BASOS-0.5 IM ___ AbsNeut-4.04 AbsLymp-1.37 AbsMono-0.79 AbsEos-0.30 AbsBaso-0.03 PERTINENT LABS: ===================== ___ 04:57PM BLOOD WBC-7.0 RBC-2.70* Hgb-8.9* Hct-27.7* MCV-103* MCH-33.0* MCHC-32.1 RDW-15.6* RDWSD-58.4* Plt ___ ___ 07:15AM BLOOD WBC-7.7 RBC-2.40* Hgb-7.8* Hct-24.4* MCV-102* MCH-32.5* MCHC-32.0 RDW-15.4 RDWSD-57.5* Plt ___ ___ 07:15AM BLOOD Plt ___ ___ 04:57PM BLOOD Plt ___ ___ 07:15AM BLOOD Glucose-106* UreaN-35* Creat-1.2 Na-140 K-4.4 Cl-109* HCO3-20* AnGap-15 DISCHARGE LABS: ===================== ___ 08:10AM BLOOD WBC-8.2 RBC-2.73* Hgb-8.8* Hct-26.9* MCV-99* MCH-32.2* MCHC-32.7 RDW-15.2 RDWSD-54.6* Plt ___ ___ 08:10AM BLOOD Plt ___ MICROBIOLOGY: ===================== URINE CULTURE (Final ___: NO GROWTH. PERTINENT IMAGING: ===================== ___: BLE DVT US: No evidence of deep venous thrombosis in the lower extremity veins. ___: EGD Normal mucosa in the esophagus Medium hiatal hernia Normal mucosa in the whole stomach (biopsy) Normal mucosa in the duodenum Small erosion noted in the hiatal hernia sac Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mr. ___ is an ___ yo man with a history of GERD, duodenal ulcer ___ years ago), and anemia (baseline Hgb 9.7) who presents with melena. ACUTE ISSUES: ======================== #Melena due to hiatal hernia erosion: Patient's most recent EGD was ___ which was normal. He had another EGD on this admission which revealed a small erosion at a hiatal hernia narrowing. Since patient's home medications, celecoxib and aspirin, increase his risk of bleeding, they were held during the hospital course and patient was started on IV pantoprazole 40mg twice daily. His hemoglobin remained stable for hospital stay without need for transfusion. Patient was transitioned to and discharged with oral pantoprazole twice daily. His hemoglobin and vitals remained stable and he no longer had melena. He was scheduled for outpatient colonoscopy. # Anemia: Patient has baseline anemia (Hgb 10) with macrocytic component. Folate and Vitamin B12 were within normal limits. #L upper arm pain: Patient had a recent fall on ___ when he fell while using his walker. X-ray showed no evidence of fracture, but MRI revealed full-length, full-width triceps tendon rupture. Patient pain was controlled on Tylenol. Physical therapy and occupational therapy saw patient did not recommend a splint; regarding rehabilitation exercises, they recommended follow-up with orthopedic surgery. #Bilateral lower extremity edema: Patient has baseline lower extremity edema with no history of cardiac disease, likely secondary to venous insufficiency. He wears compression stockings. On presentation, he had significant tenderness in his lower legs, so bilateral ultrasound of the lower extremities was done (negative for DVT). CHRONIC ISSUES: ======================== #GERD: Patient home omeprazole was switched to pantoprazole twice daily. He was discharged with changed medication. #BPH: Maintained on home Tamsulosin #Chronic pain from lumbar and cervical spondylosis and osteoarthritis: Maintained on home gabapentin and lidocaine patches. Celecoxib was held in the setting of GI bleed. His pain can be managed with Tylenol. TRANSITIONAL ISSUES: ============================= [ ] New medication: Pantoprazole 40mg twice daily [ ] Celecoxib (osteoarthritis) was discontinued in setting of bleed. Pain can be controlled with Tylenol. [ ] Outpatient colonoscopy on ___. [ ] Followup with orthopedic surgery on ___ for triceps tendon rupture. #CONTACT: ___ (___) ___ #CODE: FULL (presumed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. Celecoxib 200 mg oral DAILY 4. Omeprazole 20 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Multivitamins 1 TAB PO DAILY 3. Pantoprazole 40 mg PO Q12H 4. Calcium Carbonate 1500 mg PO QAM 5. Gabapentin 300 mg PO TID 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Tamsulosin 0.4 mg PO QHS 8. Vitamin D 1000 UNIT PO DAILY 9. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until your doctor tells you to, since it can cause bleeding Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ===================== Upper GI bleed secondary to hiatal hernia erosion SECONDARY DIAGNOSIS: ===================== Left elbow pain Gastroesophageal reflux disease Bilateral lower extremity edema, likely venous stasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, WHY WERE YOU HERE? - You were admitted for blood in your stool. WHAT WAS DONE FOR YOU IN THE HOSPITAL? - The Gastrointestinal team did a procedure and used a camera to look for the source of your bleeding. - They found an area of erosion at the top of your stomach (hiatal hernia). - You did not require any blood transfusions. WHAT SHOULD YOU DO ONCE YOU GET HOME? - You were prescribed a new medication (pantoprazole) which you will need to take twice daily to help prevent bleeding. - You will have a colonoscopy on ___. - Please follow up with the ___ clinic for your left arm pain. WHAT CAN YOU DO TO HELP PREVENT FUTURE ULCERS: - Avoid taking NSAIDs - Avoid eating spicy or acidic foods (such as tomatoes and orange juice) - Quit smoking, if you smoke - Limit your alcohol intake It was a pleasure to take care of you! -Your ___ Team Followup Instructions: ___	[ "K2211", "D649", "I351", "K449", "K219", "N400", "G8929", "M47892", "M1990", "Z86010" ]	Allergies: Lisinopril Chief Complaint: Bloody stool Major Surgical or Invasive Procedure: [MASKED]: EGD History of Present Illness: Mr. [MASKED] is an [MASKED] yo man with a history of GERD, OA (on celecoxib) anemia who presents to the ED after having had dark BMs for the past couple of days. He has noted some feelings of heartburn at home and says that he has missed [MASKED] doses of his omeprazole over the past couple weeks. He denies dizziness, light headedness, chest pain, palpitations, N,V, diarrhea, constipation. He also suffered a mechanical fall 2 weeks ago. No fracture present on XRAY, MRI preformed on [MASKED] (read pending). In the ED his initial VS were 98.0 81 113/65 20 97% RA. His exam was notable for guaiac positive stool. He was given pantoprazole 40mg IV and 1L NS. He was typed and crossed but not transfused. A bladder scan was also done for concern for urinary retention and he had 66cc in his bladder. On arrival to the floor, patient reports that overall he is feeling well. He is having pain in his L elbow (because of recent fall) and some mild abdominal discomfort. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: -GERD -knee osteoarthritis -AAA -BPH -spinal stenosis -? hx of pancytopenia per PCP, MDS [MASKED] hernia -insomnia -lower extremity edema wearing compression stockings Social History: [MASKED] Family History: coronary artery disease Physical Exam: ADMISSION PHYSICAL EXAM: ============================== VS: 97.5PO 109 / 66 61 18 98 GENERAL: NAD, appears stated age, well-nourished HEENT: atraumatic, normocephalic, EOMI, PERRL, MMM HEART: RRR, no murmurs, rubs, gallops LUNGS: CTAB, no wheezes, ronchi, rales ABDOMEN: NABS, mildly tender to palpation in LLQ, no rebound or guarding EXTREMITIES: wwp, 2+ pitting edema of bilateral lower extremities with L slightly greater than R. Contusion on L elbow with intact ROM but tenderness to palpation NEURO: A&Ox3, moving all 4 extremities with purpose, CN II-XII intact, able to say months of the year backwards SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ============================== VS: T97.7 136/63 65 18 96% RA GENERAL: In no acute distress, sitting comfortably in his chair HEENT: AT/NC, anicteric sclera, pink conjunctiva NECK: Nontender supple neck, no LAD, no JVD HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Nondistended, active bowel sounds, nontender to palpation, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Bilateral lower extremity edema extending to knee, tender to touch bilaterally, [MASKED] stockings in place PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII grossly intact SKIN: Large ecchymoses present in left inner elbow and tracking down to left wrist, some ecchymoses also present on right arm. Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ===================== [MASKED] 06:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 04:15PM [MASKED] PTT-29.3 [MASKED] [MASKED] 03:24PM GLUCOSE-99 UREA N-41* CREAT-1.4* SODIUM-140 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15 [MASKED] 03:24PM WBC-6.6 RBC-2.46* HGB-8.1* HCT-24.5* MCV-100* MCH-32.9* MCHC-33.1 RDW-15.0 RDWSD-55.1* [MASKED] 03:24PM NEUTS-61.5 [MASKED] MONOS-12.0 EOS-4.6 BASOS-0.5 IM [MASKED] AbsNeut-4.04 AbsLymp-1.37 AbsMono-0.79 AbsEos-0.30 AbsBaso-0.03 PERTINENT LABS: ===================== [MASKED] 04:57PM BLOOD WBC-7.0 RBC-2.70* Hgb-8.9* Hct-27.7* MCV-103* MCH-33.0* MCHC-32.1 RDW-15.6* RDWSD-58.4* Plt [MASKED] [MASKED] 07:15AM BLOOD WBC-7.7 RBC-2.40* Hgb-7.8* Hct-24.4* MCV-102* MCH-32.5* MCHC-32.0 RDW-15.4 RDWSD-57.5* Plt [MASKED] [MASKED] 07:15AM BLOOD Plt [MASKED] [MASKED] 04:57PM BLOOD Plt [MASKED] [MASKED] 07:15AM BLOOD Glucose-106* UreaN-35* Creat-1.2 Na-140 K-4.4 Cl-109* HCO3-20* AnGap-15 DISCHARGE LABS: ===================== [MASKED] 08:10AM BLOOD WBC-8.2 RBC-2.73* Hgb-8.8* Hct-26.9* MCV-99* MCH-32.2* MCHC-32.7 RDW-15.2 RDWSD-54.6* Plt [MASKED] [MASKED] 08:10AM BLOOD Plt [MASKED] MICROBIOLOGY: ===================== URINE CULTURE (Final [MASKED]: NO GROWTH. PERTINENT IMAGING: ===================== [MASKED]: BLE DVT US: No evidence of deep venous thrombosis in the lower extremity veins. [MASKED]: EGD Normal mucosa in the esophagus Medium hiatal hernia Normal mucosa in the whole stomach (biopsy) Normal mucosa in the duodenum Small erosion noted in the hiatal hernia sac Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mr. [MASKED] is an [MASKED] yo man with a history of GERD, duodenal ulcer [MASKED] years ago), and anemia (baseline Hgb 9.7) who presents with melena. ACUTE ISSUES: ======================== #Melena due to hiatal hernia erosion: Patient's most recent EGD was [MASKED] which was normal. He had another EGD on this admission which revealed a small erosion at a hiatal hernia narrowing. Since patient's home medications, celecoxib and aspirin, increase his risk of bleeding, they were held during the hospital course and patient was started on IV pantoprazole 40mg twice daily. His hemoglobin remained stable for hospital stay without need for transfusion. Patient was transitioned to and discharged with oral pantoprazole twice daily. His hemoglobin and vitals remained stable and he no longer had melena. He was scheduled for outpatient colonoscopy. # Anemia: Patient has baseline anemia (Hgb 10) with macrocytic component. Folate and Vitamin B12 were within normal limits. #L upper arm pain: Patient had a recent fall on [MASKED] when he fell while using his walker. X-ray showed no evidence of fracture, but MRI revealed full-length, full-width triceps tendon rupture. Patient pain was controlled on Tylenol. Physical therapy and occupational therapy saw patient did not recommend a splint; regarding rehabilitation exercises, they recommended follow-up with orthopedic surgery. #Bilateral lower extremity edema: Patient has baseline lower extremity edema with no history of cardiac disease, likely secondary to venous insufficiency. He wears compression stockings. On presentation, he had significant tenderness in his lower legs, so bilateral ultrasound of the lower extremities was done (negative for DVT). CHRONIC ISSUES: ======================== #GERD: Patient home omeprazole was switched to pantoprazole twice daily. He was discharged with changed medication. #BPH: Maintained on home Tamsulosin #Chronic pain from lumbar and cervical spondylosis and osteoarthritis: Maintained on home gabapentin and lidocaine patches. Celecoxib was held in the setting of GI bleed. His pain can be managed with Tylenol. TRANSITIONAL ISSUES: ============================= [ ] New medication: Pantoprazole 40mg twice daily [ ] Celecoxib (osteoarthritis) was discontinued in setting of bleed. Pain can be controlled with Tylenol. [ ] Outpatient colonoscopy on [MASKED]. [ ] Followup with orthopedic surgery on [MASKED] for triceps tendon rupture. #CONTACT: [MASKED] ([MASKED]) [MASKED] #CODE: FULL (presumed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. Celecoxib 200 mg oral DAILY 4. Omeprazole 20 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Multivitamins 1 TAB PO DAILY 3. Pantoprazole 40 mg PO Q12H 4. Calcium Carbonate 1500 mg PO QAM 5. Gabapentin 300 mg PO TID 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Tamsulosin 0.4 mg PO QHS 8. Vitamin D 1000 UNIT PO DAILY 9. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until your doctor tells you to, since it can cause bleeding Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: ===================== Upper GI bleed secondary to hiatal hernia erosion SECONDARY DIAGNOSIS: ===================== Left elbow pain Gastroesophageal reflux disease Bilateral lower extremity edema, likely venous stasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], WHY WERE YOU HERE? - You were admitted for blood in your stool. WHAT WAS DONE FOR YOU IN THE HOSPITAL? - The Gastrointestinal team did a procedure and used a camera to look for the source of your bleeding. - They found an area of erosion at the top of your stomach (hiatal hernia). - You did not require any blood transfusions. WHAT SHOULD YOU DO ONCE YOU GET HOME? - You were prescribed a new medication (pantoprazole) which you will need to take twice daily to help prevent bleeding. - You will have a colonoscopy on [MASKED]. - Please follow up with the [MASKED] clinic for your left arm pain. WHAT CAN YOU DO TO HELP PREVENT FUTURE ULCERS: - Avoid taking NSAIDs - Avoid eating spicy or acidic foods (such as tomatoes and orange juice) - Quit smoking, if you smoke - Limit your alcohol intake It was a pleasure to take care of you! -Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "D649", "K219", "N400", "G8929" ]	[ "K2211: Ulcer of esophagus with bleeding", "D649: Anemia, unspecified", "I351: Nonrheumatic aortic (valve) insufficiency", "K449: Diaphragmatic hernia without obstruction or gangrene", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "G8929: Other chronic pain", "M47892: Other spondylosis, cervical region", "M1990: Unspecified osteoarthritis, unspecified site", "Z86010: Personal history of colonic polyps" ]

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